STATEMENT OF SANDRA DEMORUELLE

BEFORE THE COMMITTEE ON VETERANS AFFAIRS (VA)

UNITED STATES SENATE

AUGUST 20, 2014

Thank you for providing me this opportunity to share with you my experiences with VA Pacific Islands Health Care System (VAPIHCS) as the the spouse and full-time care-giver of my Vietnam combat-infantryman husband, Joseph Demoruelle, who has been rated as a 100% permanently service-connected disabled Veteran. It is exceptional to be invited to share openly with our Senator and the Congressional Committee how we have recently interacted with VAPIHCS and what needs to be done to improve care. I will share two of my most important findings.

1. Lack of VAPIHCS administrative compliance with the VA Beneficiary Travel Program (BTP)

Ever since my husband was awarded permanent 100% service-connected disability on November 17, 1989, I have argued with him about his entitlement to Beneficiary Travel (BT) payment – and my nagging has forced him to ask orally for BT at his Hilo CBOC visits. He was consistently told by those at the front desk that “there is no Beneficiary Travel payment for on-island travel.” The desk staff knew he drove 135 miles round-trip to Hilo from his on-going complaints, but they denied they were responsible for processing intra-island BT travel. To force an appealable written decision from Hilo CBOC or Pacific Islands Health Care System (VAPIHCS), at his last clinical visit on June 17th, I accompanied him and I personally submitted two VA Form 10-3542 I found online when researching the BTP. To my surprise, a few days later, we were asked by Robynn Elliott (Hilo CBOC staff) to submit EFT information for BT payment, which I handed to her, and puzzlingly received two Treasury checks instead

Demoruelle Page 2 of 15 because the EFT deadline of December 31, 2013 promised in the GAO BT report wasn’t honored in our case. We do not understand why he had never received BT before because he had applied orally [per 38 CFR 70.20(a) and VHA Handbook 1601B.05 5.a]. This is not a minor issue since a review of our records shows at least 24 medical visits since 2012 amounting to denied mileage BT payments totaling $1,374.48. Now we find ourselves asking: how can this be rectified? As the VA policies state, BT is vital to allow distant veterans, like Joseph, to afford access to VA health care. But neither Hilo CBOC nor VAPIHCS has been responsive to my FOIA requests for how the BTP information is provided to veterans, who, like my husband, seem totally ignorant of this benefit? Burt Thornburg, Honolulu FOIA Officer, has even refused to provide me these administrative documents for free and has classified me as “commercial” because I am an individual (like Committee testifier Elisa Smithers), as opposed to an organization, even though I told him my purpose is educational, like informing this Committee or media for publicizing my findings to my fellow veterans and their families. I had requested a FOIA fee waiver as the information provided would likely “contribute significantly to public understanding of the operations and activities of VAPIHCS, a government agency, and is not in the commercial interests of the requestor,” which Mr. Thornburg has denied. According to the testimony from the organization, Concerned Veterans of Oahu, there are some within the DVA that “create confusion and block efforts of veterans seeking deserved financial and medical aid” (p.5).

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So far, I have found this to be true. It has been impossible for me to find accurate information on local VAPIHCS BHP management processes. None of the policies and procedures VA has developed for BTP as listed in the July 2013 GAO Report shows any evidence of having been implemented by VAPIHCS:

Veterans are not provided proper forms for filing for BT payments so there is no standardized method for applying in Hawaii that I can discern.

While a threatening poster “Don’t Travel Down the Wrong Road”has been posted at Hilo CBOC with no apparent VAPIHCS directive, there is none of the positive posters, brochures, or written sheets like most other, such as San Deigo or Portland, VAMC systems provide to inform Veterans of these important benefits.

Fred Ruge of the Maui Veterans Council spoke to the difficulty he faced as “setting up travel arrangements for our Maui Veterans via the VA Travel System is extremely difficult, and often turns out to be very problematic for all concerned.” Robert Strickland of the West Hawaii Veterans Council not coincidentally echoed these same BTP concerns: “Depending on the circumstances and whether care needed is service-connected or not, who pays for the travel can be a difficult process to work out.” Another important Veteran Representative from the State of Hawaii Office of Veterans Services, Ronald Han, Jr., gave even more testimony under his “Timeliness” concerns stating he worries about “the time it takes to get reimbursed for travel services from rural areas” (to Honolulu VAMC). Mr. Han further elaborated by stating: “Timely reimbursements for out of pocket transportation costs for those traveling to Tripler from the neighbor islands also have been addressed to our office for resolution. Some reimbursements have taken over 60 days or more for payment.”

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It was extremely telling that the central VA demonstrated a total lack of awareness of this very real grassroots BTP problem that these wonderful Oahu, Maui and Kona people (who are constantly dealing with the ACTUAL needs of Hawaii’s Veterans) took their valuable time to bring to your attention. The only travel mention I could locate in the lengthy testimony of Dr. Tuchschmidt, VA Acting Principal Deputy Under Secretary for Health, was under the VA Office of Rural Health (ORH) which spoke of “Transportation Investments”. He goes on to say “since 2012 VA has ‘invested’ $15 million in air travel to VAMC Oahu” [emphasis mine]. There is an odd irony in the word “invest” for the utilization of $15 million in BTP benefits by buying tickets through the sole travel outlet for this TAMC/VAMC, Carlson Wagonlit Travel. It is chilling to think $15 million that could have allowed needy Veterans to drive to their VA appointments was given to a totally commercial global business whose Board of Directors includes titans of industry representing firms like JPMorgan Chase. Thus I challenge the GAO/OIG auditors to ask the question: Why can’t the BT Office negotiate tickets directly with the airlines, without “investing” $15 million in a giant for-profit corporation? Other than further identifying the “Geographic Challenges” in Hawaii of both distance and variability, Dr. Tuchschmidt did nothing to address the BTP issues previously mentioned by the Veteran Service Organizations. Based on my husband’s 25 year denial of any BT benefits, it seems apparent that the VAPIHCS local procedures are at variance with 38 CFR 70, so I am urging prompt Senate action to remedy this situation. Thus, we seek your assistance in ensuring VAPIHCS’ compliance with the existing VHA policies and sharing information on BTP with our Hawaii veterans.

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Just last week I told Director Pfeffer directly in a letter to him:

I hate to waste any more time on bringing to your attention the clear necessity to implement the BTP in Hawaii for the following reasons:

38 CFR section 70 requires it

VHA Handbook 1601B.05 requires you follow VA policies and rules developed through legal rulemaking processes and published in the Federal Register/Vol. 72, No. 140/Monday, July 23, 2007/Proposed Rules P. 40097

OIG requires it to prevent fraud

US Treasury required the EFT by March 2013

GAO’s Report to Congressional Requesters, July 2013: VA HEALTH CARE: Additional Steps Needed to Strengthen Beneficiary Travel Program Management and Oversight promised system-wide EFT by December 2013, along with other improvements In light of this, it is apparent that that PIHCS and Hilo CBOC have unlawfully denied my husband BT benefits since 1989. From my experience on the initial OVS Advisory Board (for VAMROC “old-timers”, I was the one who always brought home-made cookies), BIVA and other veteran organizations, many more veterans are experiencing the same problem with Hawaii’s BTP. Therefore, I am asking you the straight-forward question: What are you (the medical center director or designee is the legally responsible VA official) going to do to implement VA BTP throughout the PIHCS facilities? Do I need to waste time seeking far more important people than me to bring this simple administrative problem with significant legal ramifications to your attention? I would rather assist in resolving the political heart of the BTP problem for medical centers; that is, that BTP requires a financial support that does not reduce funds available to provide actual medical care. My BTP energy could be more

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productively put to use lobbying (directly and through local vet groups) the GAO Congressional Representatives listed in the report to address this “VA BTP vs health care” monetary concern. Per the GAO, the BTP implementation appears well organized at the central VA CBO level, providing software with helpful User and Tech manuals from OIT and simple three page guidance (BENEFICIARY TRAVEL, Guidance for Application and Voucher Processing, the undated, unattributed “Attachment 2” to my FOIA request) for establishing consistent, verifiable BT payments to eligible veterans. It is mostly done via the existing kiosks adding a drop box, with the VA providing the forms, supplies and “knowledgeable personnel”. This appears to be the simplest compliance request with the most clear guidance and support (Dashboard/VistA for example) from the VA I have ever seen. Therefore, since it seems so easy to me, I make this offer from the bottom of my heart: please feel free to call upon me for any sort of assistance so that, in my hubris, I can better understand that it is more difficult than it appears. The legal requirement for VA BTP is unassailable and the sooner you (or your designee) rectify the noncompliance the less damage will be done to the eligible veterans. Implementation will be easy for me to spot at the Hilo CBOC during my husband’s next visit because BTP posters will be up, brochures and forms with supplies readily available, and Joe will promptly receive his EFT BT payment because he checks in at the kiosk. So I will look forward to your prompt reply to my request for the immediate implementation of the VA BTP throughout PIHCS so I can move on to the infinitely more life-and-death matter of continuing to address PIHCS quality of care concerns. [Signed, Sandra Demoruelle]

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I have not heard a thing from Director Pfeffer or any of his designees on this request.

2) Quality of Care/Implementation of the Accelerating Care Initiative (ACI) Based on the following regulations and problems with quality of care issues detailed in Attachment #1 (below), during his Hilo CBOC physical examination on June 17th, I formally requested a Pre-authorized Outpatient Medical Care Request from Dr. Maag, Joe’s designated VA Primary Physician to obtain routine medical services through a Medicare –approved community provider as VA services are geographically inaccessible (over 135 miles round trip) and the VA facility (Hilo CBOC) is not meeting critical on-going medical needs of this Vietnam combat veteran.

On June 24, 2014, we received a letter of denial from VAPIHCS Thomas Driskill which we tried to change by sending my well-argued evidence based, as I always do, on VA regulations cited below. VA REGULATIONS: Pre-Authorized Outpatient Medical Care The Fee Program provides payment authorization for eligible veterans to obtain routine outpatient medical services through community providers. This authorization may be granted when it has been determined that direct VA services are either geographically inaccessible or VA facilities are not available to meet a veteran’s needs. (http://www.nonvacare.va.gov/preauthout.asp)

The Veterans Access to Care requiring the VA to offer care through civilian providers if veterans live more than 40 miles from a VA facility and offer my husband the “Veterans Choice Card.”.

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That private care is preferable to VAPIHCS was well detailed by testimony of Elisa Smithers. Attorney Mark Davis points out in a Honolulu Magazine article that private hospitals have 3X less negligence than VAMC/TAMC facilities. VA and Tricare testimony stated they were building nonVA providers based on the ACI, but, again, Dr. Tuchschmidt never talked of Veterans Choice Card implementation that would allow that as required by the new Act. However, Dr. Tuchschmidt spoke often of ACI use of nonVA providers. On page 2 of his testimony he says “ Notably Specialty Care wait times are well below the national average. This is, in large part, due to VAPHCS’ robust NonVA Care Program that routinely purchases a high volume of specialty care,” though he later complains of limited nonVA resources on all islands. He ends up stating that primary care is “more problematic”, which leads inquiring minds to ask: Why would PIHCS deny Joe’s request to move out of the overcrowded Hilo CBOC and free-up a spot for someone who finds less fault with the quality of care? HOVS representative Ron Han also weighed in on the need for distant Veterans, such as my husband, by saying “allowing Veterans who live in remote rural areas from a VA hospital or CBOC to access care through private medical providers in the community.”

In conclusion, I truly identified with Mr. Han’s explanation of what Veterans and their families feel when the VA does not address our clearly stated concerns. He said “In some cases, some issues require elevation to the senior leadership in VHA and VBA because of the ineffectiveness of resolution options and alternatives at lower echelons.” In spite of solid evidence and presenting the VA with regulations, the ‘lower’ and ‘upper’ echelon continue to ignore them and the reporting persons, such as myself.

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Han went on very poignantly: “Additionally, providing written responses at all levels that have answered the Veteran’s query on paper only without follow-on execution, and more importantly follow-up, do more irreparable damage since now there is the appearance of a disingenuous ploy to respond with no intent to fix the issue.”

Let me end with the quote I found most moving throughout all the cogent testimony: “We can no longer accept or tolerate any results that are detrimental to providing quality care for our Veterans.” I can no longer tolerate VAPIHCS flagrant violation of administrative compliance in applying the VA’s Beneficiary Travel Program and Accelerating Care Initiative. Therefore, I request for my husband, myself and thousands of disabled

veterans and their families islandswide, that the Senate Committee

provide compliance oversight until the VA provides these services I

have described to all eligible Hawaii Veterans.

Again, I am so grateful for this opportunity to bring these concerns to your attention. Sandra L. Demoruelle For questions, contact: Box 588, Naalehu HI 96772 naalehutheatre@yahoo.com

Attachment # 1 Demoruelle Page 10 of 15

EVIDENCE SUPPORTING PRE-AUTHORIZED OUTPATIENT MEDICAL REQUEST (compiled without 2013-14 medical documents requested on July 7, 2014)

Request pre-authorization for payment of comprehensive geriatric examination (July 22, 2014 at 9:00 am), follow-up appointment, required lab work, and, with VA pre-approval, follow-up treatments. NonVA Practitioner: Doede Donaugh, D.O. Family Practice Board Certified Mango Medical Ocean View 92-8691 Lotus Blossom Lane Units 6 & 7 Ocean View, HI 96737 VA REGULATIONS: Pre-Authorized Outpatient Medical Care The Fee Program provides payment authorization for eligible veterans to obtain routine outpatient medical services through community providers. This authorization may be granted when it has been determined that direct VA services are either geographically inaccessible or VA facilities are not available to meet a veteran’s needs. (http://www.nonvacare.va.gov/preauthout.asp)

Current legislation passing US Congress requiring the VA to offer care through civilian providers if veterans live more than 40 miles from a VA facility.

DENIAL UNDER APPEAL: Request for National Non-VA Medical Care Program Pre-authorized Outpatient Medical Care Request to obtain routine medical services through community provider as VA services are geographically inaccessible (over 135 miles round trip) and the VA facility (Hilo CBOC) is not meeting critical on-going medical needs of this Vietnam combat veteran rated permanently and totally disabled for service-connected disability.

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Critical on-going medical needs include: 1) Pain Management; 2) Cardiac Disease Management incorporating an accurate cardiac diagnosis with heart disease management and lifestyle modification including healing nutritional and exercise guidance (which is a FAMILY PROCESS); 3) Skin Disease Management of ongoing skin problems including pre-malignant Actinic Keratosis; 4) Plus any other concerns identified by Dr. Donaugh during her comprehensive geriatric examination with lab work. EVIDENCE OF NEED FOR FAMILY PRACTITIONER NEAR FAMILY: To begin, unlike what is stated in the denial of June 24, 2014, (Appendix I) Family Practice care is NOT available from the VA because it is a Board Certified specialty defined as providing total health care of individuals and families which includes prevention and primary care of entire families. The VA solely offers care to eligible veterans while Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) beneficiaries are not able to obtain care at the Hilo CBOC where Dr. Maag is Joseph Demoruelle’s primary physician. Therefore, Joseph’s spouse, Sandra Demoruelle, receives care from Dr. Donaugh through CHAMPVA. Dr. Donaugh has been Sandra Demoruelle’s primary care physician since 2011, providing effective lifestyle modification guidance that has caused Sandra’s health to improve including loss of over 25 pounds of weight and improved cholesterol so that statins are no longer required. As a Board Certified Family Practice physician, Joseph will be seen by Dr. Donaugh so she will know and understand Sandra better and include Joseph’s needs in the family’s on-going healing lifestyle guidance.

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Provision of Dr. Donaugh’s nonVA care specifically for Joseph will include a comprehensive geriatric examination with lab work addressing the ongoing problems of pain management, nutritional/exercise management for cardiac disease healing, and skin concerns, in addition to problems she identifies upon examination. The VA HealtheLiving assessment (Appendix II) stated a reduction in “health age” of 4 years by, among the other things addressed below, asking “for a comprehensive geriatric evaluation.” It needs to be done by a physician who can provide specific nutritional guidance based on examination of deficiencies and excesses shown through extensive lab work. A physician who has orthopedic abilities can also aid with resolving the depressing stress of pain/sleep disorders combination. But most importantly, a physician is needed that will promptly incorporate and be guided by consultant notes and conclusions. (See, eg, requested Djon Lim notes 2013 regarding source of MI from cardiac artery spasm, not CAD per Subjective note Jun 17, 2014 @10:05:14, and evidence of Hilo CBOC’s continuing dangerously erroneous diagnosis of coronary arteriosclerosis a year after Lim’s consult per Appendix III.) Finally, of utmost priority, is the need for the physician to be near Naalehu, as defined as under 40 miles away. The distance and expensive hardship of travel to Hilo CBOC from Naalehu is evidenced in the FOIA requested Beneficiary Travel Claims (VA Form 10-3542) documents for June 13 and 17, 2014 medical treatments and examinations (Appendix IV); the distance being over 135 miles. Along with evidence under Pain Management, that Joseph’s pain and stress are notably increased by trips to the Hilo CBOC are documented in his VA Hilo CBOC Notes –

1) Maag Note Jun 17, 2014 @10:05:14 ASSESSMENT “he presents with a letter requesting Pre aughorized [sic] outpatient medical care requests a consult to pcp in the community as he lives more than 1 and ½ hours from the clinic.” (See, also, original request sent 5/28/2014 via Secure Messaging, Appendix V.)

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2) Henderson Mental Health Note APR 24, 2014@9:58:29 “+irritability,

difficulty being around people…being in hospital makes him anxious, even being here.” “Vitals: No data available borderline bp on 3/28 probably due to anxiety”

3) Henderson Mental Health Note JUL 03,2013@9:31:40 “would MUCH rather do CVT at home than come to office for any therapy” “Preferences few visits, less time around people”

EVIDENCE OF HILO CBOC DEFICENCIES MEETING CRITICAL MEDICAL NEEDS OF 100% COMBAT-DISABLED VIETNAM VETERAN As supported by the limited evidence currently available on MyHealthEVet without access to Dr. Lim’s cardiac notes, each of the deficiencies in current VA Hilo CBOC care is addressed.

1) Pain Management DVA Problem List: SCIATICA ICD-9-CM 724.3 – 26 Oct 2001 Henderson Mental Health Note APR 24, 2014@9:58:29 “Pain in R hip hasn’t been evaluated by MRI in years that I can see.” The description of the pain does not continue to suggest sciatica as no mention of leg pain has been reported. Joseph describes his pain as center on his coccyx which causes muscle soreness, which is the only relief given by the tens unit. The pain in the boney tailbone area remains even with tens treatment. This is why travel and driving is so painful to him. Henderson Note Jul 03, 2013@09:31:40 “sciatica, rule out CAD, see problem list” Pain is a daily concern. It robs Joseph of sleep, takes away his ability to enjoy life and makes him irritable toward those he lives with. Joseph avoids travel because long car trips increase his pain. Joseph avoids hospitals and becomes very anxious at the Hilo CBOC.

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His lower back pain has not been evaluated in many years and no one can remember when he had his MRI. He has never been examined or manipulated by a Doctor of Osteopathy for his pain. While his Psychiatrist Dr. Henderson has demonstrated concern with levels and sources of increased pain and anxiety, Dr. Maag uses the perfunctory statement “The patient’s pain was assessed or re-assessed at today’s visit. Response to previous treatment, if applicable, and any changes to the treatment plan were reviewed. [no changes] These areas, including the origin and history of the pain, were documented in the progress note.” [no further mention was made to address pain in progress or any other notes] This is the same standard statement made in Maag Jun 17, 2013@11:11:40 notes. Maag Jun 17, 2013@11:11:40 note states: “66MALE here today with the chief complaint of back and hip pain. Really this is right low back pain with radiation.” Treatment was tens unit which Joseph states helps with muscle pain but does not address the pain source.

2) Cardiac Disease Management DVA Problem List: Electrocardiogram Abnormal ICD-9-CM 794.31 - 13 Jun 2013 Dr Davies Mar 28,2013@10:44:49 “preop clearance for upcoming cataract surgery”; “ekg showed possible q waves in asymptomatic adult with no known cad”. Henderson Note Jul 03, 2013@09:31:40 “Had evidence of old anteroseptal MI on EKG” and “sciatica, rule out CAD, see problem list” The VA has not incorporated accurate cardiac disease information into its records which guide their health care decisions for Joseph including in the June 24, 2014 appealed decision which states “Diagnosis: Coronary arteriosclerosis” (Appendix I).

Demoruelle Page 15 of 15 As demonstrated in Secure Messaging email correspondence in May 2014, Hilo CBOC has not been responsive to changing inaccurate data or pursuing healthy treatments for Joseph’s actual cardiac problems. Maag note Jun 17, 2014 @10:05:14 “here today with the chief complaint of follow up cad… for CAD he will be referred to cardiology for regular follow up.” No mention is made of review of Dr. Lim’s cardiac consultation notes from 2013.

3) Skin Diseases DVA Problem List: Actinic Keratosis ICD-9-CM 702.0 - 02 May 2012 As stated in VA Secure Messaging sent 5/28/2014 (Appendix V), “Joe should have a head to toe skin exam because he has a history of sun and agent orange exposure. He has a lesion on his back that is irregular, multicolored dark and black, that has been getting larger on his back. As well he has other troublesome areas on his shoulder and arms.” The nursing note of 06/17/2014 states that the patient reported “Agent Orange Exposure” as a health problem. Maag Jun 17, 2013@11:11:40 note “aks’ to skin – cyro today”. However, no follow up was done to examine and treat or biopsy the skin problems listed in Appendix V in Maag note Jun 17, 2014 @10:05:14. Because Joseph is fair-skinned and exposes his skin to sun daily, his history of surfing and Agent Orange exposure should require annual skin examinations and documentation of changes. Hilo CBOC does not perform these regular exams and Dr. Donaugh will catalog and biopsy suspicious lesions as Joseph ages and becomes more susceptible to malignant changes.

[Follow-up: After the denied approval of the examination in July, Dr. Donaugh scheduled removal of a skin lesion and biopsy on Sept 22 that has not been approved by VHA PIHCS Managed Care personnel. However, Dr Maag did approve lab work for Dr Donaugh and VA-approved nonVA provider, cardiologist Dr Lim]