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A Warning

By John Ketwig

I have been a lifetime member of VVAW for many years, and I have recently become aware of a problem that seems to be causing many fellow veterans to have severe difficulties in obtaining outside or "Choice" medical care through the VA.

The VA Choice option occurs when a veteran lives more than 40 miles from the nearest VA facility, or when a VA facility does not offer some type of specialized care. In my case, I was having problems with a lower back condition that caused intense pain when I would bend at the waist. I lived with this condition for many years, attributing it to an occupational hazard caused by bending over far too many fenders to peer under the hoods of far too many misbehaving cars. Over the past year, however, I found my legs were often numb and clumsy, and my feet were constantly cold, although they felt warm to the touch. I was uncomfortable and losing sleep, and, as these problems got progressively worse, I began to fear that I might end up in a wheelchair. I had described my lower back pain at every appointment with my VA primary physician over the past few years, and finally the pain and numbness became so acute that I insisted something be done. I was finally allowed to visit the local hospital's physical therapy center twice a week for a varied regimen of exercises, massage, and heat and electrical stimulation treatments. That's standard medical practice these days, resulting in a vast network of physical therapy centers in every town and hamlet across the United States. Friends tell me these treatments are sometimes effective, but they did very little for me. I reached a point where walking was very uncomfortable, but standing still for a few minutes made my legs go to sleep. I was constantly afraid of falling, so I insisted my VA doctor do something.

Years before, I had undergone a series of steroid injections into my spinal column by a civilian orthopedist in Pennsylvania. The shots made my pain tolerable, so my primary physician seized upon that and assigned me to undergo a similar series of shots at a local pain management clinic. Those shots were effective in minimizing the pain for a few weeks, but they did nothing for my numbness or cold feet. A second set of "facet" injections caused severe sciatica and leg tremors. My condition was getting worse, and I insisted my primary do something. She finally seemed to understand the seriousness of my problem, and requested that I see a neurologist. That's when things got interesting.

The request had to be reviewed and approved by the VA Medical Center hospital in Salem, Virginia. It is very common for vets in central and southwest Virginia to be sent to the hospital in Salem for treatments, and I have a long and very satisfactory history with that hospital. For all the familiar horror stories that vets tell about the VA medical system, I have to say the Salem hospital is very highly regarded by all the area veterans. It is a clean, efficient, friendly, and well organized place with a caring and very capable staff. It could use a bigger parking area, but that's about the most negative thing anyone can say.

Within a few days, I received a call from Salem to say that they do not have a neurologist on staff, and I would be hearing from a company called Health Net who would set up a convenient appointment for me with an area "civilian" neurologist. After the nationwide appointment scandal that rocked the VA system in 2013, Congress had revamped the outside or VA Choice services program throughout the VA system, and enlisted the aid of this company to facilitate convenient and timely appointments with area specialists to take better care of veterans.

Sure enough, a few days later I had a call from a Health Net representative. She said she was calling from California, and asked a few questions about my medical condition and my travel limitations. I live between Lynchburg and Roanoke, Virginia, both about 20 miles from my home, so I said I would be willing to travel about thirty miles to visit a neurologist. The caller, Helen, promised to get back to me in about three days and gave me a toll-free number to call if I didn't get a call. After hearing nothing for more than a week, I called the number and was assured that I would get a call within about five days. Again, there was no call and I contacted the Health Net number again, and again. Each time they promised to call me within a few days to set up an appointment, but the call never came.

At that point I spoke to the person at the Salem VAMC who had originally called me. She promised to contact Health Net on my behalf, and the next day she called to reassure me that Health Net would be calling me immediately. The call never came, and I called Salem again. This time the lady seemed less confident, and she explained again that this was relatively new program put in place by Congress in response to the VA appointment schedule scandal about a year ago. There had been some problems, but she promised to contact Health Net again and discuss my case with them. After about two days she called back to report that Health Net was no longer returning her calls, and she confided that VA facilities "all over America" were experiencing the same problems. She suggested I contact the Salem VA Hospital's Patient Advocate, which I did.

I had met the Patient Advocate previously, and I knew her to be an upbeat and optimistic personality who genuinely cares and regularly solves problems. When I talked with her by phone about the Health Net situation she sounded tired. She called me back a few days later, and she seemed to be choosing her words carefully. She was not getting any cooperation or help from Health Net, on my case or many others. I explained that I was hurting, and asked if she would be offended if I contacted my Congressman. Her enthusiasm was startling, and she became very emotional in explaining that I was far from the only area veteran experiencing this problem. In fact, almost in tears, she suggested that Health Net was the only provider of outside medical care available to the VA across the country, and Health Net had stopped all communications with VA offices nationwide. Again, this was a person who had helped me in a previous situation and I knew she was sincerely interested in helping veterans get the medical care they deserved. She was clearly distraught because a lot of vets in need were not being cared for.

I contacted a personal friend who works in a VA medical center in another locality, and when that person heard the reason for my call they became very emotional. Health Net, or specifically Health Net Federal Services, LLC based in Arlington, VA, has become totally unresponsive, and currently is providing no services, and refusing to return phone calls or communicate, or cooperate with VA personnel in any way. My friend, who wishes to remain anonymous, explained that previously the VA contracted directly with the individual doctor or his staff, to arrange and pay for "outside" medical services. Payments were made according to a standardized VA rate schedule. For instance, to treat a broken arm they might pay $100. The doctor's office was paid directly by the VA to deal with that specific medical situation. Today, as a "third payer" or "middleman", Health Net authorizes all VA Choice medical services, contracting with the physician in advance on a case-by-case basis. According to my friend, since taking on this responsibility Health Net has developed a nationwide reputation for paying the physicians approximately HALF, or $50 in my example, of what they had been used to getting. Assuming that Congress contracted to pay Health Net a considerable amount to administer these cases, the VA community feels that the company is pocketing those fees PLUS the other half of the medical fees, maximizing their corporate profit to an unethical degree. As a result, doctors are refusing to accept these insufficient payment rates and are refusing to accept any and all Health Net appointments or patients, and veterans are left without medical care. Meanwhile, Congress feels they have solved the problem, and are reluctant to investigate this current situation.

I wrote very similar letters to both of Virginia's US Senators and my Congressman, and immediately received form letters from all three stating that they had passed my letter on to the VA Medical Center in Salem! One Senator assured me that he had taken measures to deal with the VA's appointment scandal and backlog, and a northern Virginia company would now be handling all "outside" appointment scheduling. Health Net, as noted above, is headquartered in Arlington, Virginia. The other Senator's area representative had a Town Hall meeting locally, and I was able to speak with him and explain the situation, and I was able to speak with the Senator's specialist on veterans' issues. I have also spoken with the Congressman's staff member who specializes in veterans' affairs on a number of occasions. Again, both Senators and the Congressman immediately responded to my letters by assuring me that they had contacted the VA hospital in Salem on my behalf, which told me they had not read my letters in detail nor understood the problem in the slightest.

Meanwhile, none of this was helping my medical situation at all. My contacts within the VA system were not at all optimistic that I would ever be authorized to see a neurologist via the VA Choice process. At the urging of a friend who had been battling similar lower back problems for years, I very reluctantly made an appointment to see a highly respected spine specialist orthopedic doctor using my Medicare and Medicare supplement coverages.

A bit of background is necessary if the reader is to understand my situation. I am the stereotypical angry and bitter Vietnam veteran. When I got out of the Army I wanted nothing to do with the United States government ever again. I enjoyed good medical benefits as employment benefits throughout my career, although I rarely took time away from work to visit doctors. When I retired and my wife and I found ourselves without any medical coverage whatsoever, I reluctantly applied to the VA for benefits 42 years after my discharge. We lived in New Jersey at that time, and a state veterans' affairs office helped me to submit the requisite paperwork. After a series of long talks, I was persuaded to apply for PTSD benefits, and after a lot of testing I was approved for a disability rating that included free medical care for myself for life. The medical care I received at the VA facilities in New Jersey was certainly not on par with what I had been used to in the insurance-plan sector, but when we moved to Virginia I found the VA care equal to or better than any I had ever known. Until, that is, my back problem.

Back in 1966, at the age of 18, I was into cars and rock 'n roll music. I had absolutely no interest in becoming a soldier, but the draft was relentless and finally I was boxed in. Very much against my will, I enlisted. This added a third year to my obligation, but I would get a choice of training and I hoped I might avoid Vietnam. Of course, when we entered the service we were told that our benefits would be wonderful.

So, finding myself unable to access those benefits, I took the cards out of my wallet and met with the spine specialist at the expense of my Medicare supplement policy. He immediately ordered an MRI, as he considered the MRI done at the Salem VA hospital fourteen months earlier to be outdated. Again, I had to apply the expense to my Medicare supplement insurance.

However, at the same time I decided to be as relentless as the Selective Service folks back in the 60s. I can report that the squeaky wheel sometimes gets the grease. After contacting all of my Senators and Congressman repeatedly, I was surprised to receive a phone call from Health Net's Texas office asking if I would consider visiting a neurosurgeon 49 miles from my home, as I had indicated that I would only travel a maximum of thirty miles. I informed the caller that I had gone outside the VA system due to the delays, and I was seeing a spine specialist instead of a neurosurgeon. She took all the information, and within half an hour (!) called back to inform me that Health Net had been in touch with my specialist, and they would be covering my consultation visit and the surgery if it would be necessary!

A few days later I did receive a letter from Health Net authorizing me to visit the spine specialist for a consultation. The letter was very specific that that's all it was authorizing, but it was a start. The doctor took lots of time to explain that I was suffering from spinal stenosis, a buildup of arthritis, bone spurs, and calcium deposits around the openings where the nerves come out of the spine and head down toward my legs. Pressure on those nerves was causing my discomfort, and he assured me that he could make things better by surgery. He also assured me that his office had worked with the VA for years, and he could get them to cover the costs of the operation. He was not familiar with Health Net.

Still in negotiations with a variety of Senators' and Congressman's staff specialists, I made the appointment for the surgery. Soon after, I received a call from a lady from the Salem hospital's administrative staff informing me that the hospital had responded to a number of inquiries from Senators and Congressman, and she was pleased to tell me my surgery had been authorized by Health Net! A few moments later she confided that the folks from Washington had not questioned the hospital about its experience with Health Net whatsoever, but copies of my letters had been circulated to various departments throughout the hospital and I was "a hero" for taking the problem to the highest authorities, and for explaining it so clearly. I was shocked. She made it clear that my case was most exceptional, and that a very large number of deserving veterans were still unable to get the medical care they need because Health Net refused to assist or communicate with the VA. She also assured me that it was a nationwide problem, and that VA personnel all across the country had continuously reported the situation to their upper management, but no one had seen any progress on the matter.

A few days before surgery, I went to the hospital for blood tests, an EKG, and an explanation of what was going to happen. Sure enough, when the discussion turned to payment, the hospital records showed that the billing was to go to the VA, with no mention of Health Net. The doctor's office had made it clear that the transaction would have to go through Health Net, so I drove to the doctor's office to straighten things out. I was immediately told the doctor's office had nothing to do with the hospital bill, and given a toll-free number to call the appropriate office at the hospital. I went to the car and dialed my cell phone, and they informed me that the doctor's authorization to do the surgery would include the costs of the hospital stay and the anesthetist. I went back to the receptionist with this information, and she made it clear she did not appreciate me doubting her information. Wouldn't you think by now people would know better than to get ignorant when dealing with a Vietnam veteran? I demanded to see a customer relations representative or a supervisor, and was told that wouldn't be possible. I got louder, and insisted. Finally, a lady came down from upstairs, and she actually commandeered someone's office, ushering me in and telling the occupant to "take a break." We had a long and very detailed conversation, she was completely sympathetic to my situation and very familiar with the Health Net problem, and I was assured that the doctor's authorization would indeed include the hospital and anesthetist charges. However, at that moment the doctor's office had not actually received the authorization! The lady pulled up my case on the computer screen and contacted the hospital, informing them of how the billing would have to be written. I left feeling more confident, and the next day I got a call to inform me that the doctor's office had indeed received the authorization from Health Net, and that the hospital had agreed to prepare the bill accordingly. I should point out that this a huge orthopedic practice with many doctors, and seven full-time receptionists to handle the constant influx of patients through the front doors. I was told that, since Health Net had taken over the scheduling of VA Choice patients three years earlier, mine was the FIRST procedure to be authorized by Health Net in the practice's experience.

I am happy to report that the surgery appears to have been completely successful! I am still recuperating and sore, but when I woke up from the anesthesia my feet were warm, the first time in over a year. My legs are not numb, and the pain in my back is very different. I am confident that when my bones heal from the effects of the surgery I will no longer have the lower back pain that has plagued me for years.

I am not at all confident that I will not receive a great big bill in the mail related to my surgery.

In the few days since the surgery I have spoken with a variety of people within the VA system. They assure me that my case is the ONLY one approved by Health Net, and that they are still completely unable to communicate with Health Net to facilitate medical care for other veterans. I believe Health Net tossed me a bone to shut me up, and of course I should just be quiet and grateful. I can tell you honestly that I have had VA officials cry because they are so frustrated at their inability to help other vets. I would feel guilty if I sat back with an attitude of "I got mine" and let the matter drop. I was copied in a letter from Dr. La Puz, the Director of the VA hospital in Salem, to Senator Tim Kaine, assuring the Senator that I was having the surgery and everything was fine. I wrote to both reiterating the problem, and I am confident that Senator Kaine's assistant has begun to appreciate the problem and dig a little deeper. She has contacted a number of people at the VA, and seems to be pursuing the matter. I doubt I will hear from the Senator again.

I must point out that my many calls to VA people revealed that they are, like most government employees, sometimes severely limited by established regulations and protocols. For instance, it seems that the medical guides suggest or require that a neurologist should be consulted to deal with lower back pain and any resulting numbness, etc. At least two VA health care professionals expressed surprise to learn that a spine specialist can deal with neurological problems related to the spine. One of them called to check on my results after the surgery, and seemed optimistic that my experience might serve to bring a lot of additional doctors into consideration for future VA Choice procedures like mine all over America.

There's no secret that the greatest status symbol in America today is a lucrative Defense contract. I've recently read about a small roller that is available at The Home Depot or Lowe's for seven dollars, but is billed to the Pentagon at $1,678. I'm sure the management of Health Net are very satisfied with their profits from the contract to administer the VA Choice appointment process for the VA, and if allowed to continue as they have been going, they will be just one more typical all-American corporation with a big Defense contract making huge profits while they systematically and unethically under perform. Some would say "That's what makes America great!"

I wonder how many VVAW members and other veterans across the country have found that their outside or VA Choice health care has been delayed by Health Net Corporation? I believe the VA personnel I have encountered are sincerely trying to provide quality medical care to the area's veterans, but this company, and the VA's protocol requirements, are not allowing that to happen. This is a long article, but if it helps one veteran to realize that his frustrations in getting the medical attention he needs are not unique, and that the people at the VA may actually be just as frustrated and victimized by this situation, maybe a few more letters to Senators and Congressmen will help. When I get my twenty copies of The Veteran, you can bet that a large proportion of them will be distributed around the Salem VA hospital. VVAW has a long history of leading the fight for veteran's rights, and I hope this article might help to continue that proud tradition. Fight on, brothers!

John Ketwig is a lifetime member of VVAW, and the author of ...and a hard rain fell: A G.I.'s True Story of the War in Vietnam. First published by Macmillan in 1985, it is still available at most bookstores.