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The Pentagon says it's giving top care to the tens of thousands of troops who've suffered traumatic brain injuries, or TBIs. But an investigation by NPR and ProPublica found a more troubling story. The military's insurance system, Tricare, refuses to pay for troops and veterans with brain injuries to get a form of comprehensive rehabilitation. That's even though the Pentagon's own medical advisers recommend it. And now, troops are caught in a battle over science and money.
NPR's Daniel Zwerdling has the story, co-reported with T. Christian Miller of ProPublica.
DANIEL ZWERDLING: It was a hot spring day last year near Washington, D.C. Fifty medical specialists gathered in a hotel ballroom and they accomplished something remarkable - they agreed on something.
A general at the Pentagon had called them together from all across the country: civilian brain specialists, psychiatrists, doctors from the Army and the VA. And the general basically said, give us guidance. Should troops who come home from the wars with brain injuries get the intensive treatment that doctors call Cognitive Rehabilitation? And everybody answered unanimously, yes.
Dr. STEPHEN XENAKIS (Member, Consensus Conference on Cognitive Rehabilitation): So all 50 specialists agreed. Yeah, everyone agreed.
ZWERDLING: In fact, they called it the Consensus Conference on Cognitive Rehab. Dr. Stephen Xenakis was part of it. He used to be one of the generals who ran the Army's medical system.
Many doctors in the civilian world say that cognitive rehab is like the gold standard of treatment. You get a brain injury in a car accident, doctors at civilian medical centers prescribe cognitive rehab.
Dr. XENAKIS: It's been around for decades. We know that it helps.
ZWERDLING: But most military and VA programs do not provide such comprehensive treatment. Still, troops who come home from the wars with brain injuries could get cognitive rehab at civilian clinics if the Pentagon's Tricare insurance system would pay for it. Yet, Tricare's policy won't.
Some civilian insurance companies don't cover cognitive rehab either, but a growing number of them do. Xenakis and the others at the conference concluded a lot of the troops who come home with TBIs should get cognitive rehab, too.
Dr. XENAKIS: There's really no reason not to provide it as broadly as possible, and let's figure out a way to do it.
ZWERDLING: So you might think now officials at the Pentagon would change the insurance policy. But, no.
Robert DeMartino oversees TBI for Tricare.
Captain ROBERT DEMARTINO (Director, Behavioral Health Department, Tricare): We have sets of rules that require us to measure the evidence that we have for something against, you know, standards of care. And our rules essentially say that something has to be safe and effective before it can be implemented.
ZWERDLING: And we'll get back to this debate in a moment. But first, we're going to stop by one of the best-known civilian rehab centers in the country, so we can see the treatment that officials at Tricare are skeptical about.
Unidentified Man #1: How much...
ZWERDLING: We're at the JFK Center for Head Injuries in Edison, New Jersey. At the moment, one of the therapists is starting a rehab session with six patients around a table.
Unidentified Woman #1: Picking up from where we left off Tuesday...
ZWERDLING: One of the patients is a police officer who crashed during a chase. Another fell down the stairs in her home.
When somebody gets a TBI, the cells and circuits in the brain gets damaged, whether they hit their heads in New Jersey or got hit by a blast wave in Iraq, and suddenly they have to struggle to process simple information. They have trouble using judgments and making decisions.
Keith Cicerone runs this program. He says doctors can't fix the parts of the brain that get damaged in a TBI. But cognitive rehab is designed to rewire the brain, in effect, so patients learn to compensate.
Dr. KEITH CICERONE (Director, JFK Johnson Rehabilitation Institute's Center for Head Injuries): It's like getting rehabilitation if you'd had a leg amputated. The rehabilitation is not going to cause your leg to grow back. What we teach people to do is grow and improve in their life despite the fact that they have a brain injury, and even to turn the brain injury into a positive experience.
ZWERDLING: Meanwhile, the therapist hands out this day's assignment. The patients will plan an imaginary trip.
Unidentified Woman #2: Somebody go ahead and - would you mind reading it?
ZWERDLING: That means that patients like John(ph) have to learn how to read again.
JOHN: You will make a daily - what's that - itinerary for Saturday and Sunday.
ZWERDLING: When you observe a cognitive rehab program like this one, you don't hear dramatic breakthroughs. Rewiring the brain takes slow, plodding work. For instance, the therapist asks the group to choose a leader to help plan their trip. So patients like Anne have to learn all over again, what does a leader do?
ANNE: Make suggestions, try, encourage people to contribute so that we have...
ZWERDLING: Cognitive rehab programs like this one are dramatically different than what most troops and veterans get. These patients come to Cicerone's program for 15 hours a week. In contrast, patients at military and VA programs often get a few hours of brain rehab a week. And the therapists at Cicerone's center design a complex program tailored to each individual patient. In contrast, military and VA centers often give a patchwork of standardized treatments - computer memory games, things like that.
Cicerone says why not give troops the best?
Dr. CICERONE: You're denying people services that they need in order to function. I mean, it's ludicrous.
ZWERDLING: And that takes us back to the Pentagon. Roughly four million troops and veterans have Tricare insurance.
(Soundbite of advertising video, Tricare)
Unidentified Woman #3: The Tricare At a Glance flyer explains beneficiary categories and available programs, as well as enrollment options and provider choices. Learn more at Tricare...
ZWERDLING: Troops and vets are supposed to have lots of choices. Tricare can give them permission to get treatments at civilian centers when they can't get them from the military or VA. And hundreds of civilian clinics could provide cognitive rehab. But when troops started coming home from the wars with brain injuries, Tricare refused to cover it. So, more than 70 members of Congress protested to the secretary of Defense.
Senator BARACK OBAMA (Democrat, Illinois): We need to dramatically improve screening and treatment for the other signature injury of the war: Traumatic Brain Injury.
Unidentified Woman #4: Yeah.
(Soundbite of applause)
Senator OBAMA: That's why I passed measures in the Senate to increase...
ZWERDLING: One of the legislators who protested was Senator Barack Obama. Obama and the other congressmen told the Pentagon that Tricare should cover cognitive rehab, so all troops, quote, "can benefit from the best brain injury care this country has to offer," unquote. The Pentagon still said no.
But then Barack Obama became president. And last year, officials at the Pentagon agreed to take another look. They gathered those 50 medical specialists near Washington. Their consensus conference endorsed cognitive rehab. And what did officials at Tricare do? They still didn't change their policy.
Dr. MARIA MOURATIDIS (Command Consultant, Traumatic Stress and Brain Injury Program, National Naval Medical Center): Why not?
ZWERDLING: Maria Mouratidis was part of that consensus conference. She used to treat troops with TBIs at Bethesda Naval Medical Center. She says what's going on at the Pentagon?
Dr. MOURATIDIS: Here you convened a panel of experts, why would you not follow what they suggested?
ZWERDLING: The investigation by NPR and ProPublica found part of the answer. A few weeks after the consensus conference, officials at Tricare decided, we need to get yet another evaluation of cognitive rehab. And this time, they hired a private contractor to write it.
The contractor is called ECRI. ECRI said there are scores of studies on cognitive rehab that do show it helps people with brain injuries, just as the consensus conference said. But then the contractor dismissed most of that evidence on the grounds it wasn't rigorous enough.
For instance, the contractor said some studies on cognitive rehab were too small. They discounted other studies because they weren't double blind. In other words, they weren't like drug studies, where doctors and patients have no idea if they're using a real treatment or a placebo.
Robert DeMartino, the official at Tricare, says they use science to do what's best for troops.
Capt. DEMARTINO: And so if you come to me and say, I have an intervention I would like to - I know that there's this new electrical thing. If you put a helmet on your head, that will help you. You know, we're conscious of both, on one hand providing the best services available. But not subjecting them to, you know, the newest, greatest thing which turned out to be, oops, that didn't really work. Or that was a big waste of your time. Or, wow, did that really hurt them in the end?
ZWERDLING: But when leading brain specialists read the report by Tricare's contractor, they were stunned.
Dr. JAMES MALEC (Research Director, Rehabilitation Hospital, Indiana): You know, I really am kind of dumbfounded. They missed the forest for the trees. You know, they missed the big picture.
ZWERDLING: James Malec is research director at the Rehabilitation Hospital of Indiana. When contractors write a scientific report for the Pentagon, the contractor and the military often ask other researchers to do a peer review. Malec was one of five specialists who peer-reviewed Tricare's report on cognitive rehab. And all five denounced it. They wrote that the study is deeply flawed, unacceptable, dismaying.
Dr. CICERONE: It's hooey. It's baloney. It simply doesn't make sense.
ZWERDLING: That's Keith Cicerone again. He was one of the reviewers, too. They said you can always pick apart individual studies, like Tricare's contractor did. But remember, leading medical centers have been treating patients with cognitive rehab for more than 30 years.
The specialists say if better studies show someday that another treatment works better, great. But Malec and the others say officials at the Pentagon are blocking troops from getting the best care they know of now.
Dr. MALEC: I'm horrified. You know, I just think it's appalling that we're not knocking ourselves out to do the very best we can for them.
ZWERDLING: A spokeswoman for Tricare's contractor says they stand by their report. Some civilian insurance plans are skeptical of cognitive rehab, too, but some of the top medical groups in the U.S. support it. In fact, a group of experts organized by the National Institutes of Health endorsed cognitive rehab, and that was back in 1998, three years before the U.S. went to war. And an increasing number of insurance companies are embracing cognitive rehab, too, including United Healthcare and Humana and Aetna.
Dr. Robert McDonough is head of clinical policy at Aetna. Do you, does Aetna, feel confident that cognitive rehab is a proven therapy?
Dr. ROBERT MCDONOUGH (Head of Clinical Policy, Aetna): I think the totality of the evidence appears to support the value of cognitive rehabilitation for people with traumatic brain injury in improving their function.
ZWERDLING: Keith Cicerone and the other specialists we talked to say his is not really a debate about scientific evidence. They say here's the main reason why Tricare won't cover cognitive rehab for troops who come home with brain injuries.
Dr. CICERONE: You talk to them about providing care, there's only one thing on their mind, and the one thing on their mind is they don't want to spend any money.
Dr. CICERONE: Money.
ZWERDLING: The official at Tricare, Robert Martino, says that's completely wrong.
Mr. MARTINO: There's - I am never, ever asked to comment on how much something is going to cost, ever. It's not even remotely a part of my job.
ZWERDLING: Maybe not part of his job, but a source tells us that the week after the consensus conference recommended cognitive rehab, a handful of officials from the Pentagon met to discuss the findings.
Our source says the leader of the meeting told his colleagues the military can't afford to pay for cognitive rehab. And consider this: When Tricare hired the private contractor to give another view, they didn't just pick any contractor, they picked ECRI. And our investigation found that ECRI had already denounced cognitive rehab in another report two years earlier. So officials at Tricare likely had a pretty good idea what ECRI would say.
The contractor's report contains a striking figure. Cognitive rehab can cost more than $50,000 per patient. Stephen Xenakis says multiply that by tens of thousands of troops.
Dr. XENAKIS: We could all of a sudden be opening up the floodgates, and we don't have a way of controlling what might be huge expenditures.
ZWERDLING: We asked spokesmen at the Pentagon to comment on our findings; they didn't. We also asked the White House, where does President Obama stand on all this? After all, he's commander in chief. He signed that congressional letter a couple years ago saying Tricare should provide cognitive rehab to troops with brain damage. But a White House spokesman won't tell us how the president feels about it now.
Daniel Zwerdling, NPR News.
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