VA May Lower Credentialing Requirements For Examiners Diagnosing TBI
VA just funded a research study now being used to support lowering credentialing requirements for examiners diagnosing traumatic brain injury (TBI).
The agency funded a research study performed by the organization formerly called NIH, now called National Academies of Sciences, Engineering, and Medicine (NASEM), to evaluate diagnostic requirements for TBI.
The congressionally chartered research organization evaluated whether the agency should still require that only one of four specialties diagnose the condition – a neurologist, neurosurgeon, physiatrist, or psychiatrist. The 200 plus page report argues that training and experience, “not necessarily the specialty,” is what makes a clinician capable of accurately diagnosing TBI.
About TBI Disability
TBI is the signature injury of the Iraq and Afghanistan wars.
Generally, a person struck in the head, exposed to a blast, or who suffers a penetrating injury from a gunshot, all fall under a classification potentially requiring assessment for brain injury. The severity of the initial TBI is classified as mild, moderate, or severe.
The severity of the initial TBI is generally thought to influence the severity of the residuals most of the time. Meaning, it influences the percentage of disability a veteran may receive once the residuals are assessed.
So, why is VA trying to evaluate whether to lower the standards for being allowed to diagnose TBI?
Is there more to this story?
Yes, there almost always is more to the story.
Background On TBI Disability Scandal
In 2015, I caught and exposed VA using unqualified doctors and nurses to (mis)diagnose veterans claiming benefits for TBI. Advanced practice nurses and family practice doctors were regularly misdiagnosing symptoms of TBI or failing to diagnose the condition.
RELATED: VA Regrets Using Unqualified Doctors For TBI Exams
VA apologized for using unqualified doctors, but its newest funding focus into using clinicians with lesser credentials suggests a longer play at reducing the required competency of examiners.
Congress investigated the matter as did VA OIG after it gathered enough public attention, which is about the only way you can get things changed at VA – find a sexy scandal that plays well on TV… and find a quality TV reporter like AJ Lagoe who is willing to dig deep to expose the scandal, nationwide.
RELATED: VA OIG Finally Releases Its TBI Report
Cost Of TBI Exams
If the agency used doctors with advanced credentials like psychiatrists, the cost of each examination would be substantially more. Further, clinicians with more advanced credentialing usually have more experience evaluating for conditions like TBI or the residuals that result.
Internally, VA has long argued it should be able to use simple tests like RBANS or MoCA to evaluate TBI residuals – – these are short cognitive tests originally designed to evaluate dementia in elderly patients. The agency also uses an 80-page booklet with videos to help clinicians study for a 25 question test. If you pass the test, you can diagnose TBI, in theory.
So how do they jam all the criteria for one of the most complicated injuries in history into 80 pages and a couple of videos?
Next Steps For Review
“Our scientific understanding of TBI has increased dramatically in recent years, and that understanding needs to be incorporated into the VA’s disability determination process,” said Dan Blazer, J.P. Gibbons Professor of Psychiatry emeritus, Duke University Medical Center, and chair of the committee that conducted the study. “The implementation of our report’s recommendations will represent a fundamental enhancement in the methods used by the VA to ensure the quality of its evaluations for TBI. Shifting from a focus on the consistency of the process to a focus on the reliability and validity of the evaluations’ outcomes will identify areas for improvement. Making those modifications will have the greatest impact on improving the outcomes for veterans.”
DOWNLOAD: Evaluation of the Disability Determination Process for Traumatic Brain Injury in Veterans
What is your take on the matter? Is VA hedging back to reduce overall training of the clinicians capable of diagnosing TBI? Should the standards be lowered?
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“Experience the difference” Have each one of these schmuck Doctors stand next to a 175mm during live fire . The ask them if they believe TBI to be a real thing. If they can still hear ansd speak after such event I’m sure they will have no problem believing a Vet who says ” I served at Trabong and we offloaded a thousand rounds per month, every month.(100 lb rounds) Then there are the crazy-assed drunk yard night fights among enlisted men- Oh, i forgot , that never causes TBI, loss of teeth, deviated septum, seizures, migraine headaches, hearing loss or any of the 150 other things called sequela.
VA- fuck you and your Mama too.
St a rt putting articles in paper but watch out for retaliation.
So if you actually read the NIM (whatever the new acronym is) report, you’ll see that they are talking about medical practitioners—MDs and PhDs—when discussing the state of the art and training and experience. Then, suddenly, they add in “…including non-pjysicians”. NIM, of course, imagine the VA is going to take the words “training” and “experience” in the way big University Medical Schools do—formal training and formal experience with treating the condition—not merely years in the job of deny claims. They are picturing a PA with several years working and training in the fields that contribute care to brain injuries, not a glorified admin with a ten-hour online “self-paced” training course and some video hours.
Once again, the issue comes down to the disconnect between what the VA is meant to do—care for veterans—and the tension from Party R and Party D to “economise” so they can cut taxes and spend more money on things large voting blocs want.
In order to eliminate a few thousand false claims, the VA has adopted an adversarial approach to granting veterans benefits. Under GW Bush & Obama, the Administrations forced—and that is the word—the VBA to grant claims by pushing the burden onto the VA—a claim was true unless the VA could prove it wasn’t. So the VA answered that by low-balling claims. The Administrations countered that by insisting that the Veteran be given the “Benefit of the Doubt”, and then added in the “type and nature of service” rider.
As soon as the tension between the Chief Executive and the VA slackens, the VBA goes back to denying claims en masse. It really shouldn’t be necessary for executive-level staff to force the VBA to do what it was ostensibly created to do—grant and rate claims for disability benefits. Not save Congress a few bucks while getting a big bonus for “economising”, but serve veterans who suffered for their service.
Speeding up the claims process really isn’t all that hard—stop rejecting them out-of-hand. Stop sending them back for “development” by the same rubber-stamp crew who covered each others’ asses to begin with. Use medical technology—the VA is NOT obligated to perform a MRI or CT to adjudicate TBI residuals, even if the balance of evidence is inconclusive and the test would clarify it. Why not? Because if it comes back positive, the VBA is on the hook, and that is to be avoided at all costs.
It’s too bad the NIM Board didn’t ask themselves some serious questions—like why is it that almost all claims are rejected on first submission? Why is the VBA process adversarial, and is that justified? Because THOSE are the factors that matter in the VBA adjudication process—not the qualifications of the examiner; if the VA was actually supposed to grant claims, they’d WANT to have qualified people perform the C&P exam. Not some hack who took the job to cover debt.
I spent 13.5 years as a Navy hospital Corpsman. Had I finished my 20 without a TBI, I would have been experienced and on adding the NP or PA courses, I could be one of those they are putting up.
Now, I have a different 50 years of experience. I wouldn’t be the “deny” on the report sheet. But I recognized my prior tendency to believe “they” are malingerers would have put me in the “deny” on the report sheet.
Years of experience don’t mean shit. It is the kind of experience. Self experience or family member is the best. I’ve had the worst and the best PCs. The difference wasn’t age, MD, Specialist, NP or PC. It was actual experience with TBI in a need to understand situation. Unfortunately there are too few of those especially in the upper ranks. We are at the mercy of the system which is coming down hard to curtail entitlements.
I took 48 years to get the medication I needed to manage my temporal lobe seizures. They were diagnosed 16 years after the fact and a proper treatment recommended but the VA requires “confirmation.” And the “confirmers” didn’t have the experience or training to recognize what was going on. Even when observations were clearly presented in the medical record appropriate treatment was not forthcoming.
I’m more employable now than I was 5 years after the TBI which was 45 years ago.
Guys, we have to do something. I’ve been fighting the problem since 1987 when I recognized it. It took until 2008, 21 years later and not directly from my input but I like to think it was from a seed I planted, to even get mild and moderate to moderately severe TBI disabilities recognized in the Code. They are recognized in the Code but not appropriately. If one has temporal lobe seizures, my disability, it is unlikely they will have consistent C&P exam reports and the adjudicators will always use the least favorable to the veteran.
There is no real answer except appropriate training which is non existent at this time. CA Rehab was years ahead of the VA in 1985 and probably still is. I wish the VA had put me in their program. I believe I would have been treated appropriately much sooner and would have been able to finish a career instead of being on the dole for the last 29 years, most of it in such dire poverty I was frequently suicidal.
And because the VA is unwilling to believe a state is ahead of them and look to their results we have 22 veterans a day committing suicide at a rate of 29 per 100,000 per year compared to the 12 per 100,000 average which includes the veterans suicides.
I’m still fighting. Any suggestions on how to take the fight forward in a better way than Colonel Turner? Maybe we should start carrying signs anointing Colonel Turner as our hero. He stated it flatly right in his suicide note.
I wanted to highlight something you noted almost as an aside, and which I keep bringing up to no avail when the people with jobs—or law practices—start clamouring for privitisation (and therefore civil vulnerability)—
“….much of it in such dire poverty…”.
This is my life. Even with 100% Service-Connectd Permanent and Total Disability, I do not earn—and they ARE earnings, not “the dole”, though it feels like the dole, to be sure—enough to live at the poverty level. I don’t know where Krause gets his numbers, with their tens of thousands of entitlements—maybe it’s an officer thing—but I live on what I made as an E4 (I had been posted for promotion to E5, but had not been advanced when I was wounded).
I think we’re fairly close on this one. The NIH report is writing about **relevant** experience **with TBI** and its **related** residuals (sequelae in the Academic world).
As usual, the words are sweet-sounding, but the actual results are used to cut into Veterans who apply for the benefits they are entitled to without a lawyer, mountain of FOIA paper, and their Congressional Representative.
We’re supposed to be able to apply for our benefits and receive our due. And most of our fellow citizens believe we do. THAT’S the narrative we nee to take control of. We need to make it so Americans understand that a 7 year delay to adjudication of a Disabled Veteran’s claim is **normal**; three years is what the VA admits to, but that is the time frame for the out-of-hand rejection.
Most Americans believe that if we were wounded, we will be awarded a just compensation right away. They treat an explanation of VA Math as if they were listening to a conspiracy theory—who does that? Then you show them the VA Rating schedules.
That might change things up, maybe. Show people the systematic way the VA approaches refusing claims, regardless of what the claim is—when we highlight a particular problem, they do what they did here, form a committee of Big Time Scientists who take their money and do their bidding. If we don’t let them drill down, but address the adversarial culture, maybe we can then start taking apart that culture.
Steven, Were you told by anyone to go to the VA immediately on your discharge? VA compensation is more than an E4. Did you apply for SSDI? That is presuming you had enough quarters of earnings including your military service.
I had enough service time for SSDI. I received SSDI in 1990 and was finally TDIU at 100% in 2017 from 2009 with my TBI. I’m in remand for TDIU from 1987 which will be a big pay check if granted which looks likely from the Social Security CAVES report.
Between SS (now that I’m over 65) and VA Comp I receive over $5,000 per month. VA Comp for 100% is over $3,000 per month which is enough if you are not in a high rent district. That is over $36,000.00 per year.
I agree with you that 100% SC Comp is not a dole. But it feels like it if you could have been treated and weren’t and if treated could have had a 32 year career instead of a “dole” as it turned out. A mistake that is costing the VA more than if they had done things right and had a program to do things right. Just simply lack of training on TBI. Everything was in the books but ignored in the favor of “adjustment disorder” for a behavioral quick fix which it wasn’t.
Point is Steven, you get the higher of VA Comp or E-4 100% retirement. It is your selection. I don’t know if you can get back pay but it would be worth a shot. Look for a lawyer if what I’m saying fits your case.
In my opinion you cannot expedite this unless you are medical advance directive and he is in the hospital for a duration of time.or the age over 75.best thing to do is wait.if it cannot wait and your son is experiencing symptoms of related service that are life threatening emergency room at the va hospital.if you call the va crsis line they can give you numbers to call.this is not the best option but it’s a start for resources.
I’m currently trying to get my son all his benefits. He was involved in a rocket blast in Afghanistan. He was diagnosed with severe trauma later and discharged. He is currently awaiting polytrauma services at the Palo ALTO VA whereas they wanr him on an outpatient basis. Im his mother and caregiver and i need help negotiating theu their barriers ans delays. Please someone help me .
Hi miss Mixon it depends, the only way for inpatient I believe is the emergency room for symptoms that recurring with your sons connected disability .first you want to speak either to a va benfits lawyer or benefits officer to obtain this you must let your son go through the poly tRama test.if his that bad where the injury has made such an impact to his well being,for instance missing limbs, theres special compensation.but the list goes on and you have to prepare yourself on what evidence the va says and how effects your son.i know it’s hard you must wait and see what happens and from that evidence make a determination or a goal sheet how to line your ducks in a row if you dont agree with the va determination.but first things first prepare to seek out a va benfits lawyer or an advocate for va disability by searching online in your area .
I had to see a neurosurgeon for abnormalities that showed on a head CAT scan. My PCP had me complete a brain MRI, which showed I had two arachnoid cysts in my brain. Went I went to discuss the issue with the brain surgeon, he said that I didn’t have arachnoid cysts but at some point in my life I had severe brain trauma. Luckily, he said I didn’t need brain surgery, even though I have brain damage. The VA sent me to a VA Physiologist and the first thing out of her mouth was that I didn’t have TBI and that my symptoms were caused by a slight concussion and PTSD. She also explained that the neurosurgeon’s report said that I ‘either’ had arachnoid cysts or TBI. The neurosurgeon totally contradicted what he told me. I think because since he was working for the VA, and he didn’t want the VA to have to pay for costly surgery. Don’t get me wrong, I don’t like the thought of brain surgery. But, when I was asked if I had any experiences where I could have had brain trauma, I said yes, and that it was from a bomb blast. The whole matter is a scam and the VA doesn’t want to pay benefits for the massive number of Vets with TBI!!!!
F the VA, nothing but a scam!!!
OR It could just be I’m being overdramatic. His 2011 severe head injury with 9 skull fractures , leaving him unconscious for the better part of a week in ICU, probably has nothing to do with his encephalomalacia with gliosis. But I’m not a doctor.
My vets VA turned his brain to mush. They have admitted it, diagnosed it and denies him proper care and assistance.
National tragedy is ,shortage of professionals that don’t want to take the responsibililty of such an illusion of so called help the vet gets.it just feels like a wave of federal court tort claims will clogged up the system,from under experienced staff and people leaving the va for scrutinized federal policies that more it’s likely federal court system will blame bureaucratic union practices where the va will have no choice but to usher in some what of secondary private practices where the vet will have to pay a co payment ,100 percent connected or not.va is going to be sued big time in years to come over the inexperienced practitioner it’s going to be there scape goat moving in the private sector
Just seems like va going to low ball everyone with unexperienced millinials that are taking the old practices and logistics of health care and changing it so drastically that sooner or later any diagnosis from the va will be signed off by the va jaintor in a dusty old hospital over the new age of beurcratic red tape. Watch in years to come va will be forced out the union into new code of private practice where the veterans service connected compensation will be severed .
Soon the examiners will be former McDonald’s employees, if this happens the Veteran has no choice but to seek out side professional medical help maybe that’s the way it seems this is going
Seems pretty simple to me. Lower the diagnostician bar, and the VA can claim incompetent diagnoses when the deny claims. Taadaaaaaa
Ben hit all the right points. Those with more years of training (ie, specialists), will have had more experience specific to TBI and its residuals, making them more qualified for diagnosis. However, I don’t think the conclusion drawn by the report is that far off. In a world where all clinicians applied evidence-based care for diagnostic assessment, the argument would be sound. Unfortunately, the profound deviation from such standards that many (though, not all) VA examiners practice makes their argument moot. So, while they say that training is more important than specialty, the concern that everyone should have is the fact that many of those in the system aren’t adequately trained, particularly since the DEMO training program required of TBI examiners was described as “inadequate” by VAOIG. This report fails to grasp the larger picture of a failed infrastructure. Conceivably, proper training could yield better diagnoses from less specialized providers. The onus would then fall on the VA to ensure that training is provided. Of course, this whole effort completely overlooks the elephant in the room — assessment of previously diagnosed TBI by unqualified individuals.
Oh yes, I agree with you Pragmatic. Yes being fully trained is important; but, Ben and all, being fully trained goes out the window when the topic becomes politicized. Look at the APA. Ben, look at what they have been up to. Yes and yes. Turning lots upside down.
This is an excuse for not providing neurological care or having the ability to provide muetoligical care.
Ben, the NIH change is to: “You are subscribed to Evidence-Based Practice for Agency for Healthcare Research and Quality (AHRQ).” The Agency you reported is the Parent under the Department of Health and Human Services.
That is the subscription change I received today from my NIH subscription.
I’ve been going through the TBI claim process for a couple of years now. I have had a denial without a c&p exam and 2 denials with c&p exams. Both c&p exams were conducted by the correct doctor type and both exams were inadequate due to the examiners lack of TBI expertise. Now VA is seeking expert opinion in my case, so I am told. I am well versed in what the VA should be doing, so I am able to see their blunders and force corrections. I am very worried for all veterans with TBI as it appears VA doctors are clueless.
I don’t know if it applies, but if it does, add specifically, “anosognosia.” Ask your wife and friends.
ano·sog·no·sia | \ ˌa-nō-ˌsäg-ˈnō-zh(ē-)ə
Medical Definition of anosognosia
: an inability or refusal to recognize a defect or disorder that is clinically evident
Mrs. M. ‘s form of anosognosia is even more extreme: she not only flatly denies she is paralyzed, she refuses to admit that the limp limb on the left has anything at all to do with her.
— James Shreeve, Discover, May 1995 (This article was my discovery that it was probably my condition and when I looked at my 1985 Neurobehavioral test report it was there by definition but not by diagnosis)
A prominent feature of schizophrenia and bipolar disorder is anosognosia, a sick person’s unawareness that he is sick.
— Algis Valiunas, New Atlantis, Winter 2009
— see anton’s syndrome
Damn, everyone “beat me to the punch”,(sarcasm intended here), on how VA can misdiagnose, whether by accident or design, a TBI!
Which will Cause the veteran to resubmit claims over and over again!
VA will do anything to fuck the vet!
“Delay, Deny, Until They DIE!” IS VA’s new motto!
““Delay, Deny, Until They DIE!” IS VA’s new motto!” Mind if I borrow that for a title, Elf? I have a journalist acquaintance and I’m going to write an article for him to edit and submit to AP or UPI.
That phrase was started a few years ago by a patriot living in Indiana. I can’t remember his name.
He also stated the “Billboards” with that saying on them.
He and Ben are close friends!
Lem and Crazy Elf, the guy whom both of you are speaking of orginated putting up the billboards VA is Lying or something to that effect.
Another typo, I mean originated. My phone is giving me trouble with writing my text. Delayed.
What i read from you Veterans email the Legislature who raise the Budget for Veteran Health Care jam your emails and Spread my belief.
“Our scientific understanding of TBI has increased dramatically in recent years, and that understanding needs to be incorporated into the VA’s disability determination process,” started with an NIH Neurologist visiting my booth on the Grassy Knoll opposite the Vietnam Memorial Wall on the Mall in DC in the summer of 1995 during the American Neurology Convention. She said, “This is something NIH can do.”
She was true to her word. By 1998 there were 5 times as many research reports on TBI as there were in my visits to the NIH Library in 1995.
I feel good about the results from NIH but terrible about the results from the VA. The unnecessary loss of life because of the effort to continue to put the walking talking TBI victims at risk because of not wishing to compensate them and endure the cost of treating them is beyond comprehension.
Thanks for this article, Ben. It has helped me focus. My opening statement to the Chief of Psychiatry for the Black Hill VA Medical Facilities and future C&P examiners will be the above:
“The unnecessary loss of life because of the effort to continue to put the walking talking TBI victims at risk because of not wishing to compensate them and endure the cost of treating them is beyond comprehension.”
The second line will be: The failure to rule out anosognosia in every exposure to TBI or cerebral malaria is also incomprehensible.
Thanks, Elf. I’ll email Ben for the name to put in the quote. Like to get a bill board and put it up in my territory. Maybe a couple of them if I can connect with him.
The primary injury diagnosis leading to suicide is “anosognosia”. Damage to the left anterior temporal and frontal lobes or the right mid-parietal lobe. This can only be diagnosed by a neurobehavioral testing specialist who has experience looking for it. Luckily, the first examiner I had defined it in his report but did not diagnose it. Neither did the neurologist who ordered the report or the psychiatrist who was my PC at the time.
I have a consult now form a SW to the Chief of Psychiatry for the sub diagnosis of my TBI. And it shouldn’t be just “adjustment disorder due to TBI” or as is currently, “organic personality disorder” AKA “personality disorder due to TBI”
I’ll keep you posted in the results. I’m also waiting for the “TBI” examination remanded because of Ben’s pointing out and the CAVC remanding cases for the lack of qualified TBI examiners doing the examinations. My last TBI exam and the CAVC cases are perfect examples of why not only does the examiner need to be qualified, but must be particularly qualified to look for the residuals that are leading to suicide.
“TBI is the signature injury of the Iraq and Afghanistan wars.” NOT TRUE — The statement should be it is the signature injury of Combat and hand to hand combat training. Also many sports.
The use of non military for logistics exposed the hidden fact that COMBAT Veterans have been for every war left to come home with adjustment disorders due to combat and hand to hand combat training from focal TBI and concussive TBI.
I started the effort to get these injuries diagnosed and treated properly in 1987 after two years in PTSD groups recognizing many group members had the same symptoms I had including subtle nerve sensory signs that they should be examined for TBI as I had been from catching the right psychiatrist in a C&P examination in 1985. Yes, he also diagnosed PTSD. And as he believed, I believe organic brain damage residuals of focal injuries and disease are frequently the difference between the veteran exposed to traumatic stress who develops PTSD and the veteran exposed to the same combat stress incident who adjusted to it without great residuals.
I have continued the fight and seek others to join me in it for all of those 32 years. Partial success finally came 21 years later after much effort in 2008 but not directly from my effort. I like to think the reporter that broke the story did so from seeds planted in my effort. The only way he could get the story out was to claim it was a “signature injury to current wars.” The Congress and the VA didn’t want their covering this up to get out. My primary effort occurred during the Clinton and Bush efforts after my letter writing to the VA didn’t work and my court effort, Bray v Derwinski failed probably primarily because of my untreated temporal lobe seizure residuals from my non combat TBI.
My PTSD event was also non combat. It was a personal assault by an RVN Officer. But both gave me the insight to recognize, from my 13.5 years as a Navy hospital corpsman (medic) what was going on. The VA was covering up with diagnosis of “adjustment disorder” since the Civil War. First because they didn’t recognize the injury cause and then later to curtail entitlements.
Lem, you are awesome. Well said.
Ben, I would like to point out that I do not have a website. I do not publish your work anywhere. I share information with other veterans and friends in my circle. As for what I have discussed on your website is coming from my experiences and from my information. Ben, I do not copyright anything for personal gain. I am not the type person who would take such actions. Not who I am. Best. Ben, I have lots to say about this article and your previous article about the pharmaceuticals. Got to go but will return to comment on the topics. Best.
Lowering the standards is certain to result in misdiagnoses in which (naturally) veterans will be denied much needed benefits, appropriate medical care and caregiver benefits. VA is pushing the propaganda that you can “recover” from a TBI. VBA likes to place less weight on evidence from civilian doctors at comp & pen appts. And the expense of private neurologists and testing will be cost prohibitive unless the veteran has private health insurance. This is a TRAVESTY! Why can’t veterans ever get a President that has BEEN IN THE MILITARY and might actually understand veteran issues and truly DO something about them? WHY don’t veterans use our considerable VOTING POWER in the 2020 elections. Those slimeey politicians cater to every other major voting block… We need to organize at the grassroots level and demand the rights we FOUGHT and many DIED for. These rights have been EARNED by god!
If TBI’s where recoverable then one has to ask why the NFL is placing so much emphasis on preventing them in the first place with new and improved head safety equipment.
How low can they go below drooling dancing monkey qualifiers or fresh from the hut witch dr’s? They already hire manatees and place white coats on them and call them nurses…
All this does is force the veteran to come out of pocket for a private sector specialist and force the veteran to spend more time fighting a claim. Fuck the VA. Shoot em all.
The VA has promoted its Top Plumber to TBI Clinical Diagnostician for TBI (traumatic] brain injury), after a one hour intensive course in Psychiatry.
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