Cardiac and Vascular Diseases

After that, a cardiac patient very likely could have several conditions simultaneously. They could have cardiac disease, peripheral vascular disease, and calcific baset disease. These are three significant issues that, from my medical standpoint, require a lot of testing, different expertise, and treatment and surgical options. It’s a big deal.

The Importance of Thorough Medical Visits

When a veteran goes into their primary care team, they have to insist on being listened to. I know they want to get you in and out, but if you have several major issues, you want to discuss them all. Don’t let them rush you out the door because that’s your time too. They might say they can only spend 10 or 15 minutes with you, but if it takes more than that, it takes more than that.

Dr. Bash: Yeah, I think you’re right. That’s why in the old days, a doctor visit might take longer. I always tell my patients to make a list and give it to the doctor so he can look at it while he’s reading. Now, I think I would take that list and give it to the staff before you go. Fax it in and get it into your medical record beforehand. Send a list in afterwards and say, “Look, I had six problems, and the doctor only went over three of them,” and document this stuff. Otherwise, if the doctor or nurse practitioner ignores it and never notes it in the record, it was just a verbal conversation that never gets documented.

Host: You have to tell them to put it in your record. I’ve done that.

Dr. Bash: Yes, I’ve had patients that won’t leave the hospital until they see their record and make sure it’s correct for what they said and what they wanted to be done.

Host: It pays to always get a copy of your progress report. That’s beneficial. You have to be pretty determined and say, “You know, we need to talk about this.” Usually, when I go in, I take up an hour, but a lot of veterans don’t. They’re in and out. I wonder what in the world they go in there for—a drink of water?

Dr. Bash: Yeah, get a prescription refill and out the door, nothing else.

Host: You need to discuss all your issues, or as many as you can get them to discuss.

Dr. Bash: Another thing I do is if you have access to insurance, sometimes I’ll use two doctors. I’ll have one VA doctor and one insurance doctor. All doctors have blind spots, things they don’t see or understand or remember. So, get two or three issues with one doctor and two or three with the other, and get overlap. It’s better for your healthcare and prevents errors from happening. But many veterans only have one pathway with the VA, so they have to document their problems before they go and make sure they get covered.

Host: I have outside doctors and VA doctors. Between the two, they work well together. If my outside doctor says I need a prescription, he’ll fax it straight to my primary care team, and they fill it. I’ve managed to generate that, and it’s been beneficial for me.

Dr. Bash: That’s exactly what I do with my VA claims. I suggest the patient needs XYZ medical data, and the patient takes it to his VA doctor, who then orders the testing we need. It works perfectly.

Host: That’s the way it should work. Once your VA doctor gets to know you and knows you’re not clowning around, they’ll usually work with your outside doctor. I have Medicare and gap insurance. I don’t want to drive 100 miles to see my VA doctor and sit in the waiting room. I can go over here and see my doctor right now.

Dr. Bash: Yes, all those different medical training and expertise, we learn from each other and help each other. If one doctor has an idea, you run with it, and it helps the patient get better.

Host: You’re right. It’s a benefit for everyone if they work together.

Discussion on the RAMP Program

Host: Getting back to this RAMP thing, Dr. Bash, have you had much good experience with it or many dealings with it?

Dr. Bash: Like I said, the main thing I’ve seen so far is that they’re starting to talk about relevant evidence. They used to talk about new material evidence, but now I saw a couple of decisions where they’re talking about relevant evidence. They’re starting to ramp up, and a couple of the decisions I saw said positive evidence, none. They listed the laws that apply and the positive evidence but said there wasn’t any new relevant evidence. The decisions are going to be very cut and dry. When I send my stuff in, I’m going to document that this is positive supportive evidence and that this is relevant new evidence so that they have to address it.

Host: I read something about a new foster care program for veterans. Have you heard of that?

Dr. Bash: No, tell me what you know.

Host: Apparently, it’s where someone can take a veteran in, like a foster child, only it would be a foster veteran. I was reading an article on it. They started it up here toward Springfield, Missouri. They were taking in homeless veterans or those without anyone to care for them and started a foster care program in Mount Vernon, Missouri.

Dr. Bash: So, veterans can use their benefits for the family, and the family gets benefits from it?

Host: I don’t know yet. I just ran into this the other day and was reading it. For some veterans, it may turn out to be a good thing. I have to learn more about it, but it’s new and they’re working with it.

Dr. Bash: Over the years, we’ve kind of had that informally with veterans helping veterans, like your radio show and stuff I do. We all try to help each other. This is more of a housing thing with room and board.

Host: Yes, help them keep their meds straight. It’s not for every veteran, but for someone by themselves and up in age, a family taking them in could be very beneficial. It keeps them off the street.

Dr. Bash: Yes, you don’t want to see veterans out on the street passing away. It could be a win-win for some veterans. It wouldn’t work for me; I’ve got enough kids and grandkids to take care of me. Hope I ain’t too big to whip them, but anyway.

Host: That’s something new I ran into, and I wondered if you’d heard about that program.

Dr. Bash: No, I hadn’t come across it. I’ll have to check it out further.

Host: This RAMP program, it’s going to take some doing to get it proved up to me. I’ve got a bad feeling about it.

Dr. Bash: They’ve got that higher-level review too. If you go down that pathway, you don’t get to put new evidence in. I don’t know why a higher-level review would necessarily be any better than the first review if there’s nothing new to look at. It’s not going to be an in-depth analysis; it might not result in a different outcome.

Host: They go in for one thing and get rated for another. That’s good.

Dr. Bash: Yes, that turned out good for him. There’s also some psychology going on because if it’s in the same station, and if Smith is reviewing Jones’s work and they work together, it’s hard for them to be totally objective. They might go along with the other guy. It’s going to be hard to have a really good objective higher-level review.

Host: The problem I’ve seen is they look at the last raider’s decision and go from it. They don’t give their own opinion; they go from the last raider’s opinion, and that goes nowhere.

Dr. Bash: I had a case like that today. The guy had peripheral neuropathy and spinal cord disease with leg neuropathy and radiculopathy. The first raider 10 years ago saw the claim for peripheral neuropathy and said the record didn’t have the diagnosis and denied it in one sentence. The second and third raiders did the same thing. It’s probably going to be a CUE case because they obviously didn’t read the record.

Host: That’s what we’re running into. The first raider, the second raider, and the third raider all read the same thing and write the same report, changing a word or two, but it’s actually the same thing. It’s by design, and it hurts a lot of veterans.

Dr. Bash: Yes, it’s something that can keep you fighting for years before you get someone with a third-grade education to read it.

Issues with Current Rating System

Dr. Bash: Social Security is kind of going through the same thing. They’re trying to look for more objective things and using nurse practitioners and PAs. The fact that they use those types of trained people makes the analysis more shallow. They don’t go as deep, don’t have the same knowledge base, and don’t understand the interconnections of everything.

Host: They’re not educated to read these progress reports and medical reports. Usually, the data is all there; they’re just not paying attention to it or don’t understand.

Dr. Bash: Right, right. I’m hoping the RAMP program will work, but right now, I don’t have too much faith in what I’ve seen.

Host: My strategy is to try to get as much medical testing data as I can upfront. Put in relevant testing and evidence. That’s the only option I see.

Dr. Bash: Yes, get it all in upfront. Usually, there are other things lurking in the background, but at least if you can get the ball rolling, someone will pay attention to it.

Host: If they don’t look at it on the first claim, and you reply with another claim and new evidence, maybe that’s the way to do it too. It’s cumbersome and you lose retroactive pay, but you might get the rating right.

Dr. Bash: They do believe in retroactive pay. If you get a speedy reply, it wouldn’t mean much, but if it goes on for years, it’s a big deal. The longer a claim runs, the harder it is to get a satisfactory result. That’s the way the system works. They might play with it for a while and maybe get it squared away, but they’re already having quite a backlog on RAMP.

Host: I believe you. I see these short decisions now. They list the evidence, like Dr. Bash’s DBQ and letter, but they won’t describe it or expand on it in the decision. That’s another fertile place for CUE because if things in my letters or the medical record aren’t considered, that’s a CUE. In the speed they’re trying to do these cases now, there will be many places where they’ll make lots of mistakes.

Dr. Bash: Yes, I guess the way to fix that is if RAMP sends out all these decisions that are error-filled, there might be a huge increase in CUE cases. The VA will have to pay those cases anyway, so maybe that’s how veterans can get a correct result.

Host: Let’s hope there’s some sort of recourse because it sounds like they’re already doing their thing. If there’s no evidence, the only option is to deny it. The veteran has to appeal. I don’t know if it goes back to the regular claims process, but sooner or later, I’m surprised they haven’t eliminated the claims process after switching to RAMP.

Dr. Bash: I think you’re stuck with either filing a new claim with new evidence or going to the BVA, which could take a long time.

Host: That’s going to eat up everyone’s retroactive pay if they do that. The VA still comes out on top.

Dr. Bash: Whether it’s intentional or not, that’s the way it’s going to work. It might get hard to get lawyers to help because if they eliminate all the retroactive pay, there’s not much incentive for lawyers to help. Veterans might have a harder time getting legal help.

Host: That’s another good point. I don’t know what it’s going to take to make this thing work. The VA tried to get me to go RAMP. They sent me paperwork, and today they wanted me to switch over to RAMP. I said no. It’s been in the system so long now, switching to RAMP wouldn’t make a difference. They’re really pushing RAMP.

Dr. Bash: Yes, they are pushing it.

Host: I told them no. I read through the paperwork, didn’t like what I read, and left my claim in the process it’s in. I expect them to do their job properly. That’s all you can tell them. Some people may be okay with RAMP, but it wasn’t for me. I’m going to fight it out to the end, but they’re pushing RAMP really hard.

Contact Information

Host: Well, Dr. Bash, we’re about out of time. Do you want to give us your contact information?

Dr. Bash: Yes, the best way to get me is Google Dr. Craig Bash. You can find all my websites and videos. My website is drbashdo.com, spelled out D-O dot com. My scheduler is Skip, at 925-381-7561. Call Skip up, tell him you want to talk to Dr. Bash, and he’ll set you up a time. Usually, it’s the same day or next day. You can text him or call him, and he’ll hook you up with me.

Host: Good deal. Bill is fixing to come back. When did you say he was coming back?

Dr. Bash: Bill’s going to come back in a month, I think. He has a couple of good CUE cases we can talk about in great detail with the VA regulations and the manual.

Host: He’s sharp as a tack, isn’t he? He knows those VA laws.

Dr. Bash: Yes, he does. He’s been doing it for a long time. He worked at the local office, the BVA, the PVA at the appeals level, and did a lot of work at the court. He worked at the VA central office for decades, so he has lots of experience.

Host: He does, and it shows. That’s really good. We’re certainly glad to get him on too. You gave us a lot of good information here, Dr. Bash, and we appreciate it. We want these veterans to know everything they possibly can and let them know they’re not alone. There are people trying to give them information. Thank you all for listening. That ends this show, and now I’m going to zoom off.