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Pentagon Health Plan Won’t Cover Brain-Damage Therapy for Troops

The Pentagon’s health care program run by Tricare denies coverage of cognitive rehabilitation to troops with traumatic brain injuries, claiming the treatment does not meet their standards, despite medical groups’ consensus that it improves the quality of life and despite criticism of the study Tricare did to justify its position.

Sarah Wade, 36, and her husband, Ted Wade, 33, are seen in front of the Capitol building in Washington, D.C., on Dec. 18, 2010. Ted suffered a traumatic brain injury, along with multiple other injuries, while riding in a Humvee in Iraq in 2004. Although Ted gets health insurance through the Defense Department, Sarah says "it doesn't cover what it needs to" and that he needs "more options, and less bureaucracy." The Wades live in Chapel Hill, N.C., but regularly travel to Washington for medical appointments and meetings. (Coburn Dukehart/NPR)

Versions of this story were co-published with NPR and Stars and Stripes. For more coverage, listen to NPR's All Things Considered.

During the past few decades, scientists have become increasingly persuaded that people who suffer brain injuries benefit from what is called cognitive rehabilitation therapy -- a lengthy, painstaking process in which patients relearn basic life tasks such as counting, cooking or remembering directions to get home.

Many neurologists, several major insurance companies and even some medical facilities run by the Pentagon agree that the therapy can help people whose functioning has been diminished by blows to the head.

But despite pressure from Congress and the recommendations of military and civilian experts, the Pentagon's health plan for troops and many veterans refuses to cover the treatment -- a decision that could affect the tens of thousands of service members who have suffered brain damage while fighting in Iraq and Afghanistan.

Tricare, an insurance-style program covering nearly 4 million active-duty military and retirees, says the scientific evidence does not justify providing comprehensive cognitive rehabilitation. Tricare officials say an assessment of the available research that they commissioned last year shows that the therapy is not well proven.

But an investigation by NPR and ProPublica found that internal and external reviewers of the Tricare-funded assessment criticized it as fundamentally misguided. Confidential documents obtained by NPR and ProPublica show that reviewers called the Tricare study "deeply flawed," "unacceptable" and "dismaying." One top scientist called the assessment a "misuse" of science designed to deny treatment for service members.

Tricare's stance is also at odds with some medical groups, years of research and even other branches of the Pentagon. Last year, a panel of 50 civilian and military brain specialists convened by the Pentagon unanimously concluded that cognitive therapy was an effective treatment that would help many brain-damaged troops. More than a decade ago, a similar panel convened by the National Institutes of Health reached a similar consensus. Several peer-reviewed studies in the past few years have also endorsed cognitive therapy as a treatment for brain injury.

Tricare officials said their decisions are based on regulations requiring scientific proof of the efficacy and quality of treatment. But our investigation found that Tricare officials have worried in private meetings about the high cost of cognitive rehabilitation, which can cost $15,000 to $50,000 per soldier.

With so many troops and veterans suffering long-term symptoms from head injuries, treatment costs could quickly soar into the hundreds of millions, or even billions of dollars -- a crippling burden to the military's already overtaxed medical system.

The battle over science and money has made it difficult for wounded troops to get a treatment recommended by many doctors for one of the wars' signature injuries, according to the NPR and ProPublica investigation. The six-month investigation was based on scores of interviews with military and civilian doctors and researchers, troops and their families, visits to treatment centers across the country, confidential scientific reviews and documents obtained under the Freedom of Information Act.

"I'm horrified," said James Malec, research director at the Rehabilitation Hospital of Indiana and one of the reviewers of the Tricare study. "I think it's appalling that we're not knocking ourselves out to do the very best" for troops and veterans.

Defense Secretary Robert Gates, who has complained over the past year about the growing cost of the Pentagon's health care budget, declined a request for an interview. George Peach Taylor, the newly appointed acting assistant secretary of defense for health affairs, the top ranking Pentagon health official, also declined repeated interview requests. Tricare officials defended the agency's decision not to cover cognitive rehabilitative therapy and said it was not linked to budget concerns.

Capt. Robert DeMartino, a U.S. Public Health Service official who directs Tricare's behavioral health department, said Tricare is mandated to ensure the quality, consistency and safety of medical care delivered to service members.

He said those standards can be difficult to meet with cognitive rehabilitation. Therapists design highly individualized treatment plans, often relying on a variety of different techniques. The holistic approach and lack of standardization makes it hard to measure the effects of the therapy, he added.

DeMartino noted that the agency covers some types of treatment considered part of cognitive rehabilitative therapy. For instance, Tricare will pay for speech and occupational therapy, which can play a role in cognitive rehabilitation.

DeMartino said cost played no role in the agency's decision, calling such a suggestion "completely wrong." He defended the agency's studies of cognitive rehabilitation, calling them objective scientific reviews designed to ensure troops and retirees receive the best treatment possible.

Cognitive rehabilitation therapy "is a new field for us," DeMartino said. "We don't know what it is. That's really an important thing. You don't want to send people out when you don't know what treatment they're going to get and what the services are going to be."

Officials at the Pentagon are themselves divided on the value of the treatment. A handful of military and veteran facilities provide cognitive rehabilitation therapy, though most do not have the capacity or offer programs of limited scope.

Tricare was designed to fill in such gaps in the military health system by allowing troops and veterans access to civilian medical providers. But since Tricare has a policy against covering cognitive rehabilitation, service members and retirees who seek treatment at one of the nation's hundred of civilian rehabilitation centers could have their claims denied, or only partly paid.

The contradictory policies have resulted in unequal care. Some troops and their families have relied upon high level contacts or fought lengthy bureaucratic battles to gain access to civilian cognitive rehabilitation programs which provide up to 30 hours of therapy a week. Soldiers without strong advocates have been turned away from such programs, or never sought care, due to Tricare's policy of refusing to cover cognitive rehabilitation therapy.

As a result, many soldiers, Marines and sailors with brain injuries wind up in understaffed and underfunded military programs providing only a few hours of therapy a week focused on restoring cognitive deficits.

Sarah Wade's husband, Ted, was a sergeant with the 82nd Airborne Division when a roadside bomb tore through his Humvee in February 2004. The blast severed his right arm above the elbow, shattered his body and left him with severe brain damage.

After the military medically retired her husband later that year, Wade struggled to find appropriate care for him. The closest VA hospital set up to handle such complex injuries was in Richmond, Va., a 320-mile drive from their home in North Carolina.

Tricare, however, would not pay for cognitive rehabilitation at a nearby civilian program. Wade, who once worked as an intern on Capitol Hill, turned herself into a one-woman lobbyist on her husband's behalf. She called her representatives and met with senior VA and DOD officials. She testified before Congress, met President George W. Bush and Gates, and was recently invited to the White House by President Barack Obama for a bill signing ceremony.

Wade managed to set up a special contract between the VA and a local rehabilitation doctor to help her husband. But now she wants to move back to Washington, D.C., to be closer to family.

She must begin her fight all over again -- more phone calls to Tricare, more visits to government offices, more battles to get Ted Wade the care he needs.

"We go to Capitol Hill like some people go to the grocery store," Wade joked one afternoon during a recent visit to Washington. "If we can't figure it out, then probably nobody can."

Brain Campaign

The campaign to persuade Tricare to cover cognitive rehabilitation therapy began in earnest after the scandal at Walter Reed Army Medical Center in Washington in 2007. News reports featured brain-damaged soldiers living in squalid conditions and receiving substandard care.

The Brain Injury Association of America, a grassroots advocacy group for head trauma victims, started lobbying Congress and the Defense Department to order Tricare to cover rehabilitation for service members.

The campaign was a natural extension of the association's mission. Each year, more than 1.4 million American civilians suffer brain injuries in car accidents, strokes and other medical emergencies. They and their families often have to battle private insurance companies for cognitive rehabilitation.

The insurance industry is divided: Five of 12 major carriers will pay for cognitive rehabilitation therapy for head trauma, according to Tricare's study. Aetna, United Healthcare and Humana cite national evidence-based studies and industry-recognized clinical recommendations that point to the therapy's benefits.

The federal Centers for Medicare and Medicaid Services does not have a single national policy on cognitive rehabilitation. Instead, it leaves decisions to local contractors, often insurance carriers who process claims for the agency. The contractors are able to provide the therapy case by case, so long as they determine the treatment is "reasonable and necessary," a Medicare spokesman said.

"The totality of the evidence appears to support the value of cognitive rehabilitation for people with traumatic brain injury in improving their function," said Robert McDonough, the head of clinical policy at Aetna. "We feel on balance the evidence leads us to conclude that cognitive rehabilitation is effective."

Carriers and doctors providing the service can point to a long list of medical associations and scientific studies backing the effectiveness of cognitive therapy: The National Institutes of Health; the National Academy of Neuropsychology and the British Society of Rehabilitation Medicine, among others, have weighed in supporting the treatment.

Armed with such evidence, brain injury association lobbyists did not have much trouble finding support in Congress. By 2008, more than 70 House and Senate members had signed letters to Gates asking him to support funding for cognitive rehabilitation therapy. Then-Sen. Obama led a group of 10 senators urging Tricare to pay for therapy.

They noted that the Pentagon and the VA have improved their efforts to treat brain injury, including increases in the number of doctors and therapists available at facilities.

But the military needed to do more, they said. They wrote that Tricare should cover cognitive rehabilitation so all troops "can benefit from the best brain injury care this country has to offer."

"Given the prevalence of TBI among returning service personnel, it is difficult to comprehend why the military's managed healthcare plan does not cover the very therapies that give our soldiers the best opportunities to recover and live full and productive lives," the letter said.

A response letter from the Pentagon told the representatives that Tricare officials had not been convinced by available evidence. "The rigor of the research ... has not yet met the required standard," wrote Gordon England, then the deputy defense secretary.

Everyone Agrees

On an unusually hot spring day in April 2009, 50 of America's leading brain specialists gathered for two days in a sterile hotel ballroom in suburban Washington, D.C.

The Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury, the Pentagon's lead program for the treatment of brain injury, convened the conference to help settle the debate about cognitive rehabilitation therapy.

The participants were top researchers and doctors from the military and civilian world: neurologists, neuropsychologists, psychiatrists, therapists, family doctors and rehabilitation experts.

After two days of discussion, the group hammered out a consensus report, representing the combined wisdom of the field. Their unanimous conclusion: Cognitive therapy improved the thinking skills and quality of life for people suffering from severe and moderate head injuries. Troops with lingering problems from a mild traumatic brain injury, or concussion, also could benefit from the therapy, the experts said.

The consensus was not binding. But those in attendance believed that their opinion -- based on the decades of combined clinical experience and academic study present in the room -- would lead to troops' receiving better treatment.

"When you get the right people in the right room at the right time, you'd expect it would influence the decision makers," said Maria Mouratidis, chairwoman of psychology and sociology at the College of Notre Dame in Baltimore and a conference participant.

Shortly after the conference ended, however, a handful of top officials from the military's medical system met to discuss the findings at Tricare's headquarters, an anonymous sprawl of office buildings in Falls Church, Va., known as Skyline 5.

One person familiar with the discussion, who did not want to be identified for fear of reprisal, said money was part of the debate.

Official Pentagon figures show that 188,000 service members have suffered brain injuries since 2000. Of those, 44,000 suffered moderate or severe head injuries. Another 144,000 had mild traumatic brain injuries. However, previous ProPublica and NPR reports showed that number likely understates the true toll by tens of thousands of troops. Some estimates put the number of brain injuries at 400,000 service members.

Mild traumatic brain injuries are the most common head trauma in Iraq and Afghanistan. Commonly caused by blast waves from roadside bombs, such injuries are defined as a blow to the head resulting in an alteration or loss of consciousness of less than 30 minutes. Studies suggest that while most troops with concussions heal quickly, some 5 percent to 15 percent go on to suffer lasting difficulties in memory, concentration and multitasking.

For the military's health system, the costs of treating brain damaged soldiers with cognitive rehabilitative therapy added up quickly. If tens of thousands of service members and veterans were authorized to receive such treatment, the bill might be in the billions, using high-end estimates for the cost of treatment from the Brain Injury Association.

The costs could swell the Pentagon's annual $50 billion health budget -- at a time when Gates has said the military is being "eaten alive" by skyrocketing medical bills.

Tricare "is basically an insurance company. They'll take no action to provide more service," said the person familiar with the conversation, who would only discuss it in general terms. "If they do it, it's an enormous cost."

At the meeting following the consensus conference, the person said, Tricare staked out its own position: "They had already decided not to do it," the person said.

NPR and ProPublica contacted two others who attended the meeting. Jack Smith, Tricare's acting chief medical officer, said through a spokesman that he could not recall the meeting, but "can't say for sure there wasn't one." Rear Adm. David J. Smith, the joint staff surgeon, declined comment through a spokesman.

The Contract

Soon after the meeting, Tricare sprang into action. In May 2009, records show, it issued a $21,000 contract to the ECRI Institute, a respected nonprofit research center best known for evaluating the safety of medical devices.

The contract called for ECRI to review the available scientific literature to weigh the evidence for whether cognitive rehabilitation therapy helped improve patients with traumatic brain injuries.

Tricare routinely hires contractors to carry out assessments to help determine which medical treatments to fund. But in selecting ECRI, Tricare had a pretty good idea of the response it would receive. ECRI had conducted a similar review for Tricare in 2007 that cast doubts on the evidence supporting cognitive rehabilitation therapy.

To carry out the new review, ECRI followed its standard protocol. It chose to include only randomized, controlled studies. Such studies randomly divide patients into groups that receive different treatments in order to compare their effects.

ECRI gave more credence to blind studies, meaning that patients did not know whether they were receiving genuine therapy or a placebo -- a fake treatment. Blinding reduces bias and is considered one of the most rigorous standards that can be used in scientific testing.

ECRI also excluded studies deemed irrelevant; those studies with fewer than 10 patients; and studies where 15 percent or more of the patients were injured from a nontraumatic blow, such as stroke.

The criteria resulted in the elimination of much of the published scientific literature on cognitive rehabilitative therapy. Before applying the protocol, ECRI identified 318 articles as potential sources of information about cognitive rehabilitative therapy. The firm's final report examined 18.

Based on this limited pool, ECRI graded the evidence for the benefits of cognitive therapy as being "inconclusive" or offering only "low" or "moderate" support of improvement in patients' cognitive functions.

The final report, delivered to Tricare in October 2009, noted some areas of benefit. For instance, "tentative" evidence showed cognitive therapy significantly improved quality of life for brain-damaged patients.

ECRI's review wasn't limited only to science. The review noted one study that found that comprehensive cognitive rehabilitative therapy could cost as much as $51,480 per patient. By contrast, sending patients home from the hospital to get a weekly phone call from a therapist amounted to only $504 per patient.

Overall, the report concluded, the evidence for most benefits from cognitive rehabilitation therapy remained inconclusive, especially when compared to cheaper programs.

"The evidence is insufficient to determine if comprehensive, holistic (cognitive rehabilitation therapy) is more effective than less intensive care" in helping patients, the 2009 report concluded.

Tricare Criticized

By the summer 2009, ECRI researchers had finished a draft of the study. ECRI, later joined by Tricare, asked outside scientific experts to review it.

The reviews, according to interviews and copies obtained by NPR and ProPublica, were uniformly critical.

(NPR and ProPublica obtained a copy of the ECRI reports through the Freedom of Information Act. However, Tricare denied access to reviews of the reports. ProPublica and NPR have appealed the request, but obtained copies of the reports and information on the reports from sources.)

The reviewers acknowledged that more research was needed on cognitive rehabilitation therapy. However, they noted that the Tricare report ran counter to several other so-called meta-analyses, which combine multiple, individual scientific studies to achieve greater statistical reliability.

For instance, a 2005 article in the Archives of Physical Medicine and Rehabilitation, a peer-reviewed journal that is one of the mostly widely respected in the field, examined 258 studies. It concluded that "substantial evidence" supported cognitive rehabilitation. The review included 46 randomized control studies -- more than double the number in the Tricare study.

Reviewer Keith Cicerone, a leading civilian researcher who runs the JFK Johnson Rehabilitation Institute's Center for Head Injuries in New Jersey, disputed Tricare's contention that the treatment was new and untested.

"We have a significant body of evidence describing cognitive rehabilitation and showing what works in cognitive rehabilitation," Cicerone said. "The idea that cognitive rehabilitation is new and untested is simply not true. It's got a better evidence base than most things that we do in rehabilitation."

Asked to explain in plain terms, Cicerone grew animated: "The arguments that are being made against" cognitive rehabilitation "in terms of the level of research that has been conducted are hooey," he said. "It is baloney."

The outside experts also attacked Tricare and ECRI for relying upon a methodology that ruled out important research. ECRI's protocols, they acknowledged, are well-suited for drug studies, where it is easy to prevent patients from knowing which pill they are receiving.

But ECRI's protocols do a poor job in assessing rehabilitation therapy where patients and doctors constantly interact in face-to-face treatment sessions. Other well-accepted methodologies, they said, have been designed to examine the benefits of therapeutic interventions.

They also questioned the reasons for excluding studies with a small number of patients, or with differing causes for brain injury, since a stroke can produce the same types of symptoms as a blow to the head.

Malec, the research director at the Rehabilitation Hospital of Indiana, said Tricare's study sounded like it came from a private insurance company seeking to cut costs. His review said that Tricare's study "fails to represent the evidence relevant to evaluating the effectiveness of cognitive rehabilitation after traumatic brain injury."

In an interview, he said Tricare's demand for conclusive evidence was understandable, but ill-advised. While research continues, existing evidence indicates that the therapy helps, with no studies showing that it harms troops.

"They missed the forest for the trees. They missed the big picture," he said.

Some of the researchers accused Tricare of using ECRI's strict assessment protocols as a cover to justify denying troops' coverage.

Wayne Gordon, director of rehabilitation psychology and neuropsychology services at Mt. Sinai School of Medicine in New York, called the review "dismaying" and "unacceptable." He compared it to tobacco companies that dismissed studies that showed a link between smoking and cancer.

"The ECRI Institute seems to be stating that, while sufficient evidence exists for there to be consensus among diverse groups that cognitive rehabilitation is a useful service, this evidence is 'not good enough' for Tricare," wrote Gordon, who declined to explain his comments further in an interview. He wrote that the ECRI study was "designed to reach a negative conclusion."

ECRI also asked two additional researchers to examine the report, John Corrigan, director of the Ohio Valley Center for Brain Injury Prevention and Rehabilitation in Columbus, and John Whyte, the director of Moss Rehabilitation Research Institute in Pennsylvania, both leading researchers in the field.

Both men declined to comment, citing their contractual obligations with ECRI, and Tricare declined to release their reviews. People familiar with their contents said Corrigan and Whyte closely mirrored the views of their fellow critics. They recommended that ECRI use a different method to judge studies of cognitive therapy, but the institute refused.

ECRI "said thank you very much, but we're not changing anything," said one person familiar with the review process.

More Studies, More Waiting

In an interview, ECRI Institute officials defended their firm's methodology. The system is designed to provide a rigorous review free from researchers' bias, they said.

Karen Schoelles, ECRI's medical director for the health technology assessment group, acknowledged that some of the institute's criteria -- such as accepting only studies with 10 or more patients -- were "arbitrary." But she said they were widely accepted in the assessment industry.

She also noted that Tricare officials were aware of the criteria and made no attempt to change or adjust them. Tricare used ECRI Institute for almost 10 years to carry out health reviews, though the agency recently terminated the contract and selected a new firm to carry out assessments.

Cognitive rehabilitation "may be on to something," Schoelles said. "But it needs more research."

Schoelles acknowledged that ECRI's own reviewers had criticized the report. ECRI offered to provide copies of the reviews, but later said that Tricare ordered them not to release them.

Stacey Uhl, the lead researcher on the review, said the criticism did not change her view that randomized controlled trials were the best way to assess the quality of evidence.

She noted the review found evidence that cognitive therapy did help in some way and said she would not rule out seeking such care for a loved one.

"I as a parent would want my child to receive all available therapies," she said.

DeMartino, the Tricare official who commissioned the report, acknowledged the outside reviewers had "very, very strong opinions" that were "of concern."

He said Tricare was conducting a review to determine whether ECRI's techniques were best suited to measure cognitive therapy's benefits. He denied submitting cognitive therapy to overly-strict review standards.

"You get what you ask for," DeMartino said. "They tell us what they're going to give us, and it's our job to sort of say, 'Okay, we understand that within the limitations of their methodology, this is the information that we get.'"

He added: "The better the information you have, the better that you can move forward and do the best thing." The Tricare reports, coupled with high cost projections, ended the legislative push to get cognitive rehabilitation for service members and veterans.

Last year, Congress ordered the Pentagon to conduct further studies to review the effectiveness of the therapy, but those studies have not yet begun and results are not expected for several years.

Tricare said it would conduct regular reviews to monitor developments in the field. DeMartino first said Tricare would carry out a new review beginning in September. A spokesman later clarified that the National Academy of Sciences Institutes of Medicine would perform the review. It is scheduled to be completed by the end of 2011.

Susan Connors, president of the brain injury association, said she was stunned by the need for legislation at all. As the Pentagon conducts yet more studies, thousands of troops and veterans may be going without the best known treatment available. Thousands more would have to rely on military hospitals or veterans clinics far from their homes, or with substandard programs. The Tricare refusal shut down access to the hundreds of civilian rehabilitation clinics nationwide.

"I'm very disappointed by the resistance," she said. "The military should want to do this."

Struggling for Care

Tricare's stance has not made it impossible to get cognitive rehabilitative. But it has discouraged civilian clinics from treating soldiers.

In interviews, several clinic owners and medical directors described their frustrations.

On some occasions, they were paid after developing relationships with individual Tricare claims processors or case managers, only to have the arrangements fall apart if the person left.

"We have tried to get Tricare and just beat our head against the wall," said Brent Masel, the president of the Transitional Learning Center in Galveston, Texas. "It took forever to get paid. It was always a fight."

Mark Ashley, the president of the Centre for Neuro Skills, a chain of rehabilitation clinics, said Tricare and other insurance providers were unwilling to pay because those with brain injuries can often perform basic functions that let them get through their daily lives.

They are "able to walk around, able to maneuver, but can't function cognitively in a manner that's safe, appropriate or competent," said Ashley, a past president of the brain injury association. "We can fix much of that, but it takes an exhaustive amount of time and effort. That's where the payers are out of touch."

One of the nation's top brain injury centers set up a charity program to help cover gaps left by Tricare. Susan Johnson, who runs Project Share at the Shepherd Center in Atlanta, said Tricare pays only about 40 cents of each dollar of care provided for the type of comprehensive program that the clinic has found successful. The rest comes from Bernie Marcus, a billionaire philanthropist, and income from inpatient services.

"These guys go and they put their lives on the line and we put them in this situation that's difficult for some and less difficult for others to get care," Johnson said. "I find it frustrating."

Other clinic owners said they were able to game the system by providing cognitive therapy, but billing for other Tricare-covered services -- putting them at risk of being accused of false billing.

One clinic manager acknowledged being "creative" when submitting bills to Tricare. He said that he submitted bills to Tricare for occupational therapy when the treatment focused more on improving memory.

"They won't pay for this, but they will pay for that," said the manager, who did not want to be identified for fear of damaging his ability to receive payments. "You just have to figure out how to work the system."

Soldiers and families agreed that Tricare's stance has made getting care a battle.

Sarah Wade said she patched together adequate care for Ted, arranging for him to go to a VA hospital for some services and to travel to Walter Reed Army Medical Hospital for others.

Tricare would have paid for some things, such as a physical therapist to help him learn to walk again. But she has had no luck trying to persuade Tricare to pay to treat his brain injury.

In frustration, Wade personally visited a high-ranking official at the Veterans Affairs Department. He, in turn, ordered a VA hospital to fund a special contract with a local civilian rehabilitation doctor near the Wades' North Carolina home.

"Yes, we have been able to get [cognitive rehabilitation] paid for, but it's been with a lot fighting, red tape, and bureaucracy," Sarah Wade said. "It's his greatest injury and the one that impacts his life the most, that impacts his ability to be a human." She added, "It shouldn't be this hard."

The Wades credit the rehabilitation that Ted has received with markedly improving his cognitive problems. After his 2004 injury, Ted spent months regaining consciousness. Doctors were unsure about his mental state, not certain he would ever talk or even think rationally.

Today, Ted speaks in slow, sure sentences, even cracking jokes. He can make decisions -- choices that seem simple enough to someone with normal cognitive skills, but which often stymie those with brain injury.

He knows, for example, to buy cherry tomatoes at the store rather than big tomatoes, which are hard for him to chop and slice with only one arm. He can read through a menu, and pick food that's nutritious. He can wash and fold his own laundry.

One recent day after dining at a Mexican restaurant in Washington, Ted smiled when Sarah reminded him that he was once unable to figure out whether he liked hot sauce on his tacos.

"It's been a long, slow process," he said.

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Throw them under the bus like the 99’ers.
As long as the youth thinking of enlisting don’t get wind of this prior to enlistment, who cares?
Those with brain damage aren’t worth a shit to do the dirty work anymore, so who cares- It’s the ‘New American Way’, get used to it.
Just further proof of collapse of a ‘Once Great Nation’.
Go Obama, u jive ass back stabbing miserable excuse of a world leader and don’t email me further asking for donations or campaigning for Ur re-election.
America has many woes & w/o a leader to address what Americans are beginning to believe is a complete collapse of America, were screwed- u would think with ears that large he could clearly hear the cry of the American populace to get out of all these protracted wars & address our crumbling status of a broken nation soon to suffer the consequences of disrespecting the peoples will.
Obama’s sellout to his support base, & the country as a whole, has made clear who the jive ass really is.

Lawrence F Muscarella PhD

Dec. 20, 2010, 4:12 p.m.

Interesting what Dr. Gordon found, that ECRI study’s was “designed to reach a negative conclusion.”

My research has found a similar bent toward appeasing the funding source, and, often, to a “positive conclusion” about a medical device’s safety (when, in fact, the device’s lack of safety and risk of patient injury are conspicuous and self-evident).

I wrote about this in an article that is available at: <www.myendosite.com/htmlsite/2008/sleepingdogs2.pdf>.

That ECRI “did not see the forest for the trees” and missed what not only its non-profit status mandates it to oversee, but also what may be the most significant breach in aseptic technique in U.S. history - the use in most U.S. operating rooms of an adulterated and misbranded (i.e., illegal) instrument “sterilizer,” not just for one or two years, but for more than 20 years, from 1988 until 2009, without the patient’s knowledge, exhibits a non-profit model that has gone awry and requires repair.

My concerns about ECRI’s evaluations of medical devices, this “sterilizer,” and its changing of its recommendations and ratings of health care product based, not on scientific data, but on financial pressures appear both on the front page of the “Wall Street Journal” (see:  http://www.myendosite.com/articles/wsj122404.pdf) and is discussed in another of my articles, which can be read at: http://www.myendosite.com/htmlsite/2009/ss1.pdf

The public would benefit greatly if ECRI were in earnest to address its shortcomings, act in accordance with its mission statement and non-profit status, become independent of (and no longer have “working relationships” with) manufacturers, and steer itself back into scientific (and out of conjectural) waters. We wait in anticipation and with hope.

If we can’t afford to adequately care for U.S. soldiers injured as a result of wars we chose to instigate or perpetuate, I’d strongly suggest to you that we cannot afford to keep warring.

Defense Secretary Gates, do you have so little respect or regard for your fellow countrymen who’ve voluntarily put their lives on the line to fight your ongoing “hostilities” that you can callously complain about the rising costs of meeting their medical needs when they’re injured?

Those of you who continually purport the need to remain engaged in futile conflicts are consequently responsible for the deaths & injuries that occur as a result of your decisions.

See that these soldiers have the best care available, or get the hell out of the war business.

sophia matyiku

Dec. 21, 2010, 10:06 a.m.

simply stated….APPALLING !!! this horrible decision must be reversed immediately….what a way to take care of the men/women who protect this country…..i’m disgusted with the politics here…....

We can’t afford to go to war if we can’t afford to take proper care of the soldiers.  We need to get out of these countries and stop trying to make them what we think they ought to be.

Another thought,. we can’t afford medical care for our soldiers, but let an illegal cross the border and drop and baby or sneak in and bring the whole family and this country will pay every last bill these people have,.. education, housing, medical, etc.
It totally disgusts me.

Brian Donnelly

Dec. 22, 2010, 1:03 p.m.

Then pull them all out of Afghanistan and Iran, then send our congressmen and woman as they are brain damaged already. This is a disgrace

this is a sad note.  Brain trauma is as common as dirt in the middle east catastrophe.  every time those humvees was dumped by a IED, EVERYONE ABOARD IS ASSUMED TO HAVE HAD HIS OR HER BRAIN CONCUSSED.  but the government has no use for these people.  Limb loss has also been a major problem in these wars.

Pamela A. de Liz

Dec. 23, 2010, 7:45 p.m.

The problem is this treatment is just the TIP OF THE ICEBERG!

We now have new non-invasive technologies that allows us to begin to understand the impact of head and brain injuries.

We now are amassing lots of research which is allowing us to look at brain injuries and comparative treatments in new ways.

But mostly we are still discussing only RECENT brain injuries—-the below URL leads to an article in Science Daily tells us that these recent brain injuries will probably morph over time into CHRONIC conditions and thus even more costly to treat.

“Researchers Urge Reclassification of Traumatic Brain Injury as Chronic Disease”
http://www.sciencedaily.com/releases/2010/08/100826182504.htm

And what of former military members, who had head and brain injuries from past wars or incidents?

Have they been identified and reassessed in light of the new knowledge we are now learning about brain injuries?

Is the VA Medical Health System prepared to read their own research both historic head injuries and new on chronic brain injury and PTSD and put that research into clinical action at their medical facilities?

HAS A VA database and associated VA MIRECC yet been established and funded to track past and present vets who may have Chronic Brain Injuries
and to develop programmes and technologies they will need long term?  Look for yourselves…

http://www.mirecc.va.gov/index.asp

Cognitive rehabilitation therapy is not just costly, it speaks to the fact that brain injury is more than likely a chronic condition that might require cognitive rehab therapy on multiple occasions throughout one’s lifetime and really ANY brain injury has unknown long term consequences and we are blind in the present to lifetime associated costs.

It also means that the VA and DOD’s mental health programmes must now be COMPLETELY REVAMPED AND RETOOLED to reflect the new reality and that is the real root of this problem!

Yeah, sticking your head in the sand and pretending the VA and DOD are clueless to the magnitude of the problem is allot cheaper all around….

WELL.  you must work for VA and or you’re a nurse.

surely not a veteran.  think VA and DOD give a shit about these veterans?  try thinking again.  you expectorate a lot of useless garbage, probably verbatim from the VAs website, or even DOD.  No one said these people are clueless.  They just won’t respond.

Maybe some Haliburton profits should be diverted to the Pentagon I am sure Dick Cheney and his cronies can make a more than substantial contribution. His lies, misinformation, and bloodlust for profit started this mess.  His money can help in cleaning it up.

Lawrence F Muscarella PhD

Dec. 24, 2010, 10:29 a.m.

Yes, but this may not be the first time that the VA may have made an assessment that was in error and to the detriment of the veteran.

See my article about infection-control lapses in Veterans Affairs medical centers that, contrary to my recommendation, were not disclosed to the veterans as arguably medically and ethically required:

http://www.myendosite.com/htmlsite/2010/VAOIG_PR.pdf ...

or read my comments on the front page of the “San Juan Weekly” newspaper, from last June:

http://www.myendosite.com/articles/SanJuanWeekly.pdf

Happy Holidays.
Lawrence F Muscarella PhD

Lawrence F Muscarella PhD


and your point is?

Magnus Mortensen

Dec. 25, 2010, 5:36 p.m.

THIS CALLS FOR ONLY ONE WORD=
SCANDALEOUS !!
HOW CAN OUR POLITICIANS GO TO SLEEP AT NIGHT OR FACE THE VOTERS THEY REPRESENT KNOWING THAT OUR INJURED SOLDIERS ARE TREATED LIKE USED GARBAGE?

our injured soldiers?  how quaint.  where were YOU when we came back from the nam.

our politicians?  speak for yourself.  politicians are lower than pedophiles.  you probably still think your vote is your ‘voice’ in government.  how naive.

I am disgusted at the “penny-pinching” that is going on with the VA and TriCare trying to save $$ at the expense of our wounded heroes!  I have a unique perspective on this issue.  No, I’m not a wounded warrior, but I am a disabled veteran and spouse of an active-duty soldier.  I also have a passion for my job as an Occupational Therapist, providing services to a wonderful community of disabled veterans at a state Veterans Home. 
From my experiences as a child, being raised by my mother who was a Nurse and suffered a severe TBI, I had my heart and mind set on a career in the Rehabilitation services.  I was trained as an Occupational Therapy asst in the Army, and completed my Masters in OT through the VA’s Voc Rehab program.  OT/ PT/ Speech Therapists often work with TBI/ cognitive rehab.  OT’s have the knowledge and training to provide holistic (cognitive and physical) therapy services to individuals with TBI/ neurological conditions.

If it wasn’t for my military training and education benefits, I might not be able to do a job that I love, and have the opportunity to help other veterans rehabilitate.  I guess what I’m trying to say is that I don’t understand how the VA is willing to put out all the money to “re-educate” those of us with physical conditions that prevent us from working in the certain jobs.  Yet, they are not willing to provide our wounded heroes with ANY available resources/ treatment that could potentially allow them to cognitively rehabilitate and live happy, productive lives.  And I personally and professionally know that what it does come down to is $$$!!! 

During my 6 months of fieldwork I worked at the military hospital as well as at the military school system.  During that 6 months I worked 40 hrs/ wk without pay and still had to pay tuition/ do online coursework, while raising 4 kids and a husband that was deployed.  But my financial loss was balanced by the rewards of being able to “give back” to my fellow veterans, especially the wounded warriors.

Maybe they should consider training more therapists that are active duty, as well as using students (especially in the Voc Rehab program) in their fieldwork education phase to provide more services to our active duty soldiers.  I would be honored to do therapy with these heroes!! 

To the Wades, may your fight for rehabilitation services be a stepping stone towards better overall health benefits for all our fellow veterans.

What is happening to the TBI Iraqi and Afghan people?I haven’t seen anything said about them.Are they getting daily readings from the Koran and plenty of goat’s milk?If so,
has anyone done an outcome study of it’s effectiveness?Those who are agitating for Cog.Therapy might be surprised.Those vets who WANT Cog.‘Therapy’‘should get it-that is my serious view.A problem can be that if someone is told that they cannot have something that may want it all the more.There will always be claim and counter claim about efficacy-Kaiser Permenente have some thing on the relative ineffectiveness of Cog.‘Therapy’ on the Web- not their study but studies by others.Rather than pay ‘therapists’ 50,000 dollars to give the ‘therapy’ it would be better to pay each vet the money directly.I manage a mva TBI patient and find that it is best to give as much autonomy as possible.Given a choice of ‘therapy’ at 80 dollars a week or have the money,the choice was the latter.He certainly seems no worse for it so I will go along with that for a while and observe this individual case for further improvement.A TBI patient of long standing ,he has made remarkable progress to here.He was originally damaged by incompetent psychotherapy when he ‘decompensated’ and a short time later was TBI in mva.I urge those fighting for help for the vets to make sure first that it is not just fighting for the sake of fighting. These cases are a lifetime commitment and ‘doggedness’ is vital if the patients are to have the best they can get.These TBI people must not be deserted by family at the very least.They may have in some cases already been betrayed to be in their current situation. KRWood BA(Psych),M.Medica

This article is part of an ongoing investigation:
Brain Wars

Brain Wars: How the Military Is Failing Its Wounded

The military has failed to diagnose brain injuries in thousands of soldiers returning from overseas.

The Story So Far

Traumatic brain injury is considered the “signature wound” of soldiers fighting in Iraq and Afghanistan. Official military statistics show that more than 115,000 soldiers have suffered mild traumatic brain injuries since the wars began. Shock waves from roadside bombs can ripple through soldiers’ brains, causing damage that sometimes leaves no visible scars but may cause lasting mental and physical harm.

More »

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