The following is the second chapter in an NPR/ProPublica investigation on the military's health plan's refusal to cover cognitive rehabilitation to traumatic brain-injury patients.
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 t he 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.
Continue reading this NPR News/ProPublica investigation:
* Chapter 3: Pentagon Contractor Finds Therapy Inconclusive
* Chapter 4: Service Members Struggle to Receive Care