VA doctors are being overruled on veterans treatment plans. Heres why. – inewsource

Table of contents: Part I | Part II | Part III | Part IV | Part V

This story was produced as part of a collaboration with USA TODAY.

When Christine Russell read the message from the San Diego VA announcing it would no longer pay for her cancer treatment, all the pain came rushing back.

Russell filed four federal complaints in early February this year about her ongoing challenges accessing health care, medication and caregiver services through the VA. Days later, a group of San Diego VA administrators mailed her a letter that called her disruptive and announced they would no longer fund her appointments outside the VA because her health care was too fragmented.

For nearly three years, the federally funded veterans health care system had misdiagnosed her breast cancer as mental illness, she and her team of advocates contend. After discovering the cancer in late 2018 when the tumors had already spread the VA agreed to pay for the former Navy Reserve lieutenant to get her medical care from other doctors in the San Diego area.

There are 19 million veterans in the U.S., and almost 5 million of them have disabilities documented from their time in service. San Diego County is home to roughly a quarter million veterans, the fifth-highest of any county in the nation.

Under the VA MISSION Act of 2018, the U.S. government agreed to cover veterans medical costs inside and outside the VA health care system to ensure they do not go without the care they need.

Russell was $30,000 in debt from medical expenses since developing cancer. She couldnt afford to see her doctors if the VA didnt pay for it.

It was like they cut my legs off, Russell said. They cut off my lifelines, because all those doctors are my integrative support team. They are why Im still alive.

An inewsource investigation in partnership with USA TODAY has found that like Russell, veterans across the country are caught in the crossfire of the VAs battle to retain patients and funding since the passage of a landmark health care law known as the Mission Act.

When Congress and then-President Donald Trump passed the bipartisan law in 2018, they said it would ensure American citizens who fight to protect the U.S. can access high quality medical care after leaving the military. When the Department of Veterans Affairs cant deliver that care for any of six reasons, its supposed to pay other health care systems to do it instead.

A review of thousands of pages of department manuals and medical records, along with interviews with dozens of patients, advocates and providers, shows that VA administrators are overruling doctors judgments and preventing them from sending their patients outside the VA health care system.

This bureaucratic process has ramped up over the past two years as part of an effort to save money and retain patients within the VA, records show.

Thats tragic and jarring, said Ryan Gallucci, a national director for Veterans of Foreign Wars, after learning what the VAs manuals show.

I think it warrants an organization like ours asking more pointed questions and ensuring the VA is upholding the intent of the Mission Act, he added.

More than 9 million veterans are enrolled in the VA, the nations largest health care system, which is composed of more than 170 medical centers and 1,000 outpatient offices.

The U.S. is facing urgent demands from veterans for medical and mental health care. Veterans have faced almost 20 million canceled or delayed health care appointments during the COVID-19 pandemic, and the U.S. withdrawal from Afghanistan in August has caused crisis hotline calls to spike as former service members have struggled to process the unfolding events.

If I was still at the VA and someone showed me this in July, I would have ripped it to shreds and I would have said theres no way in Hell youre going to use this stuff.

Dozens of veterans and caregivers throughout Southern California described their struggles to access health care outside the VA since the Mission Act was passed: A partially blind skin cancer survivor was told to take a dangerous trip to the VA when a new lesion developed, instead of visiting his neighborhood dermatologist. A veteran with a seizure condition has waited years for a course of treatment outside the VA. Suicidal patients were cut off from what they considered life-saving mental health treatments by employees overwhelmed with paperwork against the advice of the VAs own psychiatrists.

In interviews, service groups and Congresspeople from both political parties said veterans should be offered the best health care available, and money should not affect the quality of care they receive.

We just spent trillions of dollars prosecuting this 20-year war in Afghanistan, and by comparison were arguing nickels and dimes in caring for the veterans who prosecuted those wars, Gallucci said.

The Mission Act has had financial consequences for the VA. Since the law was enacted, more veterans have left for other health care systems than the VA anticipated, forcing the government agency to shell out billions of dollars for private care. If the trend continues, the VAs own hospitals could end up with smaller budgets to spend on their services and staff.

In late 2019, the VA began the referral coordination initiative to return veterans to its hospitals. An internal department manual shows the changes are supposed to help the VA make good financial decisions and maintain funding of specialty care in the future.

Like the VA, private health care systems have financial incentives to retain patients and cut costs. The difference, experts said, is that veterans represent a unique and vulnerable population that the government has pledged to care for.

If they have a problem with the budget, they need to come and talk to Congress, said Rep. Mike Bost, R-IL, ranking member of the House Committee on Veterans Affairs. They dont need to go ahead and try to figure out how to take services away from our veterans.

Under department policy, VA doctors usually dont send their patients outside the health care system on their own, records show. They can make recommendations that go through reviews by other staff such as administrators, clerical workers or clinicians trained by hospital leadership who can cancel treatment requests and insist patients come to the VA instead.

Following the VAs new initiative, department hospitals have also set up select teams of health care personnel who can review medical records and use algorithms to decide if patients qualify for care outside the VA before interacting with those patients.

And for veterans ultimately approved for treatments elsewhere, the VA can require checkups at its hospitals anyway that includes veterans facing severe disabilities, burdensome drives or long wait times for VA appointments.

It basically defeats the whole purpose of the Mission Act, said Darin Selnick, senior advisor to Concerned Veterans for America, an organization pushing for veterans to have more access to private health care.

We need to be veteran centric, he added. Its about what the patient needs, not what the VA needs.

Selnick helped write the Mission Act, working in the Trump administration and the VA as a health care policy expert to implement the law until July 2020. He read excerpts of the department manuals obtained by inewsource.

If I was still at the VA and someone showed me this in July, I would have ripped it to shreds and I would have said theres no way in Hell youre going to use this stuff, Selnick said.

The VA received its largest-ever budget this year an amount that has doubled over the past decade. A national spokesperson said the department has sufficient funds to send veterans out for private care.

VA officials said they are following Mission Act requirements, and treatment decisions are based on patients medical needs. They added that the review process is supposed to ensure veterans can always get their care at the VA if they want to.

Hospital doctors and managers at the VA said they believe they can deliver the most effective care internally, because they offer high-quality services and can more easily coordinate treatments and paperwork.

Dr. Kathleen Kim, the San Diego VA chief of staff, said physicians sometimes incorrectly try to relocate patients for treatments her hospital can offer, and administrators are regularly educating them to help keep veterans at the VA.

Because of the nature of the Mission Act, the VA is sending a lot of care in the community, and frankly were worried that were not going to be able to pay our bills, Kim said.

The VA has approved over 12 million referrals for outsourced care since the Mission Act was implemented, including 5 million in the most recent 12-month period, according to data the department supplied. inewsource, through a series of records requests and direct inquiries, attempted to determine how many doctors requests for outsourced care have been denied by the VA, but the data provided was incomplete.

An August inspector general report highlights the personal impact the VAs administrative decisions can have. When the San Diego VA stopped paying for ketamine treatments at a private clinic, 28 mentally ill patients experienced unnecessary distress, the report found. Inspectors pointed out the drugs unique properties for combating severe depression.

Shortly after learning the VA wouldnt fund her treatments, a former Marine Corps pilot took her life.

They need to do right by these veterans, said Rainelle Wolfe, a full-time caregiver for her husband Kiowa, another veteran who was cut off from the private ketamine treatments over a year ago.

The San Diego VA has started offering a low-dose version of the drug that many veterans have not found therapeutic, including Kiowa Wolfe.

Now, the Marine Corps veteran spends most of his time lingering in bed, reliving trauma from the Afghanistan War.

Were not political, he said. Its not in our nature to be political. But keep politics and all this BS out of veterans health.

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Long before anyone realized she had cancer, Christine Russell walked slowly and painfully to the car waiting for her outside the San Diego VA emergency room. Her body hurt so much she could barely move.

The Lyft driver came out to assist her, then approached a nurse at the hospital entrance to ask if Russell would need any special care during her transport home. As the driver would later retell in a court filing, the nurse assured him the answer was no. The 39-year-old Navy veteran was crazy and imagining her symptoms.

It was mid-2018, almost two years since Russell first felt the unbearable pain in her body. It had become too difficult to drive or take care of herself, so she started paying thousands of dollars out-of-pocket for caregivers to look after her.

In her medical chart from late 2016, Russells VA physician wrote that she displays abnormal anxiety about her health, especially with an unwarranted fear of having a serious disease.

Russell said doctors told her she had post-traumatic stress disorder and refused to run tests until she tried psychotropic medications. Without a clear explanation for her escalating symptoms, Russell rushed to the emergency room more than a dozen times.

Finally, in the summer of 2018, her new primary care doctor agreed to order a scan of her chest. A radiologist noticed something unusual and asked for more tests.

The diagnosis: stage IV breast cancer.

Her case was complex. Russell suffers from severe allergies and sensitivities, which she believes came from her exposure to hazardous chemicals on a counter bioterrorism mission in the Middle East. Perfumes, highly processed foods and a long list of medications can aggravate her symptoms.

The VAs course of cancer treatment, chemotherapy pills, was excruciating.

It felt like my whole body was burning and on fire, Russell said.

The veteran was also experiencing hormone imbalances and pelvis pain, which needed tailored treatments that wouldnt cause their own unbearable side effects. Russell thought she would be better off getting care from specialists elsewhere doctors she could trust who could better address her complicated symptoms.

Over the next three years, the VA approved a slew of requests for Russell to see at least eight specialists outside the department.

Her symptoms slowly improved. But traveling to her appointments was impossible without the help of an at-home caregiver. The VA tried to provide her with aides, but they didnt follow the protocols Russell required for her sensitive immune system.

Russell hasnt been able to get a new caregiver since November 2020, the same month she was supposed to begin radiation therapy. With no aide to assist her, the veteran never got the treatment.

Months of correspondence with VA employees didnt resolve the issue. In February, Russell filed complaints with the VAs inspector general and the White House.

Thats when she lost it all.

In a three-page letter, VA administrators told Russell they would no longer pay for her health care outside the department and insisted she follow the code of conduct moving forward. They said she had engaged in disruptive behavior by intimidating social work staff with angry voicemails, using profanity and telling them they should be fired for not doing their jobs.

The multidisciplinary team reviewed your current status and confirmed that your health care is fragmented due to a disproportionate amount of care received in the community, the letter states.

The administrators said this care was no longer reasonable or necessary and would be limited to services that cannot be provided in a timely manner or are unavailable at the San Diego VA, as required by national policy.

The letter was signed on Feb. 19 by the director of the Veterans Experience Office, the section chief of primary care and the chair of the Disruptive Behavior Committee.

Russell was not consulted about her health care needs before the letter was sent.

It was a nightmare, Russell said, adding, They really didnt know me or what I had gone through or why I was even still alive.

If you are having thoughts of suicide, you can call the National Suicide Prevention Lifeline at (800) 273-8255 or the San Diego Access and Crisis Line at (888) 724-7240. Other resources are available here.

She described her reaction as a heavy mental breakdown as she struggled with thoughts of suicide and almost checked herself into a hospital for psychiatric care.

But she chose to argue her case instead.

Russell had done it before. When enrolled in the Navy, she filed a complaint about entry fees for military parties, which led officials to relieve her of her duties, escorting her out of Kuwait by military police. She then filed a whistleblower retaliation case, which was substantiated a year later by the Pentagon inspector generals office.

Im always about integrity, Russell said. And if I see something thats not ethical going on or if I see an error, because of what Ive been through, Im going to question that error.

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Armed with a copy of the Mission Act and her long clinical history, Russell told the San Diego VA that it was in her best interest to continue her medical treatments elsewhere.

inewsource wants to hear from veterans, caregivers and others who have interacted with the VA health care system. Tell us about your experiences with the VA by filling out this form.

The federal health care system will pay for veterans to get medical care from other doctors if the patients meet any of six criteria, including long drives or wait times for VA appointments.

The most contentious and some argue, most critical reason to send veterans outside the VA is when its in their best medical interest. That decision should be made by the veteran and their referring clinician, the law says, and can help address a patients unique needs.

For instance, a dermatologist might not specialize in a patients skin condition, or a veteran suffering from military trauma could be triggered by trips to the VA. In these kinds of cases, if it would improve a patients health, a doctor could send them to another medical provider.

Every patient experiences things differently, Russell said. And if theyre not getting all their needs met, then it is in their best medical interest to go somewhere else to have all their needs met.

Russell told the VA that stopping her current treatments would exacerbate her cancer symptoms and it would put her health care back in the hands of a hospital that didnt have the expertise for her conditions.

Her VA primary care doctor requested she return to her medical team outside the hospital, the veteran said, but warned the request probably wouldnt be approved.

At the San Diego VA, these kinds of treatment requests are usually reviewed by delegated authorities who can deny them if they think the hospitals own doctors can deliver the care.

Kim, the hospitals chief of staff, said these designated physicians go through regular training, so they understand all the services the VA offers and can make more informed decisions than other doctors.

Some of it, in my mind, is just a lack of knowledge about what the services are, Kim said.

San Diego County is home to roughly a quarter million veterans, the fifth-highest of any county in the nation. Its local VA health care system, which also covers the neighboring Imperial County, serves about 85,000 patients.

Kim, who oversees veterans health care across the region, said its often best for patients to come to the VA, even if thats not what their doctors want.

The reality is that does not trump the fact that the service can be provided at the VA within a timely fashion, Kim added.

For a complicated case, Kim and leaders at other VA hospitals can personally review medical records and decide whats in a patients best interest, documents show.

The VAs many hospitals can rely on different procedures, but nationwide, employees are instructed to follow handbooks. VA spokespeople were hesitant about providing them, saying they were intended for internal use.

Over the past two years, the VA has started putting treatment requests in the hands of referral coordination teams made up of registered nurses and other personnel, according to the manuals. A team member is supposed to spend 10 to 25 minutes reviewing a patients medical charts and deciding if they qualify for care outside the VA. They can also forward requests to designated physicians for approval.

The initiative shifts the referral responsibility so most doctors arent choosing to relocate their patients themselves, the documents show, which will decrease inconsistent and inappropriate treatment plans.

Hospital leaders are told to monitor health care costs as a key performance indicator of success.

That is not what the Mission Act says, said Rep. Bost of Illinois about the review process.

I understand my health care and my doctor understands my health care, he added. Between the two of us, we make the decision, not some (team) thats put in place by some government agency, nor should it be.

The National VA pointed to federal regulations stating it can conduct reviews of doctors decisions so long as they focus on health outcomes. Spokespeople also said that VA doctors still have the power to send their patients outside their hospitals.

To do that, doctors have to use a specific software program that offers a pre-established list of justifications otherwise its not considered a true medical decision, according to department manuals.

Once veterans are approved for care outside the VA, staff are supposed to call them and try persuading them to come to the VA anyway.

Employees are told to follow scripted language that outlines the benefits of staying at its hospitals and the burdens of leaving them. The scripts tell veterans they will be responsible for transferring their own medical records if they choose a different provider.

If you wanted to stay in the VA, you always can stay in the VA, but once youve made a decision to go to community care, youve decided for whatever reason its best for you not to, said Selnick, who helped write the Mission Act.

Doing extra hoops to keep you in the system is counterproductive.

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VA doctors are being overruled on veterans treatment plans. Heres why. - inewsource