Introduction to Guests and Call-in Information
Hey, we’re here today with co-host J. Basser, and our guest speaker today is Dr. Craig Bash, a Veterans Medical Advisor. If you have any questions or comments, feel free to call in. Our number is 347-237-4819. Once again, that number is 347-237-4819. You’ll hear a lady talking; just hit one while she’s talking or after she talks, and that will bring you into the queue with us. Feel free to call in.
Discussion on VA Processes and Concerns
Host: How are you doing today, Dr. Bash?
Dr. Bash: I’m doing good. I’m kind of worried about this new VA process and the way they’re going to try and process claims, you know?
Host: Yeah, yeah, we’ve been talking about that for a good while. Being new, it’s always a concern to me. It takes them so long to get the bugs worked out of things. Is it even feasible? Are they going to make the process better, or are they going to make it worse?
Dr. Bash: Yeah, the big thing I worry about is trying to put in new evidence. One of those pathways talks about how you can go for a higher level review, but you don’t get to put new evidence in. New evidence would be like my medical opinion or new medical data. Not having new evidence could really hurt the claim because oftentimes, the veteran doesn’t know what he needs, and medical testing gets better over time. They have a better chance of success with more evidence, I think.
Host: What I run into, Dr. Bash, all through my claim is that they were sitting on the evidence that I needed. By the time I’d get my hands on it, it would be several years down the road, and then I’d have to submit it. Coming from the VA, that’s problematic when they mention that you can’t put in new evidence. Many times, it’s years before you know it’s there. Of course, they can never find it. You have to give them the page number and everything else. You’ve got to nail it down for them and put it in their hand before they’ll consider it. Now, with medical evidence such as what you provide, that’s a little different. But the evidence in your records, they won’t go hunt for it. Even if you tell them it’s there, they’ll just say they can’t find it or it doesn’t exist. When you realize it really does, it could be five, six, seven years down the road.
VA’s Approach to New Testing and Evidence
Dr. Bash: Yeah, and some of the VA people told me that they won’t let them do new testing. In the old days, if they had a question about some issue, like if they needed a chest x-ray or an expert opinion, they would go out and get it. But they’ve told them now if the evidence isn’t there, just deny the case. If they won’t allow new evidence, it makes it very difficult for the veteran to be successful, like you’re talking about.
Host: Oh, they won’t be successful unless they get a VA doctor to work with them, which is not very likely.
Dr. Bash: So my philosophy now is to try and do a lot of these cases with the evidence upfront. In the old days, I might write an opinion and say this was this way because of this reason, and we might need a certain test. Now, we’re trying to get the testing done ahead of time. I might get a podiatrist, a neurologist, or a pulmonary doctor to weigh in behind me. By the time the claim is ready to be put in, I have my opinion plus three or four other doctor opinions with all the needed evidence.
Addressing Supplementary Appeals
Host: Well, the way it’s structured now, I can see that’s about the only way you have to go, isn’t it?
Dr. Bash: Yeah, try and get it upfront, which is hard because it’s costly and time-consuming. But they have a thing called a supplemental appeal. In the supplemental appeal, I might do another medical opinion with a new medical test, like a new chest x-ray or a new pulmonary function test. It has to be relevant because the VA is going to say if it’s not relevant, they won’t admit it. Another way to do it would be to get a second physician behind myself, so Dr. Bash says this, and Dr. Jones says that. That’s another piece of relevant information. You can do that three or four times, and after that, if you’re still in distress, you have to wait until the BVA, which could be years, like you’re talking about, six or seven years.
Host: That’s unfortunate too because if the VA would really honestly work with a veteran, they got his dog on B; they know what’s going on. They shouldn’t have to depend on the veteran to tell them. They have to figure it out themselves.
Dr. Bash: Yeah, and guys told me they’re trying to do things so fast that if the raider asks for information or tries to get a test, it slows the case down. They’re trying to put the workload on the patient, which is not right.
Problems with Short Medical Visits
Host: That’s what they’re doing. Many times, a patient doesn’t remember years back or something could have happened that might be in the records. I have found getting a proper claim file out of the VA is really difficult. I’ve gone through five different claims files on CDs, and each one gets larger. How does that work? Here’s additional information that could have been utilized from the get-go. There’s something seriously wrong with that. You should have a real-time claims folder that you can look at. I know they have them for some of the VSOs and stuff or claims practitioners, lawyers, but a veteran can’t get it.
Dr. Bash: Yeah, because once the veteran gets it, they can get it to some expert like myself. Secretary McDonald was very good at that. We used to write a letter to him, and he could get the claims file in a couple of days and send it out on a disc. The VA can do that if they want to, but they don’t seem to be invested in that process. A lot of the data inside the records is not being looked at. That’s one of the things I wanted to touch on a little bit. Bill wants to come on in a month or so and talk about CUE in a deep way. Some examples I find on the medical side are that they don’t understand the terms. For example, you have a little fracture in the spine called the pars defect, and the raiders just go by it without realizing it’s a spine fracture, which is CUE. Or things like reactive airway disease, which is a precursor for asthma, are often missed. They miss stuff with the nerve distribution in the hands for the spinal cord, confusing the C6 and C7 roots. Bill’s got a good case on that. Not only is the record not presented well, but the raiders aren’t looking at it as carefully as they could to find these details that can make a big difference in the case. They’re trying to get raiders to do cases in 30 minutes now, really pushing them fast to get things out the door, leading to more sloppy evidence.
Vascular Issues in Veterans
Host: They sure ain’t done mine in 30 minutes, but anyway, it’s a new process, Dr. Bash, and it’s got to be proven up. If they can’t prove it up, pretty soon we’re going to find out. When everything is piled in this new process—I keep wanting to call it fracking, but it’s the ramp program—everything’s going to pile up in the ramp program, and they won’t be able to meet the timelines they have indicated. That will tell the tale.
Dr. Bash: Yeah, I understand they’re already getting behind rather quickly.
Host: Well, I saw a case last week that came through. They’re already starting to talk about the relevant evidence. They said the information presented wasn’t relevant, so they’re going to discharge it. If the veteran puts in redundant evidence or literature, they’re just going to say it’s not relevant and push it back. That relevant evidence definition could be detrimental to a veteran for sure because there can be relevant evidence out here—articles, newspaper articles, memos, all sorts of different things. Just because the raider doesn’t think it’s relevant doesn’t mean that it isn’t.
Dr. Bash: The raiders are being pushed a lot on that M21 too. Bill was talking about that. He said the M21 often doesn’t relate very much to what the laws are, so the VA kind of makes up their own internal rules and puts them in the M21, and the raiders follow it, but they’re not necessarily backed up by the legislature. I’ve had arguments with them. I’ll say, “Look, if you just read this thing, here’s what it says,” and they’ll say, “No, no, that ain’t my interpretation.”
Future of the Ramp Program
Host: That’d be something so obvious that it’s crazy. But the ramp program, I think, will show its ugly face here in six months, less than a year. There’ll be 500,000 behind there waiting, and they’re just changing the names of the same problem, giving it a new name.
Dr. Bash: Jay Basser, you wanted to talk about vascular things, right?
- Basser: Yeah, cardiac heart disease and peripheral artery disease, things like that. A generalized discussion on those issues. There are a lot of veterans with these issues, and many don’t realize they have it or know what’s going on.
Dr. Bash: You have to think about etiology. One etiology is something toxic in the blood vessels. We talk about agent orange or diabetes with high sugar levels. Those toxic things can cause the vessels to react in an inflammatory way, leading to ischemic heart disease or ischemic changes in the legs for artery disease, arteritis obliterans. It’s kind of the same common pathway. Diabetes causes changes in the brain, leading to things like dementia and mini-strokes due to vascular changes in the brain. The organ responds the same way when it doesn’t have enough blood, losing function. In the heart, you might get angina or chest pain; in the legs, you might get claudication, where you walk a certain distance.
Host: Is there any treatment for hardening of the arteries, especially in your legs? Any special medication a person can take?
Dr. Bash: It depends on the cause. There are overlapping problems. High blood pressure can cause artery narrowing. High sugar and toxic exposure can also cause problems. If you have all three—sugar, agent orange, and blood pressure—you can treat part of them, get the blood pressure down, fix your cholesterol, and some of that stuff can be reversed. The toxin stuff like agent orange is more concrete, not as reversible. The body is always trying to make things better, so if you optimize the environment, you can improve things. For a single narrowing, they use stents and vascular surgery, but a lot of this can be chronic.
Host: When it gets bad, your feet go numb. I know several veterans who claim their feet went numb. That’s a serious situation, isn’t it?
Dr. Bash: Yes, it’s a huge problem. The small blood vessels that run alongside the nerves get damaged, leading to peripheral neuropathy, numb feet, loss of balance, and the need for a cane. You might get into high levels of SMC based on loss of use and balance. Peripheral neuropathy can lead to serious complications like amputation, infection, and even death.
Host: It’s not really possible to go in there and clean plaque out because it could cause a stroke or worse, kill you.
Dr. Bash: Yes, you can get a stroke in your leg, leading to the loss of your foot. Some processes are continuous, like a freeway jam, and others are more like a bottleneck at an intersection. Imaging and angiograms can help determine the exact issue and tailor the treatment.
Host: If you had both symptomologies but your cholesterol is in good shape, what would be the factor in that issue?
Dr. Bash: You try to separate cholesterol problems from those caused by agent orange or diabetes. It’s a process of elimination. If your cholesterol is good, it’s less likely the problem. Check blood sugars and toxin history. Manual testing and the ankle-brachial index can help determine the cause. Often, you have two processes causing similar results. In such cases, tie goes to the veteran. If it’s impossible to tell which one is the cause, the veteran gets credit for one of them.
Host: How would 35 years of uncontrolled hypertension fit in the mix?
Dr. Bash: High blood pressure causes similar issues, damaging the blood vessels and leading to plaque buildup. Chronic hypertension can contribute to the problem. The size of the cholesterol particles also matters. Smaller particles can get through the vessel wall and build up plaque. Medications and vitamins can change the particle size, improving the condition.
Host: That could affect your brain if you started getting plaque buildup there.
Dr. Bash: Yes, anything happening in the heart and legs can happen in the brain. MRI scans show tiny areas of increased T2 signal caused by hypertension and diabetes, leading to microscopic brain damage. This can be part of the aging process, where the brain doesn’t work as well due to blood vessel pathology.
Host: It’s a rough way to go, but most of that can be service-connected if you can evidence exposure to something or agent orange.
Dr. Bash: Yes, service connection helps with benefits and also helps identify the medical issues. Many patients are cared for by nurse practitioners and PAs, who might not find the root cause. If you get service-connected for a sophisticated process, it gets into your medical record. Then the nurse practitioner or PA can read about it and think about how to treat it.
Host: If they know what the symptoms are, they can treat them. If your foot is numb, it’s bound to be in the leg somewhere. If they treat the symptom with medication, you’d know pretty quick if it’s working.
Dr. Bash: Part of the problem is that visits are so short now. Patients come in with high blood pressure, and the whole visit revolves around that. New findings like a numb foot are often ignored. It’s a systemic problem in all medicine, propagated in medical schools. They tell students to deal with one problem and get the patient out the door. It’s not good medicine.
Host: I’ve seen that. I’ve told the VA about different things, and they just go right over the top of it and keep going.
Dr. Bash: The sector is doing the same thing because of the short visits. It’s bad medicine. Even in cases like mine, where I do ratings and medical opinions, I see many issues missed. Thank you all for listening. That ends this show. Now, I’m going to zoom off.