Monday, July 21, 2014

We’re Giving Our Veterans Unacceptable Care

By Austin I. King, MD
President, Texas Medical Association

It’s an eight-hour drive from the Rio Grande Valley to my office here in Abilene. It takes just as long for someone to drive from Abilene to Albuquerque, New Mexico. And that’s just part of the problem that military veterans here in Texas face when they try to get health care from the U.S. Department of Veterans Affairs ― the VA.

We’ve all read and heard about the long waits our veterans must endure to see a doctor. A VA audit found that nearly 60,000 new patients nationwide waited up to three months for care. In Texas facilities, the average wait time for a new patient to get a primary care appointment ranged from 31 days in Amarillo to 85 in Harlingen and McAllen. “It was worse for specialty care patients at clinics in Harlingen and McAllen, where the wait was 145 days — the longest in the nation,” the San Antonio Express-News reported.

And what does that have to do with the eight-hour drive from Abilene to Albuquerque? The VA health system is divided into regions across the country ― and some of those regional lines don’t make much sense. We have a small VA hospital and clinic not far from here in Big Spring, Texas. It’s set up to handle routine care for veterans. But to see a specialist, or to have serious surgery or to undergo any in-depth testing, you have to go to Albuquerque. Out here in West Texas, even though it takes only a few hours to get to Dallas or Houston or San Antonio, our big VA regional hospital is in Albuquerque.

If you’re in a huge bureaucratic system like the VA and you’re assigned to a hospital 600 miles away, that’s just the way it is. There’s no logic to it, it’s just the system.

As an ear, nose, and throat doctor, how can I tell a 92-year-old World War II vet with a lump on the side of his neck that he has to go all the way to Albuquerque to get that lump looked at? Can he drive that far? Can he even afford the gas for the trip? It’s just heartbreaking.

The bottom-line problem is this: The VA just doesn’t have enough doctors to meet the demand for medical care. For decades, the U.S. Congress hasn’t given the VA the money it needs to hire those doctors. With about 2.5 million vets returning home from the wars in Iraq and Afghanistan, the demand has grown even larger ― further overloading the VA.

The news reports about the waiting lists ― and the veterans who died waiting to see a physician ― peaked last month just as doctors from Texas and around the country joined me in Chicago for the annual meeting of the American Medical Association. At the urging of Texas physicians there, the AMA voted overwhelmingly to ask President Obama to take immediate action to provide timely access to care for veterans using the health care sector outside of the VA system until the VA can provide that care itself in a timely fashion. AMA also urged Congress to enact long-term solutions rapidly so eligible veterans can always have timely access to entitled care.

Our veterans have stepped up and served our country, so physicians want to be able to step in and serve them. It is tragic that our veterans have been forced to wait for the health care they need and deserve, so Texas physicians and our colleagues across the nation want to help care for them until the VA can right the ship.

As part of this plan, the Texas Medical Association created a registry of private physicians across the state who are willing to see veterans in their offices. We share the registry with community groups that work with Texas veterans and with the medical directors of VA facilities in Texas.

More than 325 Texas doctors have already signed up. But even if we had every single Texas physician on that registry, it wouldn’t bring care to our veterans any faster without some action in Washington. Congress is actually working on a bill to bring some changes to the VA system, but it will take months before it passes, and even longer before it does any real good.

That’s why we asked President Obama to help. With the stroke of his pen, the president could issue an executive order establishing an emergency system where veterans could get the care they need from private doctors quickly and easily. Unfortunately, more than a month has gone by with no action by his administration and no response from the White House. Each passing day carries the real-life risk of death and worsening illness for the men and women who have served our country so bravely.

To be fair, the idea of local physicians helping to provide care for patients in the VA system isn’t exactly new. In fact, officials from the largest VA network in Texas reached out to TMA to try to patch some of the current holes in their system when they heard about our registry. (We haven’t heard from the other networks yet, though.) The VA has turned to private doctors in the past when they just didn’t have specific specialists they needed in certain communities.

It just hasn’t worked very well. At all.

Once again, it’s because we’re dealing with a closed, bureaucratic system that has trouble seeing beyond its own walls.

Consider, for example, San Antonio, a city with a long and proud history of military service and 150,000 veterans. More veterans live in Bexar County than just about any other county in the nation.

A physician friend of mine in San Antonio tells me there’s almost no interaction between local doctors and those who work at the South Texas Veterans Health Care System and the Audie L. Murphy Memorial VA Hospital. They don’t know each other, and they don’t often work together.

Doctors across Texas who have tried to contract to provide medical care that the VA needed tell me the same story. Here’s what they find:

  • The VA has a very large electronic medical record system, but there’s no way for someone outside the VA to get information into or out of that system. This means the doctors either have to wait for paper records to be printed and delivered or they have to repeat tests and procedures whose results are buried by the VA bureaucracy.
  • Getting clearance or approval to conduct a test or perform a procedure on a veteran is a mysterious and time-consuming process. It can take days or weeks to get the request to the right person inside the VA and get an answer back out.
  • Even something as simple as writing a prescription for medicine and having it filled is complicated. The VA only allows veterans to use a VA pharmacy ― which can be miles away.
  • Finally, getting paid for providing care for a veteran is maddeningly difficult. You have to fill out the right government forms correctly, make sure they get to the right office, and pray that the local VA has enough money left in its budget to pay the bill. And wait.

Former VA Undersecretary for Health Kenneth Kizer, MD, says this is not a new set of problems and the VA knows those problems are making it hard for them to do business with private physicians.

“Many of these private providers are happy to take care of veterans,” Dr. Kizer said in an interview this week with Kaiser Health News. “They feel an obligation, and they’re willing to do it for whatever the payment amount is. But it’s just getting it that is so difficult and frustrating for them.”

Monira Hamid-Kundi, MD, is a surgeon in Baytown, Texas, who saw an Iraq War veteran in the emergency room with severe pain from rectal cancer. She and the patient had to wait five days before they could transfer him to the VA hospital.

“I will never forget that gentleman’s face, and I never will forget how he looked at me and how he just wanted to be relieved of the discomfort that he had, and there was nothing much we could do except give him pain medication,” Dr. Hamid-Kundi told TMA. “If this had been a non-veteran, we would have been able to offer him more. But because he was a veteran, he actually fell down to the bottom of the line.”

As a professional who is trained to relieve my patients’ pain and suffering, this is unacceptable.

As an American who is so grateful that these men and women were willing to put their lives on the line to defend our freedoms, this is unacceptable.

On behalf of the more than 47,000 members of the Texas Medical Association, I once again urge President Obama to take immediate action to relieve this crisis ― to allow private doctors to provide care to veterans quickly and free from bureaucratic delay. And I urge Congress to move as fast as it possibly can to really fix this crisis.

Anything less is unacceptable.

Austin I. King, MD, is an ear, nose, and throat specialist (an otolaryngologist) in private practice in Abilene, Texas. He is the 149th president of the Texas Medical Association. 

Average Number of Days to Wait for an Appointment at a VA Facility
From VA Access Audit, June 9, 2014

Primary Care Wait Time
Specialty Care Wait Time
Mental Health Wait Time
New Patient Established Patient New Patient Established Patient New Patient Established Patient
Dallas 60.3 5.4 58.9 6.2 49.9 5.9
San Antonio 36.7 2.6 42.6 1.0 29.8 2.0
Temple 49.9 7.6 54.3 5.5 35.9 3.0
Valley 85.2 12.5 145.2 1.2 55.4 1.8
Houston 44.1 1.9 58.1 1.1 39.4 0.6
Amarillo 31.2 2.0 40.5 2.5 60.9 1.1
Big Spring 37.7 12.1 53.1 6.4 33.0 4.1
El Paso 35.1 1.7 89.6 4.7 60.1 16.0

Source: www.va.gov/health/Access_Audit_Data_Archive.asp

Thursday, July 17, 2014

The Role of Prevention and Population Health in the Texas 1115 Medicaid Waiver ― Part I

by Jeffrey Levin, MD, MSPH; Daniel Deslatte, MPA; Joseph Woelkers, MEd; and Kirk Calhoun, MD

from The Center for Rural Community Health
at The University of Texas Health Northeast

The following invited remarks were prepared for the Code Red Task Force deliberations as it updates its recommendations. The comments were delivered on June 18, 2014, in Dallas, Texas. They are presented here as the first of a brief two-part series.

Background and the Waiver

There is little doubt that there are many definitions of public health, and in recent times, the Institute of Medicine (IOM) has given careful consideration to the interface between major population health challenges of the last century and the present-day medical care delivery system in the United States. It has commented that, “Creating health more efficiently throughout the population will require both addressing the social and environmental determinants of health and taking a more systematic and concerted look at the clinical care delivery system’s effectiveness in creating health through the services that it delivers.” (IOM, 2012)

There have been a number of recent trends that have shaped public health and prevention in the industrialized world. (Wallace, 2007) Included among these have been:

  • Increased incorporation of business and administrative practices into prevention and public health service delivery;
  • Changes in the definition of the group or population, the fundamental unit of public health;
  • Enhanced conceptualization and measurement of personal health status;  
  • Increased codification and interpretation of scientific findings relevant to prevention and public health;
  • Establishment of goals for communities to attain improvement in health status; and
  • Application of more advanced community health information systems. 

(Wallace, 2007)

In the short time since the Code Red 2012 report, Texas continues to witness an unprecedented pace of change in approach to health care delivery for the Medicaid population and uninsured. The complexity of this change is tied to a combination of many variables, including growth in traditional and nontraditional health care workforce development initiatives, early unfolding of the Affordable Care Act, and implementation of the 1115 Demonstration Waiver or the Texas Healthcare Transformation Quality Improvement Program.

The Role of Prevention and Population Care

Over the last two decades, it remains clear that our nation and our state continue on an unsustainable trajectory in which resource utilization is outstripping availability. By any number of measures, the health condition of Texans is poor. As articulated in Code Red 2012, “significant improvements in health outcomes and the reduction of healthcare costs will require additional investment in public health and prevention.” (Code Red, 2012)

Though this statement, on its face, may seem or appear quite intuitive, its implications are not. In a society accustomed to receiving medical care rather than health care, we have a tendency to focus disproportionately on identifying health problems in their advanced stages. We concentrate our resources on managing those problems (referred to as “tertiary prevention”) with considerable limitations of return on this investment, whether in terms of mortality, morbidity, or length and quality of life. The end result has been a growing recognition of our need to push forcefully upstream along the continuum of prevention if we are to make substantive progress toward achieving the goal of “significant improvements in health outcomes and the reduction of healthcare costs.” That upstream focus must be on risk factor intervention along the continuum (referred to as “primary prevention”) or early identification and management of disease (also known as “secondary prevention”). Though we cannot stifle new discovery to identify and clarify risk factors, there must be a more balanced approach. We should examine and derive a scientific and evidence-based approach to population and public health practice while advancing prevention through health promotion and health maintenance.

In the context of medical delivery systems, we are accustomed to thinking about these three levels of prevention in a very classic or traditional sense. Paternalistic providers advise patients (“you need to quit smoking”), order screening tests to uncover early disease (if people have access and participate), and prescribe (“take this medication”).  We fail to identify the many gaps or opportunities for intervention success by not taking a system-approach or considering the continuum of health care delivery and prevention. The perspective is a fragmented one, inwardly focused more on the process rather than on the population or people. This fragmented system is perpetuated by its very design, up to and including mechanisms for funding and reimbursement of care. Is it any wonder that overuse of hospital emergency departments and readmissions to hospitals have been significant contributors to our high cost of medical care? The corollary then to a need to invest in public health and prevention was also eloquently stated in Code Red 2012, namely, that it “can be achieved by redirecting funds from high-dollar, low-value services and delivery methods.” (Code Red, 2012)

In short, it is imperative that we, in the medical and public health communities, work together aggressively to shift from perpetuating an unsustainable system of care, intensify our focus on primary and secondary prevention efforts in a broader sense, and completely transform our systems of delivery to that end.


Code Red.  (2012). Code red: The critical condition of health in Texas, 2012.  Accessed June 8, 2014, at www.coderedtexas.org/files/Code-Red-2012.pdf.

Institute of Medicine (IOM). (2012). For the public’s health: Investing in a healthier future. www.nap.edu/catalog.php?record_id=13268, p. 35.

Wallace, RB. (2007). Public health and preventive medicine: Trends and guideposts. In Wallace, R. B., & Kohatsu, N. (Eds.), Maxcy-Rosenau-Last public health & preventive medicine (15th ed., pp. 3-4). New York, NY: McGraw Hill Medical.

Wednesday, July 16, 2014

TMA Repeats: President Obama, Let Private Docs Help Care for Veterans

Calling it a “life or death issue,” TMA President Austin I. King, MD, repeated his urgent request for President Barack Obama to take immediate action to enable private physicians to care for U.S. veterans.

For the second time in a month, TMA is seeking an executive order from the president to establish a simple system for non-Veterans Affairs (VA) physicians to care for men and women who served in the American military.

“Mr. President, one month has gone by with no action by your administration and no response from you,” Dr. King said in TMA’s letter to the president. “Each passing day carries the real-life risk of death and avoidable morbidity for the men and women who have served our country so bravely.”

A presidential executive order would open the door for Texas veterans to begin seeing doctors who want to care for them. More than 300 physicians have signed up for TMA’s volunteer registry of doctors willing to see veterans in their offices — despite VA’s reputation among private-sector physicians for bureaucratic problems and uncertain payment. Nearly 1.7 million veterans live in Texas — the second most of any state.

A recent audit of the VA system found “systemic problems” resulting in nearly 60,000 veterans waiting for health care appointments nationwide, and a widespread effort to make wait times appear shorter than they are.

Because of this news, TMA and Florida physicians in June led the American Medical Association to pass policy urging the president to help and calling on Congress to pass a bipartisan, long-term solution to ensure veterans can receive timely health care.

Congress is reportedly working on legislation to solve this issue, though reports indicate August would be the earliest that a bill could reach the president’s desk.

Monday, July 14, 2014

Video: Sacred Bond Between Physician and Patient

Denton obstetrician-gynecologist Joseph Valenti, MD, says the relationship physicians have with their patients is "the most sacred thing we have." In the video below, Dr. Valenti discusses how it amazes him when patients he met five minutes ago are ready to put their life in his hands. Dr. Valenti says this relationship ― this trust ― is what motivates him the most as a physician and fulfills him as a doctor.

Friday, July 11, 2014

El Paso Physicians Step Up to Help Care for Immigrants Caught in Border Crisis

El Paso physicians, in coordination with the  Border Regional Advisory Council, are stepping up to help Central American immigrants (children, parents and/or guardians) being flown into the city to be processed by US Customs and Border Protection. Around 140 immigrants will arrive daily from July 9-12.  Texas physicians want to ensure every child and mother receives the care they need. TMA president Austin King, MD, says, “Medical aid not only protects the Central American refugees, but it also protects U.S. residents from potential serious and deadly diseases. Taking care of these people who have traveled days is the humanitarian and right thing to do.”

The following El Paso physicians are standing by to help: Jose Burgos, MD; Randy Goldstein, MD; Carlos Gutierrez, MD; Gilberto A. Handal, MD; Azalia Martinez, MD; Ascension Mena, MD; David Palafox, MD; Nancy Torres, MD; and Bruce Applebaum, MD.

Wednesday, July 9, 2014

Physicians may help move people from poverty

By Chris Berry, MD, DCMS CARES medical director; and Billy Lane, DCMS director of community service

This article originally appeared in the June issue of the Dallas Medical Journal. The Dallas County Medical Society Cares program (DCMS CARES) helps physicians deliver quality care to their uninsured or underinsured patients by providing access to affordable prescription medications at more than 600 retail pharmacies in the Dallas/Fort Worth area. 

In July, DCMS CARES will surpass the $10,000 mark. This means the program will have paid more than $10,000 in pharmacy expenses for uninsured and underinsured patients of DCMS physicians. In the “big picture,” $10,000 is not a tremendous amount of money, especially for a program that helps people with essentials such as food, housing or, in this case, medication. However, even fractions of this amount can stabilize a financially stressed household budget.

Dallas internist Roger Khetan, MD, participates in DCMS CARES because the program “gives me an alternative to help my patients who have significant financial distress and who cannot afford their medications.”

He has enrolled one patient in DCMS CARES.

“It was a true live-saver for her,” he says. “She was without a job, had no disabilityincome, had lost her home, and had moved in with her son. DCMS CARES helped her get medications for her seizures and diabetes, which had just gotten better controlled, and has helped her while she is awaiting disability benefits to kick in.”

According the United Way Community Financial Stability Initiative, a key factor for a family to move out of poverty permanently is the ability to leverage public benefits as a bridge to a well-paying job. “Public benefits” refers to major programs such as SNAP (Supplemental Nutrition Assistance Program), WIC (Women, Infants and Children), CHIP (Children’s Health Insurance Program), and TANF (Temporary Aid to Needy Families). Yet, smaller, privately funded benefits such as DCMS CARES easily could join this list.

Consider this monthly budget representing a household of two — a working parent and his or her child. Imagine that the adult makes $10.10 per hour (the minimum wage in Texas is $7.25) and works a 40-hour week. The parent’s total monthly gross income is $1,750; see the table below for expenses.

Estimated Monthly Expenses
Rent, one-bedroom apartment $550
Child care $400
Utilities $90
Cell phone $80
Vehicle $200
Vehicle insurance $65
Fuel $200
Basic groceries $300
Infant's groceries $140
Internet $60
Total $2085

Obviously, the bottom line on this budget exceeds the gross monthly income of $1,750 (before taxes). Suppose that you are the patient’s physician, and you treat the patient at no charge. You determine that the patient’s asthma is best controlled using a medication that retails for about $250 for a 30-day supply. Your assistant prepares a pharmaceutical manufacturer’s prescription assistance application on behalf of the patient, and the application requires at least 60 days to process. During this time, your participation in DCMS CARES can provide the patient with a point of leverage so that the other critical line items in the budget remain fairly stable. Your patient can go to any retail pharmacy in the Dallas area, pay a maximum copay of $20, and get the medication needed to control his or her asthma. By taking fewer sick days at work, the patient can continue on the path to a well-paying job.

Donations to the Dallas County Medical Society Foundation and a grant from the Texas Medical Association Foundation enable DCMS CARES to pay the bulk of the cost for this medication. As of July, this scenario will have played out to the tune of $10,000. More than a dollar amount, the money becomes an important factor toward financial stability for dozens of patients.

“Physicians who use the program are very good stewards of the fund and sign up patients who really need assistance,” Dr. Khetan says.

“The process of enrolling my patient was very easy and well-supported by DCMS administration,” Dr. Khetan continues. “Response time is quick, and support of the program comes from people you trust — fellow DCMS physicians.”

DCMS physicians: For details on how to participate in DCMS CARES, contact Billy Lane at billy@dallas-cms.org or 214-413-1433.

Monday, July 7, 2014

Two Mosquito-Borne Diseases Confirmed in Central Texas

The Texas Department of State Health Services (DSHS) confirmed two mosquito-borne diseases in Central Texas. The first case was West Nile virus in Travis County. West Nile virus can cause headache, fever, muscle and joint aches, nausea, and fatigue. It’s more severe form, West Nile neuroinvasive disease, can cause neck stiffness, stupor, disorientation, coma, tremors, convulsions, muscle weakness, and paralysis. Most people infected with the virus (80 percent) will not have any symptoms. The second mosquito-borne disease to strike Texas was the state’s first human case of chikungunya in Williamson County. Chikungunya is a viral disease that began spreading in the Caribbean in 2013 and causes fever and severe joint pain. Both chikungunya and West Nile are passed to humans through mosquito bites.

Texas physicians and DSHS encourage people to take these precautions to avoid getting bitten by mosquitoes:

  • Use an approved insect repellent every time you go outside, and follow label instructions.
  • Drain standing water where mosquitoes can breed.
  • Wear long sleeves and pants when outside.
  • Use air conditioning or make sure doors and windows are screened to keep mosquitoes outside.

Texas is no stranger to West Nile virus. In the summer of 2012, we experienced the worst outbreak of the disease in our state’s history. The virus severely sickened more than 400 people and killed 19, many of them Dallas County residents. West Nile survivor and Dallas physician Don Read, MD, chair of the TMA Board of Trustees, shared his experience fighting the illness with fellow physician Dan McCoy, MD. You can view their video here.

To learn more about the signs, symptoms, precautions, and treatments for these diseases, check out the DSHS website on West Nile and the latest news release on chikungunya.



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