Patrick Malone, a former Army combat medic, had been waiting more than a year for a surgery to repair a service-related knee injury that was rapidly getting worse. 

The 38-year-old veteran can still walk but has a noticeable limp. His doctor has warned him not to play basketball or do anything else that would exacerbate it until he gets proper treatment.

He had cartilage cells from his knee harvested in 2019, with all costs covered by the Department of Veterans Affairs. Part two of the procedure, putting the cartilage into his bad knee, was finally scheduled for June 18 after coronavirus-related delays.

“I’ve had to plan life around this surgery,” Malone said in an interview on the back porch of his home in Aiea.

But in a preoperative appointment on June 16, Malone says staff at Pali Momi Medical Center told him the procedure was indefinitely postponed because the hospital wouldn’t accept the insurance he gets through the Department of Veterans Affairs. 

Malone, who has experience in health care, was immediately suspicious.

“They have a whole legal team and all of these resources to go after that money from the VA, they are not supposed to deny the care to the patient,” said Malone, who receives care through the MISSION Act.

The VA’s Pacific Island Healthcare System, headquartered on Oahu, oversees health care for all veterans across Hawaii, American Samoa, Guam and the Commonwealth of the Northern Marianas. It has for years struggled to reach veterans across its far-flung territory with its own limited facilities.

As a result, it relies heavily on partnerships and contracts with hospitals and clinics across the region that accept the insurance provided by the VA, allowing veterans to seek care elsewhere. Pali Momi Medical Center, which is part of the Hawaii Pacific Health network, is one of those partners.

Malone said that since leaving the military all his health care has been in community clinics and facilities, and the VA has always paid for the treatments.

So he was stunned when the staff at Pali Momi told him that his June 18 procedure had been canceled because the VA has been delinquent in paying medical bills at other hospitals on the mainland. While that had not happened yet in Hawaii, Malone said the hospital told him there was concern it could, so he could only go forward using alternative insurance.

When asked for comment an HPH spokesperson responded with an email statement from Pali Momi Chief Operating Officer Barb Craft. She said the hospital couldn’t discuss what happened, citing privacy concerns.

“While we can’t comment on specific patients, Pali Momi Medical Center works closely with the Department of Veterans Affairs to ensure veterans seeking services at our facilities receive the highest quality care possible using their VA medical benefits,” said Craft.

HPH would neither confirm nor deny whether it has begun rejecting VA insurance for certain procedures. Craft said simply that “in those instances when services they need may not be covered, we will work with the veteran to provide financial assistance as needed.”

But representatives of the VA and TriWest Healthcare Alliance, which handles VA claims, said they had guaranteed that Malone’s surgery would be covered so it should have gone forward.

‘Care Should Never Be Delayed’

“We talked with the provider, assured them that the VA authorization is good to go for the surgery,” said Karl Kiyokawa, TriWest Pacific Regional Director. “However, the provider wants assurance that the implant will not be denied by the VA.”

But Kiyokawa added that the specific code for the cartilage implant shouldn’t have been needed. “The VA authorization is inclusive of items covered in line with (Medicare and Medicaid) guidelines,” he explained.

Haywood Pittman, deputy chief of VA Community Care for the Pacific Island system, said the VA provided a specific code for the cartilage implant when Pali Momi requested that, but the hospital then demanded that the VA amend the authorization papers to include it, which wasn’t possible because federal policy doesn’t allow such amendments.

“The surgeon is authorized and agreed to perform the procedure, but the facility is declining it,” Pittman said. “Care should never be delayed by requesting addition of network facility or codes.”

Malone, who is currently studying health care administration and worked in health care contracting after he left active military service, said his inside knowledge has helped him navigate the process. But he worries other veterans are falling through the cracks.

“I’m sure there’s all kinds of veterans out there and it breaks my heart and it pisses me off,” he said. “Veterans who don’t understand the system like I do.”

The VA has for years weathered complaints and scandals regarding long wait times and difficulty accessing care. Former President Donald Trump’s administration pitched a series of reforms to move more veteran care to the private sector and potentially even shut down VA medical facilities altogether, instead sending veterans to private companies for care that would still be financed by VA insurance.

The controversial push had proponents who said it would expand choices for veterans, but some veterans groups expressed concern that it would essentially privatize the VA and lead to even more confusion.

Ultimately in 2018 Congress compromised with the passage of the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act, better known as the VA MISSION Act, which established a new Veterans Community Care Program. The rollout has been rocky with scattered reports of unpaid bills.

New Hampshire Congressman Chris Pappas told the Federal News Network that care providers in his district have reported unpaid bills. “If the bills aren’t paid then these networks won’t be sufficient to meet (veterans’) needs,” he said.

An Unfinished Procedure

Malone was born in California but met his wife and started a family in Hawaii. He enlisted in the Army in Honolulu in 2005. He spent three years in Germany before returning to Hawaii at Schofield Barracks and served in Iraq in 2010 as a member of the Oahu-based 25th Infantry Division. 

He went into the reserves in 2015 and left the Army in 2017 with a 60% disability rating, owing largely to the wear and tear of military life resulting in injuries to his left knee. Soon after, it became apparent to him just how disruptive his knee injuries would be, and he was diagnosed with severe cartilage damage and damage to his femur.

“At this point I’m in culinary school and I’m on my feet and I can’t stand to do class,” he said.

The doctor told Malone that he was too young to qualify for a knee replacement and instead recommended a Matrix-induced autologous chondrocyte implantation, which uses a patient’s own cells to regrow new cartilage for the knee joint.

First a surgeon performs a cartilage biopsy to harvest healthy cells, with the results sent to a lab to grow. Once ready, the surgeon cuts the cartilage implant to fit into the patient’s knee where the cells grow into place during recovery.

The VA approved the MACI, and Malone had his cartilage harvested in December 2019. He planned the recovery process for his school’s winter break.

His doctor had advised him that after the second surgery he was going to have to stay off his feet for 10 weeks to recover, so he planned it for the summer of 2020.

“Then coronavirus happened,” said Malone. The pandemic threw every aspect of life into upheaval, including health care. Malone’s appointment was among the countless treatments that had to be postponed.

The wait was so long that his VA authorization expired.

“The VA kept losing my paperwork, over and over again. My provider was sending it to the number that they have; VA said that’s the wrong number,” he recalled. “But finally I got the authorization squared away.”

Malone left culinary school, which required him to be on his feet, to study health care administration. He said he hoped he could someday be a resource for people navigating the system to find treatment.

When the week of the surgery came, Malone was crushed when he learned it had been called off again since the cancellation threw off his entire treatment and recovery plan.

He said he also had to cancel physical therapy that was scheduled to begin after the surgery and was also still authorized by the VA insurance. 

Meanwhile, Malone’s cartilage cells remain on ice. He said he’s been assured that his cells will be maintained indefinitely and will still be good if the surgery ever goes forward.

“I’m sure they will (keep the cells),” Malone said. “Because they’re getting paid by the VA to.”