Opinion ID: 4707703
Heading Depth: 1
Heading Rank: 2

Heading: veterans’ health care

Text: The VA provides medical care to veterans through the Veterans Health Administration (“VHA”). The Secretary of Veterans Affairs (the “Secretary”) manages the provision of health benefits to eligible veterans. See Veterans Health Administration, About VHA, https://www.va.gov/health/aboutvha.asp (last accessed July 29, 2021). Dr. Robert Ferris, an expert witness retained by Mr. Smith, testified that the standard of care for medical treatment received through the VA is no different from the standard of medical care that applies throughout the United States. 1 See Anestis v. United States, 749 F.3d 520, 527 (6th Cir. 2014) (noting a veteran’s widow’s claims of malpractice by VA hospital staff were “based on standards of care that govern medical professionals” generally). The VA provides medical care to veterans by two means: (1) by providing care directly through the VA’s own medical professionals and their supporting personnel; and (2) by paying medical-care providers in the local community outside the VA when veterans need care that cannot be provided within the VA 1 As part of the limited initial discovery in this case, Mr. Smith had expert reports prepared by a physician, Dr. Ferris, and a nurse, Karen Rose. The United States deposed both experts prior to filing its motion to dismiss the complaint. 3 USCA11 Case: 20-11365 Date Filed: 07/29/2021 Page: 4 of 58 system. See Community Care, Veterans Overview, https://www.va.gov/ communitycare/programs/veterans/index.asp (last accessed July 29, 2021). As to outside treatment, the medical care is arranged through a purchasedcare model where the VA must authorize the outside treatment in advance. See 38 U.S.C. § 1703. The VA’s approval process for outside care has two components: (1) administrative review; and (2) clinical review. The process begins when a VA provider (such as a doctor) completes, signs, and submits a non-VA care referral through the VA’s Computerized Patient Record System. Members of the VA’s Care Coordination Team then perform an administrative eligibility review to determine whether to approve the outside care. The administrative review involves determining whether the patient is eligible as a veteran to receive VA benefits. The VA’s Care Coordination Team also performs a clinical review. That clinical review—which cannot occur unless the patient is administratively eligible—concerns whether, for example, the services are available within the VA and whether the outside services are medically necessary. While the eligibility review may be conducted by someone acting in a solely administrative role, the clinical review is conducted often by a nurse, sometimes with the oversight of a doctor. The “referral review process” is complete once the referral is approved or denied. 4 USCA11 Case: 20-11365 Date Filed: 07/29/2021 Page: 5 of 58 Here, both the administrative and clinical review were performed by Nurse Nkechi Ekwueme (“Nurse Ekwueme”), who was the VA’s Care Coordinator for Mr. Smith. After the outside medical care is approved, another VA employee schedules the appointment with an appropriate outside care provider. The VA’s Care Coordinator has another substantive role in a veteran’s medical care. Nurse Karen Rose (“Nurse Rose”), another expert witness retained by Mr. Smith, testified about the functions of a VA nurse care coordinator and whether Nurse Ekwueme acted “within the standard of care for nursing care coordination” throughout Mr. Smith’s care. 2 In particular, Nurse Rose, a registered nurse with VA work experience, opined that one of the primary functions of a VA care coordinator was to “[t]rack and monitor” the patient’s medical care and treatments throughout the time he is receiving outside VA care. According to Nurse Rose, Nurse Ekwueme was responsible for, among other duties, managing, coordinating, and monitoring the medical consultation and 2 Nurse Rose’s past employment included positions as a “Nurse Case Manager” at Fort Bliss, Texas, a case manager for high-risk patients within the VA, and an “Alternate Traveling Veteran Care Coordinator.” In these positions, Nurse Rose was involved in coordinating care for soldiers and veterans, including “facilitating care . . . with outside facilities.” Nurse Rose based her opinions in part on the “Case Management Society of America Standards of Practice” (which lays out “standards of practice for all case managers who coordinate care”) as well as her education and work experience. 5 USCA11 Case: 20-11365 Date Filed: 07/29/2021 Page: 6 of 58 treatment Mr. Smith received from an outside ear, nose, and throat (“ENT”) specialist, Dr. Sanford Duke. 3 We now detail Mr. Smith’s medical care.