Tuesday, July 13, 2010

Veteran's Disability Compensation; Ready for a Second Opinion?

I have a bad heart!
The veteran yelled. He had served stateside for two years in the mid 1970s and after some slightly elevated blood pressure readings during that short time period he has been receiving service connected disability compensation for hypertension. Collecting over $50,000 tax free over the last thirty years in disability compensation for having high blood pressure plus free Veterans Administration (VA) medical care for life wasn't enough. Thirty years later he just didn't have as much pep as he did in his twenties and knew it had to be related to the two years he served. He wanted to get some more disability compensation for other conditions that could be related to hypertension. VA disability compensation is a monetary benefit paid to veterans who are disabled by an injury or a disease that was incurred or aggravated during active military service. Rating percentages start at 0% and end at 100% (total disability). Any veteran getting a disability rating is also entitled to almost free VA health care services for life. While his hypertension was certainly not caused by military service, he was getting disability compensation for it because it started while he was in the military. He decided to claim possible heart disease secondary to his hypertension. The VA allows a veteran to get an exam for virtually any request. Obese and out of shape, he sat on the exam table demanding that I diagnose him with heart disease. At significant government expense and solely to examine his claim, the VA had already done an echocardiogram and thallium cardiac stress test that were both normal. His VA primary care physician, not wanting to leave any stone unturned in advocating for her patient, even ordered an unnecessary stress echocardiogram…completely normal. When he demanded to know if he would be getting more money for his hoped for heart disease, I broke the rule that examiners are not to answer such questions. "No, there is nothing wrong with your heart… which is good, right?". He demanded that I explain why he had no energy. "May be it's the smoking, weight gain, lack of exercise... there are many different possibilities" I said, just inflaming the encounter. He didn't like my answer still demanding some heart disease, took down my name, and said I would be hearing from his congressman.

I hate to disappoint you.
No, this is not going to be another one of those stories about how poorly the VA treats and under compensates veterans. There are plenty of those. I take a somewhat different perspective and will illustrate how the veteran’s disability compensation system is, in my opinion, way too generous to hundreds of thousands of veterans with medical conditions that have little to nothing to do with actual military service. While there is an economic recession, record home foreclosures, falling stock prices, tumbling 401k plan values, and a 2 trillion dollar plus annual federal deficit, there is a bull market in veterans' disability compensation benefits. The veterans know it and are applying in unprecedented numbers. It’s usually not greed, but normal economic behavior.

Maybe it was a Poor Part-Time Job Choice.
My involvement in the whole field starts with my being a veteran, having served in the military on active duty for six years and in the reserves for another two years. I earned a Masters Degree in Business/Health Care Finance and then another Masters Degree as a Physician Assistant. Until I left the VA a few months ago, I worked for two VA Hospitals for over ten years as a Primary Care Provider. A few years ago when the wars in Iraq and Afghanistan generated a big surge in disability claims I started to do some disability physical exams in order to make a few extra bucks. Over last few years until 2009 I have done hundreds of disability medical exams and been the official reviewer of hundreds more done by other Physicians, Psychiatrists, Psychologists, Nurse Practitioners and Physician Assistants. The cases I present are true and are very typical of what makes up a significant percentage of VA disability compensation. The quotes are accurate but are not verbatim, as I obviously didn't record the conversations and maintain no records. For those of you who blindly support anything veterans request, this article won‘t be for you. Read it anyways…it’s good to get a different perspective once in awhile. I also realize in this political climate any one who advocates decreasing any benefits to veterans will be called unpatriotic or anti-veteran. I am neither. I believe the disability compensation that is going to veterans who have suffered real major traumatic injuries in the service should in fact be increased. I believe the contributions made by veterans are great, however, I do not believe this means veterans deserve a lifetime of generous tax free monthly disability checks for medical conditions that are not really related to military service. My opinions are my own and obviously don't represent those of the VA.

First Some Real Disability Compensation.
He is now in his mid 20s. He suffered a major blast injury in Iraq that caused major damage to his legs. He has had over ten leg surgeries to remove shrapnel, reconstruct bones, tendons, nerves and muscles. He has some chronic pain but despite that he functions at a high level and is in the long process of being accepted as a local policeman. He is service connected at a 100% rating and in my opinion deserves every dollar he receives.He is another Iraqi war veteran. He suffered a blast injury that severely traumatized his skull and brain. His skull bone was damaged, permanently deformed, and he had has major head surgeries. He is also blind in one eye, suffers from chronic headaches, seizures, and Post Traumatic Stress Disorder (PTSD). He obviously can not work. He is also service connected at 100%. These veterans get slightly more than $30,000 tax free a year in disability pay plus other monetary benefits and are obvious examples of justified disability compensation. Some, including me, might contend that these veterans are under compensated for the injuries they suffered.

We treat our Veterans very well.
He served for 2 years in the 1980s and was discharged early for drug abuse. Fifteen years later he was diagnosed with schizophrenia. Because he has no income he is already getting free VA medical care. Twenty years after discharge from the service he submits a disability claim contending that his schizophrenia type symptoms started while in the service in the 1980s. The VA paid psychiatrist doing the disability exam agrees based only on an interview with the veteran and a relative‘s statement about his behavior in the 1980s…no other medical documentation that the condition started in the service is submitted. He is awarded a 100% disability rating which also entitles his family to full free medical care.

Unbudgeted and the Real Cost of the War in Iraq.
She served in the Army for two years with one year in Iraq. She drove a truck in Iraq and saw a lot of carnage. After discharge from the Army she is diagnosed with PTSD. More about PTSD later. She has PTSD in addition to other mental health problems that clearly started before she ever entered the service. She is attending college part time. She is awarded a 100% disability rating, over $30,000 a year. At the young age of 24 and with no physical problems, she can expect to live well into her eighties and over the next sixty years receive about.... $2,000,000 tax free.

Half a Mill for Sleep Apnea…Rewarding Obesity.
When it comes to disability compensation for its veterans, the United States is one very generous nation. Contrary to the popular belief that disability compensation goes mainly to injuries from IEDs in Iraq or gun shot wounds from Vietnam, the majority of veteran’s disability compensation goes for conditions that have nothing to do with combat related injuries in Vietnam, Iraq or Afghanistan. First off, most claims come from veterans who never served in actual combat. The majority of compensation is paid to combat and non combat veterans for common medical conditions that we all get such as heartburn, hypertension, chronic fatigue, depression unrelated to combat, allergies, nasal problems, acne, dandruff, non traumatic tension or migraine headaches, irritable bowel, diabetes, heart disease and prostate cancer. Ever hear of sleep apnea? Sleep apnea is a major medical problem in this country that is caused by a throat blockage and often associated with obesity. It has nothing to do with military service yet disability compensation paid is in the multimillion's for this condition. If you gain a lot of weight while active duty, develop sleep apnea and are lucky enough to get it diagnosed while active duty, you will be handsomely rewarded when you are discharged. Based on an arcane VA disability rating system that rates sleep apnea more highly than many combat related military injuries, almost all veterans with sleep apnea are rated at 50%, which translates to $728 a month or about $10,000 a year. For the typical 28 year old departing veteran with an expected 50 year life span this would come to $500,000 tax free... unless he diets or exercises his way out of the condition. With that type of money I can't imagine any veteran would want to shed the pounds.

$4,000 a year tax free for life for what?
The claim request is to evaluate the veteran’s umbilical hernia and gas as she claims an increase in her hernia/bowel 30% disability rating is warranted. The veteran is a twenty six year old who delivered a baby five years ago and post delivery developed a small belly button hernia and some chronic gas and constipation that was diagnosed as irritable bowel. Later on the hernia was successfully repaired. For that she has been receiving $346 per month or about $4,000 a year and free VA medical care. With a normal life span she can expect to rake it over $200,000 tax free but she is seeking more money. I ask her what has changed in her disability condition, given the fact that, according to the VA medical notes, she hasn’t discussed the issue with her primary care provider in the last 2 years. She doesn’t like the itchy one inch scar and too much gas. I measure the scar and put down all the symptoms she claims knowing that no increase will likely be granted, but thinking what a generous disability system we have for our veterans. Her $4,000 a year is safe.

$8,700 a year for life for what ?
The claim is a request for an increase in disability compensation for a veteran who had an abdominal hysterectomy. The veteran is in her forties and has been receiving disability compensation with a rating of 30% or $356 a month for the last 5 years because she had her uterus removed while in the service. She had painful menstrual periods from uterine fibroids and she had a successful surgery to remove her uterus and the painful menstruation went away. She already had her children so she was happy that the procedure relieved her pain and she has had no further symptoms. A service representative advised her that she was receiving disability compensation at the partial hysterectomy rate of 30%, not the total hysterectomy rate of 50%. She is quite angry about this….she feels under compensated. An easy exam for me. For you taxpayers not so easy…her monthly disability check will increase to $728 or $8,700 a year for a medical condition that in reality no longer affects her. 

Triple dipper times two.
He is a fifty four year old military retiree collecting a nice military pension. As a military retiree he is also entitled to VA disability compensation and has a rating of 90% for all sorts of minor medical problems. He also has three types of medical insurance and three or four primary care providers. At various times he goes to a military hospital, veterans hospital, tricare insurance medical providers and also has a medical provider under the wife’s medical plan. He limps into my office for a visit. His current mission is to add on social security disability compensation. This one is pure greed. He butters me up and tells me since I am the primary care provider that takes the most time to listen to his problems he wants me to complete a statement for his lawyer stating he is totally unable to work in any form. After multiple x-rays, MRIs, and Cat Scans with no significant abnormalities his final diagnosis from his two rheumatologists is fibromyalgia….a controversial medical diagnosis that in latin basically means painful muscles. He likes to focus on those insignificant mild disc protrusions in his spine as evidence he is totally disabled. He has seen many military, VA, and tricare Orthopedists, Pain specialists, Rheumatologists and Physical Medicine doctors but never a Psychiatrist. In a country with over fifty million uninsured citizens, I guess you would call him the exact opposite of being uninsured. He has a Masters degree and was a supply specialist in the service. After multiple visits with me I tell him I believe he is capable of working at some sort of desk job. He is not very happy with the statement I give him. He angrily tells me he plans on shredding it. I suggest he see one of his three other primary care providers for the statement and then see a mental health provider. He races out of my office down the hall to the patient’s advocate office…at least the limp is gone

You do the math.
He is in his late twenties discharged a little early from the service for moderate asthma that resurfaced when stationed in the cold north as an adult. The VA is quite generous with asthma and his disability rating is 50% or $781 a month, as he is married and gets the family rate. The good thing is since he got out of service and moved south, his asthma is basically non existent and doesn't affect him at all as an MBA student. He has not needed an inhaler in over a year. He is worried that the VA will catch up with him at some point and reduce the compensation rating and asks me to get some inhaler prescriptions on the books. "Don't worry", I tell him, "your rating percentage is still too low for a regular review and the claims backlog is so great it is unlikely the VA will ever get around to reviewing your status for years if at all." At $781 a month for this one condition it doesn't take an MBA to compute the total projected financial windfall, well over $500,000 tax free for a normal life span.

Smoking can be really healthy for your disability rating.
He is a veteran in his late fifties and is service connected for chronic bronchitis and is seeking an increase. He has continued smoking for over thirty years. I review the military medical records and note only three visits in the military record in the 1970s related to the condition. To me, the symptoms indicate he had common colds not acute bronchitis and the disability diagnosis of chronic bronchitis was probably in error. In my opinion, he has been getting disability pay for thirty years in error. At this late date, the VA will never correct the error, and in fact I am only being asked to review his request for an increase. After thirty years of continued smoking and a terrible pulmonary function test, he definitely now has emphysema and his disability rating will no doubt increase at least to at least 30 or 50%. Before he leaves, he wants to know what his rating will be if he can get on some oxygen.

Gender Identity Disorder and Menstrual Cramps…. Pay Me!
I am reviewing the latest odd disability compensation request. The veteran currently identifies himself as a male but was formerly a female who served a few years in the 1980s. His record is flagged because he has been abusive to the VA police. He claims he started to have heavy menstrual periods during his 3 years of active duty in his 20s and the hysterectomy he had 20 years later and paid for by the VA started or was a result of his active duty service. He has also been diagnosed with gender identity disorder and general depression secondary to this disorder and of course claims his mental health problems started during his 3 years of active duty service decades ago. The fact that the VA allows disability compensation requests for these types of problems amazes me. The physician and psychiatrist have opined in favor in the veteran’s contention. As I read the psychiatrist’s opinion I note to myself I can’t remember the last time a VA paid psychiatrist doing a disability exam has NOT opined in favor of a veteran. They are very generous with your tax dollars. I don’t know what the veteran’s final disability rating will be, but I estimate about $10,000 a year...tax free. 

Reaching for the Gold after a Long Run.
He is seeking an increase in his 90% disability rating. He was discharged twenty years ago with a 10% knee disability rating for a “knee strain”. There is only one military medical note describing what appears to have been minor knee overuse pain after a long run in physical training and in his discharge physical exam it says he has “occasional minor knee pain.” Over the last twenty years he has been successful in turning his long run into a 90% disability rating by claiming this knee strain later caused some knee arthritis which caused him to also suffer chronic back pain, mental depression and the inability to maintain employment. He is now service connected for all these conditions. He also claims his recent central sleep apnea diagnosis is secondary to all the pain and sleep medications he takes and he wants disability compensation for that. In his current medical and employment state he will likely get his 100% disability rating. The VA simply needs to put an end to allowing disability compensation for these multiple secondary conditions. 

A Rapid Cure.
He is a 28 year combat veteran getting a 70% service connected disability compensation for mild PTSD per his VA psychiatrist, a minor shoulder problem and tension headaches. Since he got out of the army infantry he really hasn’t found the job he wants. He is currently a security guard. He comes in for a visit seeking a detailed letter of medical clearance from me, his primary care provider, because he wants to get into the Homeland Security Department as a Customs officer. He wants me to write that his disabilities of PTSD, shoulder condition and tension headaches have no affect on him and he is physically and mentally fit. “I would be glad to write it”, I say “but just a few months ago you put in and received a significant increase in VA compensation for your PTSD, shoulder tendonitis and headaches because you claimed your anxiety was increasing and your shoulder was hurting you much more and you were getting more headaches.” He smiles and says “that was a few months ago, they don’t bother me any more.” I gladly write the letter as I agree he appears physically and mentally fit. Homeland Security would be lucky to have this guy but whether the taxpayers should continue to send him $14,000 a year tax free for life (over $700,000 for a normal life span) is another question.

Agent Orange causes Diabetes.
The Congress and the Courts have ruled that the Herbicide Agent Orange is a likely cause of diabetes and many cancers such as prostate and lung cancer. This has opened up the flood gates for Vietnam war veterans who have diabetes and prostate cancer. Most in the unbiased medical community know that Agent Orange is not a major risk factor in the development of Diabetes, Prostate or Lung Cancer, although a recent article supports some association with Prostate Cancer. A veteran who served in Vietnam in the 1960s and then developed diabetes or cancer 30 years later most likely had their diabetes or cancer caused by obesity, smoking, family history or just plain old age. Nevertheless, Vietnam era veterans (including Navy veterans who served in the waters off Vietnam) are now all getting service connected for diabetes and many cancers. We are talking big money. Getting service connected can often land a veteran with a 100% disability or $2,527 a month tax free. Veterans are also getting disability compensation for multiple other secondary conditions that they claim were caused by their diabetes or cancer. There are thousands of veterans whose total service was two years in the 1960s who claim and receive disability compensation for medical conditions that occurred thirty years later such as heart disease, strokes, hypertension, peripheral vascular disease, nerve damage, kidney disease, and erection dysfunction. The VA is very generous and more often than not agrees that these secondary conditions were all caused by the veteran’s diabetes which was caused by agent orange exposure. Only a disability medical exam from a busy VA clinician is necessary. Forget about tobacco use as the cause of a veteran’s stroke or heart attack. The compensation is quite nice when all these multiple conditions get service connected. Typically $225 a month just for the diabetes plus on average another $501 for other conditions. ay225 a month just for the s on average another $501 a month for the other conditions.age another $501 a onth other conditions.

Diabetes Disability Compensation for Veterans without Diabetes.
He is a 60 year old receiving diabetes disability compensation for the last four years . He developed his so-called diabetes about four-five years ago and is able to receive his disability pay because he was exposed to agent orange in the 1960s. He is expecting another big pay day and requesting increased disability compensation because he claims his recent heart attack, hypertension, and the increasing peripheral neuropathy (numbness) in his arms and legs are all secondary to his so-called diabetes. I am reviewing the rushed examiner’s report and in his opinion all these conditions are now secondary to the so-called diabetes…diabetes is after all a major risk factor for development of heart disease and nerve damage. The veteran can expect his huge pay day and compensation increase based on this report. Before signing off on the exam I review the lab section. The original 2005 diabetes diagnosis by the VA disability examiner was a weak and quick exam based on a note from a private physician prescribing a diabetes medication for a fasting glucose of 123. I review all the labs in file and the VA medical record and there is not a single one with a fasting glucose value of over 125. His current fasting glucose is 96 and three month sugar test is well below the diabetes range and he is no longer on any diabetes medication. The veteran may have had what is called pre-diabetes but never diabetes. The VA medical notes indicate the veteran is a long term smoker and alcoholic and these are the likely cause of his recent heart disease and long term neuropathy. I send the exam back to the examiner who agrees and corrects the report. The VA will never recoup the thousands of dollars paid out for his “diabetes”. I have seen this type of case multiple times in my reviews of claims. It is likely there are hundreds of these types of “diabetes cases” at the many VAs that don’t have the time to do real peer reviews of exam reports. 

What percent of the time can you achieve Vaginal penetration?
The request for exam and medical opinion received from regional office asked the following question…I couldn’t make this one up,"If you feel the veteran's erectile dysfunction (ED) was aggravated by the diabetes mellitus type II, please provide the following. Please provide objective evidence of baseline manifestations of the veteran's erectile dysfunction. (The baseline manifestations of disability which are due to effects of (nonservice connected disease or injury), prior to aggravation or at the earliest date ascertainable. This should be based on a review of the veteran's treatment reports. Please provide objective evidence of the natural progression of the baseline condition. In other words, in objective terms, to the best of your ability, please provide an estimation as to what the current disability level of the erectile dysfunction would be without aggravation. Please provide objective evidence of the current level of disability per the respective examination worksheet."Somehow I didn’t see myself penetrating too deep into the whole issue with the elderly veteran sitting in front of me and I pulled out the old "I can not provide an opinion without resorting to mere speculation" answer. I like that one. Nevertheless in order to complete the ED disability template we did spend some quality time getting a little naughty. “What percent of the time can you achieve vaginal penetration?”, I asked with a straight face. We were both already quite confused but the exam disintegrated downhill from there. Is your ejaculate normal? Testicle size exam, unnecessary prostate exam and bulbocavernosus reflex comes next. It's all in the new and improved complex ED computer template. What a country when you can get disability pay for erectile dysfunction but at what cost to the taxpayer and future generations?

Can I receive VA disability compensation for a medical problem that didn't even start when I was in the Navy?
Yes, of course. He is in his late twenties served three years stateside and already has a 40% disability rating receiving over $6,000 a year (over $300,000 for a normal life span) in disability compensation for some depression. He is now requesting disability compensation for hypertension. The thing is he acknowledges that the hypertension started about 6 months after he was discharged from the service. No one has ever diagnosed him with hypertension while he was in the Navy. He is right... the VA is very generous with your tax dollars and many conditions such as hypertension that start within one year of discharge are presumed to have started while on active duty. He sends in a barely legible medical note from his private doctor diagnosing him with hypertension and starting him on a medication. His disability check for hypertension will be $230 per month for life and likely only increase. Giving a veteran in his twenties a service connection for hypertension is a major future government financial liability. Especially this veteran, who smokes and drinks too much. If he has a stroke or any type of heart disease thirty years later, he can claim his service connected hypertension as the cause and get disability compensation for the stroke or heart disease as well. It is simply too generous a system.

Can you prescribe me some Medical Marijuana?
He is a walk-in patient without an appointment sent by a VA service officer to see a clinician solely to document his medical complaints to support his new disability claim. There seems to be a great increase in these types of unnecessary visits. He is service connected for a left knee condition after a sprain in the service in North Carolina 10 years ago. A few years ago he was able to get right knee compensation after he complained that some pain there was caused by the left knee condition. Now he claims that both hips and lower back hurt because of his left knee condition. He wants a full orthopedic exam and work-up including MRIs knowing that the MRIs are bound to show something wrong in an average 40 year old. He wants no treatment….daily marijuana use is his treatment. I take down all his complaints and do a little exam. As expected his back turns stiff when I ask him to flex his spine...he has been coached well. I tell him this is not a disability exam and that MRIs are not indicated. He is not happy with that and asks if I can at least prescribe some medical marijuana for his pain. No to that one too. Total waste of VA clinician time.

It measures about half the width of a pencil eraser…barely visible and I need my magnifying glass to see it. The pleasant Air Force veteran is seeking monthly VA disability compensation pay for a minuscule foot wart and the VA is stating it is a priority exam because she served a few months in Kuwait. She claims the wart she has now is the same one she had in the service ten years ago and some two line military medical note about a foot wart is enough proof. She claims it hurts when pressed and when she wears tight shoes. In order to fill out the VA disability template I ask her an endless number of questions about the wart. I touch the wart and in a case of bad acting she almost jumps off the table in pain. I submit the exam but my reviewer sends it back and reminds me I missed the questions about how the wart affects her activities of daily living and employment. Another one hour waste of examiner time and taxpayer monies. A claim for razor beard bumps is scheduled later in the day.

It’s a Mad, Mad, Mad, Mad World.
The exam is ready to review and sign off. The veteran is seeking disability compensation for Syphilis. Syphilis is a sexually transmitted disease (STD). The VA is at the forefront in treating veterans with infectious diseases but we can’t possibly pay a veteran for getting a STD.. .or can we? We have already paid a clinician about $100 to do the exam. I make a few calls to some VA disability experts and still can’t get an answer…one gives me the standard answer that a veteran can claim anything. Another case for disability compensation for genital herpes is in the pile for review.

Update the Computer Program… make it a flippin mess.
The VA recently computerized the disability physical exam process with a multimillion contract. It has made the medical examination process far more costly and time consuming. Until a few years ago, the clinicians performing the disability physical exams were dictating on average a simple one or two page note on each veteran's claim. The VA claim raters seemed to be satisfied and were able to provide a veteran with their disability rating based on these old exams. Enter VA central office and well paid contractors who don't perform physical exams to create a massive, time-consuming, blizzard of computerized templates called CAPRI. The templates take the clinicians hours more to complete and requires that the clinicians collect reams of useless medical information not needed to make the final medical diagnoses and mostly unused by the raters who have to come up with disability ratings. Under the new CAPRI computer system, a clinician who examines a veteran with say five or so medical conditions will often be required to complete separate templates for each of the conditions and answer dozens of questions unrelated to their actual claimed conditions. Symptoms related to say one condition such as back pain or asthma have to be retyped in multiple templates. All veterans who submit their claim package within one year of active duty discharge are also automatically entitled a broad general medical exam where they are allowed to bring up any medical complaint even if they were never treated for it in the service. For example in the general medical template, the gastrointestinal section alone has over twenty symptom questions that examiners must ask including such questions as whether the veteran ever had a history of indigestion, nausea, or hemorrhoids.
Completing these computerized templates is not without cost. Clinicians are getting paid multimillions of dollars for the multiple hours required to complete the average veteran's claim. The average payment to a contract clinician for even the simplest of claims is about $200. It is not uncommon for a veteran with only a few years of active duty service to submit a claim with over five to ten separate medical conditions. I have a veteran in my clinic in her early twenties who had four years of service that is getting disability compensation for eight common general medical problems including heartburn, gum disease, acne, nasal congestion, hemorrhoids, migraines, foot callous, and arthritis of the lumbar spine. The arthritis comes from an overly generous radiologist interpretation of a lumbar spine x-ray read as "very minimal degenerative disc disease" and an examiner way too busy answering useless CAPRI template exam questions to take a second look at the x-ray. I have seen hundreds of claims from recent military retirees with over ten to fifteen claimed conditions that require three to four hours for the clinician to complete using the CAPRI templates. The thousands of diabetes claims with multiple secondary conditions usually take over two hours to complete as each claimed condition such as kidney disease, high blood pressure and nerve problems require separate templates. I summarized the problems with the CAPRI computerized templates in an email I sent March 14, 2007 to the Dole Shalala commission that was tasked with making recommendations to improve the delivery of benefits to veterans. I received no response from them. The time consuming templates are a major reason why completing veteran’s claims are so costly and time consuming.

The Hulk.
He is 24 years old, six foot two, eyes of blue, 225 pounds of muscle and looks like a combination of the hulk and superman. He has just left the military. As always I introduce myself and tell the Hulk he is here for a disability compensation exam. He responds no, “ I am here for compensation, I don’t have any disabilities”. ‘Wrong!” I say, “this is a VA disability compensation exam” and I ask if he still wants the exam. He must as he has 15 claimed medical conditions on his request. Back, bilateral knee, shoulder and heel pain. Excessive ear wax, prior nasal bleeds, pink eye, foot fungus, acid reflux, high cholesterol, ringing in the ears, healed scar from a mole removal, and of course the money maker, depression. The veteran’s representative who helped him with the claim threw in everything but the kitchen sink on this one. Using the computer templates it will take 5 different clinicians about 6 hours to do finish his claim, over $1,000 of examiner and review time. His final disability rating ends up to 60%, over $10,000 a year and if he lives a normal life span over $600,000 tax free. As part of the exam I ask about his current employment to assess the impact of his so-called claimed disabilities on his work. The Hulk states he is already working as a personal fitness trainer. 

Money for Snot !, Money for Snot!
"Purulent drainage" yelled a hard working, dedicated co-employee of the disability compensation program at a large Veterans Administration hospital . "Purulent drainage?" I calmly responded, already jaded with whole subject, as I knew where it was going. "Yah we got a big fat zero on our monthly performance review report because in the sole exam the reviewers selected, the clinician forgot to mention whether the veteran had purulent drainage!" (nasal snot). "We need to start doing separate nose computer templates for all these nasal claims... We are not going to get any more zeros". "Whoa" I said. "The nose section in the general medical template covers drainage issue and more. If we have to do a separate nose template, the clinicians are going to demand extra nasal template pay. I think the reviewer was just too lazy or overwhelmed with the multi pages of medical information in the general medical template to find the purulent discharge answer". Needless to say I lost that battle. While the whole issue of nasal snot may sound somewhat comical to you, it shouldn't because this one little medical condition compensates veterans multimillions of dollars a year even though most veterans likely had snot problems prior to entering the service. Whether a veteran, who has applied for disability compensation for nasal conditions, has chronic sinus infections or purulent drainage means in cold hard cash an extra $115 a month… usually for life. For the typical twenty five year old just out of the military this will add up to thousands of dollars tax free over an average life span…and yes you are paying for it. 

Hundreds to Thousands of Unnecessary Disability Physical Exams.
The request from Regional office is to do a Peripheral Nerve Template…that’s it. The veteran is a Navy veteran in his sixties who served off the Vietnam coast on a ship. He already has a 100% service connected disability. According to the VA, Agent Orange exposure in the 1960’s most likely caused his adult onset diabetes in 2000 which later caused his stroke, heart disease, and depression in 2005. As I get ready to do the exam I see that three months earlier another examiner did a two hour stroke exam using the Brain and Spinal Cord template…over five pages of in-depth and mostly unnecessary complex physical exam data including all the useless peripheral nerve data a rater would need. Why on earth are we spending a few hundred dollars to bring this disabled veteran in simply to gather more physical exam data? These exams are not free. There is travel pay to the veteran (yes the VA pays for the veteran’s travel to a disability exam), an examiner payment of about $100, and reviewer time and costs. The VA has created in its CAPRI computer system a blizzard of computer templates such as the Brain and Spinal Cord template that are so complex and detailed that it takes repetitive exams before the precise data can be found.

Preexisting medical conditions.
The cost of the war in Iraq is already in the hundred of billions. One of the untold costs will be the billions upon billions of future compensation to be paid to veterans returning from Iraq and Afghanistan. A lot of this compensation is for obvious and real war injuries but as much of it is for conditions totally unrelated to combat. The use of reservists and the national guard in the war has created huge disability compensation costs. Many of these service members are in their forties and even fifties and are being activated with multiple preexisting but never officially diagnosed common medical conditions. After discharge they are claiming that these conditions started during their one year of active duty and they are applying for and getting VA disability compensation pay for virtually all their claims for such conditions such hypertension, sleep apnea, enlarged prostates, hemorrhoids, heartburn, flat feet, bunions, dandruff, and common age-related spine problems. The clinicians doing the exam and the claims reviewers are way too busy to investigate whether these conditions started pre-active duty. Once these veterans get their back problems service connected and the normal aging process takes over and turns the mild disc disease into advanced arthritis or spinal stenosis they are applying for and getting generous increases in compensation ratings. Under current law there is no limit to the number of reevaluations for increases that a veteran can ask for. It is a recipe for true future financial disaster.

$2,950 Billion Dollars Off.
She is now a 49 year old reservist who was called to active duty and sent to Kuwait for six months in 2005. Reservists generally can’t file for VA Disability compensation unless they were called to active duty or injured during their active duty drills. She did a total of one year of active duty in an administrative job. Her disability claim conditions include headaches, carpal tunnel syndrome, back pain, knee pain, bunions, heartburn, asthma and mental depression. She is a physical and emotional mess and has all these medical problems. There were no actual combat or physical injuries that she can identify, but she claims all these conditions started during her one year of active duty. There are medical records that document she was seen while active duty for all of these problems. After active duty discharge, her next stop is the VA disability affairs office. Obviously most of these problems starting pre active duty service but there is no way to prove it. She ends up with a 70% disability rating or about $15,000 a year tax free for life….she might get occasional reviews, but few if any veterans will have their ratings ever decreased. At the onset of Iraqi war, some Administration experts predicted the cost of the war would be 50-100 billion dollars. Many economists predict the true cost will be closer to $3,000 billion. It’s doubtful that even in their 3 trillion dollar cost estimate they have factored in these typical disability costs for many gulf war veterans.

Uncle Sugar.
The Army has recently admitted to having to lower its recruiting standards to meet goals and has brought in thousands of soldiers with preexisting mental health and medical disorders. Many of these soldiers don't make it more than six months before getting medically discharged. One recent case I had is of the thirty eight year old who lasted four months in the Army and was discharged early for developing some painful shin splints that prevented long marches or runs. His next stop was to the VA to get his disability compensation evaluation. His final rating 20% (10% a leg) or about $250 per month for life plus free VA healthcare for life…not bad for four months of active duty service and a condition that only bothers him when he runs for miles which he never intends to do again.

I think I am going to kill myself.
The mental health disability compensation exam was pending in a few weeks. He was a twenty year old veteran with seven months of stateside active duty service and was discharged early basically because he couldn't get along with anybody. Antisocial personality disorder versus Bipolar Disorder with borderline traits was the official diagnosis. I had seen him as an unscheduled walk-in patient. From reading the VA medical notes I sensed that VA mental health providers indicated he had previously faked a-little suicidal ideation to get himself admitted. He was quite intelligent and had been well coached on the VA disability process. He knew his mental health disability claim needed some teeth. The task for the VA psychologist doing his disability exam was to determine whether the veteran had any preexisting mental health problems and whether the veteran's mental health condition was caused by or a result of his seven months of military service. I already knew the answer. Like almost all VA mental health providers who don't want to rock the boat, the final answer would be to the benefit of the veteran. No on pre-existing mental health condition and yes on the mental health condition starting while in the military. His final take $348 per month for life and with periodic requests for increases his take will only increase… not to mention free VA health care for life. My calculation well over $200,000 for a normal life span… again not bad for seven months of active duty service.

Post Traumatic Stress Disorder (PTSD).
PTSD is a real mental health disorder that VA surveys indicate affects at least 30-40% of all veterans who served in Iraq and Afghanistan. The disability compensation costs for PTSD are staggering and are already in the billions for the veterans who served in the very short war in 1991. I believe the veterans who served in Iraq and Afghanistan are true heroes and deserve to be fairly compensated for their military related medical and mental health problems. Having said that, I can say that after being the primary care provider for hundreds of these veterans that there is a quite a bit of PTSD symptom exaggeration going on for disability compensation purposes. Any veteran who served in these countries, and there are now almost 2 million such veterans, can get service connected disability pay for PTSD by simply stating they have the symptoms. Exaggerate your symptoms and stretch what is termed sub-threshold or mild PTSD into moderate or even severe PTSD and you can increase your rating from 10% or $115 per month to 30% or 70% or $348 to $1,135 a month, or even 100% currently $2,527 a month. I hear the veterans talk among themselves about their ratings and how to take full advantage of the system. It's good money and very hard to resist. In this political climate it is the rare for a VA mental health provider to discuss such things in their notes. I have numerous veterans come to me who I believe are seeking referral to overstretched VA Mental Health Clinics solely because they want to put in a disability claim for PTSD or increase their existing disability rating, not because they want to get actual treatment or counseling. 

Encouraging the Disability Mindset.
He is an extremely intelligent and physically fit 25 year old and served active duty for 2 years including a year in Iraq. He is service connected for PTSD, muscular back pain, knee tendonitis, migraines, acne and nasal congestion and collects a total 70% disability or about $15,000 per year. He was near some blasts while in Iraq that slightly dazed him for seconds and subsequently he developed some PTSD type symptoms of difficulty sleeping and irritability. He believes his PTSD symptoms have decreased recently. Using the VA's screening questionnaire he screened positive for a possible Traumatic Brain Injury (TBI), was referred to a VA TBI specialist who diagnosed him with a “possible mild TBI“, even though his residual symptoms are much more likely related to his PTSD. He tells me he was advised to apply for more VA disability compensation for his "TBI" even though he is already being compensated for PTSD. He knows he has no brain injury but the extra money would be nice. Since this veteran was discharged from the service and has entered the VA medical system six months earlier he has seen me (his primary care provider), a psychiatrist, psychologist, neuropsychologist, audiologist, optometrist, dermatologist, orthopedist, physical therapist, TBI physician, neurologist, sleep specialist, social worker, and vocational rehabilitation counselor. He has had six hours of separate disability exams where he has seen five different physicians and specialists. Since a teenager he gets a migraine headache every couple months so one of his specialists ordered a Brain Cat Scan and the TBI specialist has referred him to see a neurologist. For his mild occasional knee and back pains, he has had unnecessary MRIs of his back and knees. He is pending an overnight sleep study for possible sleep apnea, more memory testing visits, Brain MRI, attends PTSD group visits and was offered a separate Persian Gulf registry exam. He has become overwhelmed with all his VA visits. In the back of my mind I realize we have really over tested, over treated, and overwhelmed this young man with "quality care". As his primary care provider, I have made many of these referrals and take most of the blame. I also blame the whole VA corporate medical/nursing/social work complex (hope I haven’t left anyone out) for establishing a new treatment mindset where much more is better. Where the primary care provider is criticized for taking a chance on some cost effective conservative medical care and dares not make costly referrals for everything. Any critic contending the VA lacks the interest or resources to care for veterans should read this case. Thousands of other veterans receive similar care from the VA. I ask this veteran what his career plans are as I am also concerned that just going to medical appointments is not in his long term best interest. He fortunately agrees and states he wants to work for Homeland Security or become a Police or Fire officer but is concerned about how all his VA disabilities will affect the application process and whether a job will affect his VA disability compensation. After getting the same question from dozens of other veterans, I still don’t have a good answer. After multiple visits with me over the last few months I strongly advise him to go for it, as he obviously has the physical and mental abilities to succeed as a law enforcement officer.

Less than a Head Concussion (Many Mild Traumatic Brain Injuries), another $50 Billion liability ?
She is a Navy veteran in her mid 30s. While playing sports in 1998 she hit her head and may have suffered a mild head concussion. She claims she didn’t lose consciousness but was dazed for a few seconds. Since she was discharged from the service in 2000 she has been receiving disability compensation for the occasional headaches she claims started after this “concussion“. She is requesting increased disability for her “traumatic brain injury” without submitting any medical documentation that she is currently receiving medical care for it. She will get it. The VA has recently increased compensation for any TBI, including these subjective mild TBIs that may involve less than a head concussion, from a 10% rating of about $100 a month to a 40% disability rating of $500 per month for life. We spend what seems like hours completing the TBI template and answering a series of endless all encompassing subjective questions about her TBI. She is eager to answer yes to almost all the symptoms I ask including claiming she has an occasional loss of taste and smell from her TBI. She seems to take great pride in her "TBI". The VA has spent a lot of time and money designing a monstrosity of a TBI computer template and will spend millions more for scarce medical specialists to complete these templates. Private studies indicate there may be over 300,000 veterans with these types of “TBIs”. Thousands of veterans will soon be applying for this generous compensation that will in large part be based solely on the subjective symptoms. I would bet the VA has not even estimated or disclosed the future costs to taxpayers of this recent policy change. I don’t think they care as it is your tax dollars. I estimate that for a 25 year old this would add up to about $300,000 tax free for life. My calculator doesn’t have enough zeros but if my math is correct and half of these veterans apply for this “TBI” compensation this comes to about 50 billion dollars. 

I have a heart murmur.
He was a new patient. He told me his only medical problem was some medical person told him he had a murmur. He had no symptoms and he was an athlete with no heart disease, so I thought he had what's called an innocent murmur. He was however service connected for valve disease at 30% and collecting $348 per month. At 28 years old a little young for valve disease, I thought. After I later reviewed his military echocardiogram report, I knew he had no real valve disease. It only showed "trace tricuspid regurgitation" which is basically an insignificant finding. Somehow it generated the 30% rating for valvular disease. Because he had no symptoms and a basically normal echocardiogram, I couldn't even justify repeating the echocardiogram at the VA. Lucky for him as his primary care provider, I would never think of reporting this to VA regional office.

The Worthless Great Debate of 2008.
The veteran served for a few years in the 1970s in NY and is service connected for a low back muscular strain. Now at almost age sixty he has a common age related bulging disc and some mild arthritis in his spine. He claims his current erectile dysfunction and nighttime urination is caused by the back condition and he wants some more disability compensation. We spend awhile discussing all the possible causes of ED and nighttime urination and he knows to deny all other causes including a history of an enlarged prostate, tobacco abuse, medications, low testosterone, bored with wife, and depression….he says, it has got to be his back problem which started in the service. I send my report in that the nighttime urination is probably secondary to an enlarged prostate. The ED is not caused by the bulging disc but I don’t speculate on the most likely cause.. I don’t have enough medical information as I have spent way too much time answering useless questions in the CAPRI spine and genital templates. The report is sent back asking me to try to come up with the most likely cause. The clinical supervisor and I debate about possible ED causes and I am leaning towards age related ED. Before we come up with the grand opinion I estimate we have spent an hour debating and rewriting this claim and I am more confused than before I started the exam. 

The hip bones connected to the thigh bones, the thigh bones connected to the knee bones.
He is a veteran of about sixty years old service connected for his lumbar spine condition. During his few years of service in the 1970s he had strained his back a few times while active duty and has been collecting a 10% later increased to 20% disability or about $200 a month in disability compensation. Advancing age caused arthritis in his lumbar spine. In addition in about 2000 he started to get painful knees diagnosed as meniscal tears and osteoarthritis by x-rays and MRI’s. Naturally the knee problems were caused by the back problem that was caused by the service in the 1970s... at least that was what he claimed. If he could get his knees service connected too, that would be a nice little monthly bonus check. Already experienced with these claims, I said unlikely to myself even before I started the exam. Little did I know that another clinician had already submitted an opinion that the veteran’s back problem caused an altered gait that led to his left knee osteoarthritis and two years ago the VA had already awarded him a 10% disability rating for the left knee. I was only being asked to examine his right knee for the same contention. My opinion was that normal aging, being overweight, or some undisclosed knee trauma post service most likely caused the right knee problem not an altered gait or the back condition. I never did follow up on what happened with my opinion, but before he left the veteran did tell me that his both of hips and ankles were also hurting. 

Yes it’s Time to Find a New Job.
The next veteran is ready to be examined. He served for 3 years in the early 1990s and is requesting service connection disability pay for his recent diabetes. He claims his diabetes and hypertension which started about 15 years after he was discharged from the service were both caused by the anti-depressant medications he takes for his depression that was diagnosed 3 years ago which he claims was caused by the left ankle sports injury incurred in the service 15 years ago. A weaker examiner might buy this convoluted line of B.S. and give a favorable opinion. The computer templates required to complete this exam include diabetes, hypertension, and joints. Dozens of subjective questions need to be asked and loads of detailed mainly useless physical exam signs need to be collected. I take a deep breath and realize it’s time to get out of the VA disability exam business. As you can probably tell doing these exams made me a bit cynical, burnt out, and it is no doubt best for all parties that I move on. Unfortunately it means I have to give up my day job in VA primary care. Not that I care, but the most of the brass at the VA are not going to like this article. Fortunately in this country we believe in freedom of speech and supposedly the federal whistle blower act protects employees… plus the job market in primary care medicine is still pretty good.

Fix it soon to save billions and billions of dollars.
I believe economists need to lay out the projected future costs of veteran’s disability compensation under the current system to taxpayers and politicians. I tried but I can’t find any reliable numbers. I believe the new President, Congress, and Secretary of VA should look into what the VA disability compensation system has become and where disability compensation is going. The system should be changed to eliminate all of the common medical conditions discussed above from disability compensation but increase the benefits for traumatic combat related injuries and illnesses. Smart people can figure out how to distinguish the two types of conditions. Net savings to future generations would be in the billions of dollars. The projected federal deficit for the current fiscal year 2009 alone is about two trillion. I don't think this country can afford or ever wanted the current VA disability compensation system. It will take courageous politicians and VA employees to fix it. I am not too optimistic.

Louis Dean