Iraq convoy was sent out despite threat

Unarmored trucks carrying needed supplies were ambushed, leaving six drivers dead. Records illuminate the fateful decision.

“Can anyone explain to me why we put civilians in the middle of known ambush sites?”

“Maybe we should put body bags on the packing list for our drivers.”

T Christian Miller The LA Times  September 3, 2007

Senior managers for defense contractor KBR overruled calls to halt supply operations in Iraq in the spring of 2004, ordering unarmored trucks into an active combat zone where six civilian drivers died in an ambush, according to newly available documents.

Company e-mails and other internal communications reveal that before KBR dispatched the convoy, a chorus of security advisors predicted an increase in roadside bombings and attacks on Iraq’s highways. They recommended suspension of convoys.

“[I] think we will get people injured or killed tomorrow,” warned KBR regional security chief George Seagle, citing “tons of intel.” But in an e-mail sent a day before the convoy was dispatched, he also acknowledged: “Big politics and contract issues involved.”

KBR was under intense pressure from the military to deliver on its multibillion-dollar contract to transport food, fuel and other vital supplies to U.S. soldiers. At Baghdad’s airport, a shortage of jet fuel threatened to ground some units.

After consulting with military commanders, KBR’s top managers decided to keep the convoys rolling. “If the [Army] pushes, then we push, too,” wrote an aide to Craig Peterson, KBR’s top official in Iraq.

The decision prompted a raging internal debate that is detailed in private KBR documents, some under court seal, that were reviewed by The Times.

One KBR management official threatened to resign when superiors ordered truckers to continue driving. “I cannot consciously sit back and allow unarmed civilians to get picked apart,” wrote Keith Richard, chief of the trucking operation.

Six American truck drivers and two U.S. soldiers were killed when the convoy rumbled into a five-mile gauntlet of weapons fire on April 9, 2004, making an emergency delivery of jet fuel to the airport. One soldier and a seventh trucker remain missing.

Recriminations began the same day.

“Can anyone explain to me why we put civilians in the middle of known ambush sites?” demanded one security advisor in an e-mail. “Maybe we should put body bags on the packing list for our drivers.”

Please read the entire story here

Testing Program Fails Soldiers, Leaving Brain Injuries Undetected

A version [1] of this story was co-produced with NPR and aired on All Things Considered [2]. (Check here for local listings [3].)

by T Christian Miller and Joaquin Sapien at ProPublica and Daniel Zwerdling at NPR

About 40 uniformed soldiers take the ANAM test inside this squat rectangular building on the Fort Lewis-McChord military base near Tacoma, Wash., in early September, weeks before they deploy to Afghanistan. (Joaquin Sapien/ProPublica)

In 2007, with roadside bombs exploding across Iraq, Congress moved to improve care for soldiers who had suffered one of the war’s signature wounds, traumatic brain injury

Lawmakers passed a measure requiring the military to test soldiers’ brain function before they deployed and again when they returned. The test was supposed to ensure that soldiers received proper treatment.

Instead, an investigation by ProPublica and NPR has found, the testing program has failed to deliver on its promise, offering soldiers the appearance of help, but not the reality.

Racing to satisfy Congress’ mandate, the military chose a test that wasn’t actually proven to detect TBI: the Automated Neuropsychological Assessment Metric, or ANAM.

Four years later, more than a million troops have taken the test at a cost of more than $42 million to taxpayers, yet the military still has no reliable way to catch brain injuries. When such injuries are left undetected, it can delay healing and put soldiers at risk for further mental damage.

Based on corporate and government records, confidential documents, scores of interviews and emails obtained under the Freedom of Information Act, our investigation found:

• The people who invented ANAM and stood to make money from it were involved in the military’s decision to use it, prompting questions about the impartiality of the selection process. No other tests received serious consideration. A report [4] by the Army’s top neuropsychologist circulated last year to key members of Congress labeled the selection process “nepotistic.”
• The Pentagon’s civilian leadership has ignored years of warnings, public and private, that there was insufficient scientific evidence the ANAM can screen for or diagnose traumatic brain injury. The military’s highest-ranking medical official said the test was “fraught with problems.” Another high-ranking officer said it could yield misleading results.
• Compounding flaws in the ANAM’s design, the military has not administered the test as recommended and has rarely used its results. The Army has so little confidence in the test that its top medical officer issued an explicit order [5] that soldiers whose scores indicated cognitive problems should not be sent for further medical evaluation.
• Top Pentagon officials have misrepresented the cost of the test, indicating that because the Army invented the ANAM, the military could use it for free. In fact, because the military licensed its invention to outside contractors, it has paid millions of dollars to use its own technology.
• The military has not conducted a long-promised head-to-head study to make sure the ANAM is the best available test, delaying it for years. Instead, a series of committees have given lukewarm approval to continue using the ANAM, largely to avoid losing the data gathered so far.

Several current and former military medical officials criticized the Defense Department’s embrace of a scientifically unproven tool to use on hundreds of thousands of soldiers with TBIs

Please read this article in it’s entirety at ProPublica

Injured War Contractors Sue Over Health Care, Disability Payments

T Christian Miller ProPublica September 27, 2011

Private contractors injured while working for the U.S. government in Iraq and Afghanistan filed a class action lawsuit [1] in federal court on Monday, claiming that corporations and insurance companies had unfairly denied them medical treatment and disability payments.

The suit, filed in district court in Washington, D.C., claims that private contracting firms and their insurers routinely lied, cheated and threatened injured workers, while ignoring a federal law requiring compensation for such employees. Attorneys for the workers are seeking $2 billion in damages.

The suit is largely based on the Defense Base Act, an obscure law that creates a workers compensation system for federal contract employees working overseas. Financed by taxpayers, the system was rarely used until the wars in Iraq and Afghanistan, the most privatized conflicts in American history.

Hundreds of thousands of civilians working for federal contractors have been deployed to war zones to deliver mail, cook meals and act as security guards for U.S. soldiers and diplomats. As of June 2011, more than 53,000 civilians have filed claims for injuries in the war zones. Almost 2,500 contract employees have been killed, according to figures [2]kept by the Department of Labor, which oversees the system.

An investigation by ProPublica, the Los Angeles Times and ABC’s 20/20 [3] into the Defense Base Act system found major flaws, including private contractors left without medical care and lax federal oversight. Some Afghan, Iraqi and other foreign workers for U.S. companies were provided with no care at all.

The lawsuit, believed to be the first of its kind, charges that major insurance corporations such as AIG and large federal contractors such as Houston-based KBR deliberately flouted the law, thereby defrauding taxpayers and boosting their profits. In interviews and at Congressional hearings, AIG and KBR have denied such allegations and said they fully complied with the law. They blamed problems in the delivery of care and benefits on the chaos of the war zones

Gov’t Watchdog Criticizes Pentagon Center for PTSD, Brain Injuries

By T Christian Miller and Joaquim Sapien at ProPublica  July 11, 2011

If you want more explanation about the military’s troubles in treating troops with traumatic brain injuries and post-traumatic stress, read no further than two recent but largely unnoticed reports from the Government Accountability Office.

It turns out the Pentagon’s solution to the problems is an organization plagued by weak leadership, uncertain priorities and a money trail so tangled that even the GAO’s investigators couldn’t sort it out. The GAO findings on the Pentagon’s Defense Centers of Excellence (DCOE) echo our own series [1] on the military’s difficulty in handling the so-called invisible wounds of war.

“We have an organization that exists, but we have considerable concern about what it is that it’s actually accomplishing,” said Denise Fantone, a GAO director who supervised research on one of the reports. She added: “I can’t say with any certainty that I know what DCOE does, and I think that’s a concern.”

First, some background. After the 2007 scandal over poor care delivered to soldiers at the Walter Reed Army Medical Center, Congress ordered the Pentagon to do a better job treating soldiers suffering from post-traumatic stress disorder and traumatic brain injury. The Pentagon’s answer was to create DCOE [2]. The new organization was supposed to be a clearinghouse to foster cutting-edge research in treatments.

DCOE was rushed into existence in late 2007. Since then, it has churned through three leaders, including one let go after alleged sexual harassment of subordinates [3]. It takes more than five months to hire each employee because of the federal government’s glacial process. As a result, private contractors make up much of the center’s staff.

“DCOE’s development has been challenged by a mission that lacks clarity and by time-consuming hiring processes,” according to the first report in the GAO series [4], focusing on “management weakness” at DCOE.

Just as concerning, the GAO says that it can’t quite figure out how much money DCOE has received or where it has all gone. DCOE has never submitted a budget document that fully conformed to typical federal standards, according to a GAO report released last month [5]. In one year, the center simply turned in a spreadsheet without detailed explanations

Please read the entire article at ProPublica

Epidemic: Over 400,000 Traumatic Brain Injuries for Vets Coming from Iraq and Afghanistan

With like numbers of Contractors in Iraq and Afghanistan, similar casualty rates though we do not know who they are, why are contractors not receiving screening and medical treatment for Traumatic Brain Injuries? 

The Defense Base Act Insurance Companies deny diagnoses and treatment for TBI for the precious years that are so vital to the injured contractors recovery.  Years that no amount of money can ever bring back.

“We now know that the brain can heal. It has an intrinsic plasticity that allows it to recover, and this is particularly true for the young brain.”

A recent study by the Massachusetts Institute of Technology found that “neurons in the adult brain can remodel their connections,” thus “overturning a century of prevailing thought.”

The DOD has long resisted the diagnosis of mTBI, as it has avoided paying for a successful – but expensive – way to treat it. The price of that resistance is escalating suicide rates and domestic violence incidents among returning soldiers. In 2010, almost as many soldiers committed suicide as fell in battle.

By Conn Hallinan at AlertNet

America faces a huge challenge in caring for the shocking number of traumatized war vets.

“We are facing a massive mental health problem as a result of our wars in Iraq and Afghanistan. As a country we have not responded adequately to the problem. Unless we act urgently and wisely, we will be dealing with an epidemic of service related psychological wounds for years to come.” — Bobby Muller, President Veterans for America

According to official Defense Department (DOD) figures, 332,000 soldiers have suffered brain injuries since 2000, although most independent experts estimate that the number is over 400,000. Many of these are mild traumatic brain injuries (mTBI), a term that is profoundly misleading.

As David Hovda, director of the Brain Injury Research Center at the University of California at Los Angeles, points out, “I don’t know what makes it ‘mild,’ because it can evolve into anxiety disorders, personality changes, and depression.” It can also set off a constellation of physical disabilities from chronic pain to sexual dysfunction and insomnia.

MTBI is defined as any incident that produces unconsciousness lasting for up to a half hour or creates an altered state consciousness. It is the signature wound for the wars in Iraq and Afghanistan, where roadside bombs are the principal weapon for insurgents.

Most soldiers recover from mTBI, but between five and 15 percent do not. According to Dr. Elaine Peskind of the University of Washington Medical School, “The estimate of the number who returned with symptomatic mild traumatic brain injury due to blast exposure has varied from the official VA [Veterans Administration] number of 9 percent officially diagnosed with mTBI to over 20 percent, and, I think, ultimately it will be higher than that.”

Serious consequences from mTBI are increased when troops are subjected to multiple explosions and “just get blasted and blasted and blasted,” in the words of Maj. Connie Johnmeyer. Out of two million troops who have served in Iraq and Afghanistan, over 800,000 have had multiple deployments, many up to five times or more.

But mTBI is difficult to diagnose because it does not show up on standard CAT scans and MRIs. “Our scans show nothing,” says Dr. Michael Weiner, professor of radiology, psychiatry and neurology at the University of California at San Francisco and director of the Center for Imaging Neurodegenerative Disease at the Veteran’s Administration Medical Center.

They do now.

An MRI set to track the flow of water through the brain’s neurons, has turned up anomalies that indicate the presence of mTBI. However, the military has blocked informing patients of results of the research, and if history is any guide, the Pentagon will do its best to shelve or ignore the results.

The DOD has long resisted the diagnosis of mTBI, as it has avoided paying for a successful – but expensive – way to treat it. The price of that resistance is escalating suicide rates and domestic violence incidents among returning soldiers. In 2010, almost as many soldiers committed suicide as fell in battle.

MTBI is hardly new. Some 5.3 million people in the U.S. are currently hospitalized or in residential facilities because of it, and its social consequences are severe.  Please read the entire story at AlertNet

U.S. Insurance Firm CNA Neglects Survivors of Iraqi Translators, May Face Criminal Charges

U.S. insurer faces criminal probe over Iraqis’ unpaid death benefits

By T Christian Miller at ProPublica   May 23, 2011  and The LA Times

An administrative law judge has referred a U.S. insurance company for criminal investigation after the firm failed to pay benefits owed to survivors of Iraqi translators killed while working for the American government.

Under a federally funded program, Chicago-based CNA Financial Corp. provides insurance coverage to contractors killed or injured while working overseas for the United States. The slain translators were helping to train Iraqi police recruits.

Instead of paying out benefits, however, CNA withheld information from the federal government and avoided making payments to nine families who lost relatives in a 2006 attack, according to court files and interviews. One widow lost her home, unable to keep up payments after her son and other translators were ambushed by insurgents in the southern city of Basrah, one of her attorneys said.

In a ruling this week, administrative law Judge Daniel Solomon ordered CNA to begin making payments to the families. In an unusual move highlighting the government’s concern over potential fraud, the judge also told the Labor Department, which oversees the program, to investigate whether the insurance carrier should face criminal charges. A Labor spokesman said the agency would “fully investigate” the allegations to determine whether to ask the Justice Department to prosecute the case.

CNA said it was also looking into the case.

“We are investigating the matter and will take all appropriate actions,” said Katrina Parker, a company spokeswoman.

Attorneys for the families said they believe CNA withheld documents to avoid making payments.

“These were people who helped the U.S. in Iraq,” said Agnieszka Fryszman, an attorney for the families. “Their families were kicked to the curb when they were most in need of help.”

CNA’s failure to pay out benefits underscores the continuing problems with the Defense Base Act, essentially the workers compensation system for overseas federal contractors.

The system was little-used until the wars in Iraq and Afghanistan sent hundreds of thousands of private contractors onto the battlefield. All told, the government has paid out nearly $1.5 billion in premiums since 2001.

Reporting in 2009 by ProPublica, the Los Angeles Times and ABC’s 20/20 [1] revealed deep flaws in the program. Workers fought long battles for medical care, including such things as prosthetic devices and treatment for post-traumatic stress disorder. Foreign workers, including Iraqi and Afghan translators, often did not receive payments or treatment. The Labor Department seldom took action to enforce the law. One official called the system a “fiasco.”

Congress subsequently held hearings [2] that showed that American insurers were reaping large profits from the program. Documents showed that CNA reported the highest profits margins, taking in nearly 50 percent more in premiums than it paid out in benefits.

The case decided this week began on Oct. 29, 2006, when insurgents boarded a bus and killed 17 Iraqi-born translators working in Basrah for Sallyport Global Services, a logistics and security contractor. The insurgents later scattered their bodies around the city.

Under the law, CNA was responsible for paying death benefits to the translators’ dependents. CNA paid when translators had children and spouses, according to interviews and court records, but not to other survivors. Several translators had no children, but supported parents or other family members.

In such cases, the Labor Department demands proof that survivors relied on contractors’ earnings. CNA hired investigators who interviewed nine families, confirmed their eligibility, and even set up bank accounts. But CNA withheld portions of the investigators’ findings when it submitted the claims to the Labor Department, court records show.

One CNA file shows that the slain translator had supported his mother, a widow, since his father was killed in the Iraq-Iran war. The town council even issued a statement of support, confirming the translator was his mother’s “sole provider.” Another CNA file shows that another translator killed in the ambush was sole support for his family, which “could be described as very poor.”

But those pages were missing from the information CNA submitted to the Labor Department. As a result, Labor officials accepted CNA’s declaration that there were no dependents to pay in any of the nine cases.

The translators’ attorneys at Cohen Milstein, a well-known Washington firm doing pro bono work on the case, estimated that CNA owed a total of about $500,000 to the nine families. Instead, CNA paid about $45,000 into a special federal fund set up to help support the workers compensation system.

The company subsequently recovered some of that money plus additional fees under an obscure law—the War Hazards Compensation Act—that allows insurance carriers to recoup costs for contractors killed in hostile acts, court documents show.

In one case, CNA paid $5,000 into the special fund and $518 to a translator’s family for burial expenses, but was reimbursed $9,289 by the federal government for investigating and handling the claims.

A Sallyport official said the company believed that CNA had made payments to all of the translators’ families except one, which declined to accept money because of security concerns.

In an emailed statement, the company declined further comment due to the litigation. It said it would “continue to monitor the situation and support the families within our remit.”

Few Troops Exposed to Bomb Blasts Are Screened For Concussion

And very rarely are contractors Screened for TBI

By T Christian Miller ProPublica and Daniel Zwerdling NPR  May 10, 2011

More than half of U.S. combat troops in Afghanistan have been exposed to bomb blasts in the last year, but only about 1 in 5 of them said they were examined for concussions, according to a draft of a recent military survey [1].

Medical officials failed to screen about 80 percent of soldiers and Marines who reported being within 50 meters of a roadside blast during their tour of duty, according to combat troops surveyed in July and August of last year.

The survey noted, however, that the troops were quizzed before full implementation of a new military policy [2] in June mandating screening for troops exposed to such bombs.

The survey, which has not been finalized, but was obtained by ProPublica, NPR and USA Today, is conducted to assess the mental health and morale of America’s troops. Part of the survey examines the military’s efforts to treat traumatic brain injuries, also known as concussions.

Screenings for such wounds are important because concussions caused by blast waves are difficult to detect, yet may cause lasting cognitive issues, especially when soldiers absorb multiple injuries. Most soldiers recover within two weeks. But civilian and military studies have suggested that a minority of concussion victims, between 5 percent to 15 percent, go on to suffer cognitive problems, such as having difficulty reading or following instructions. Multiple concussions over a long period have been linked in athletes to a condition called chronic traumatic encephalopathy, which has dementia-like symptoms.

Official military figures [3] show that more than 155,000 troops have suffered concussions since the beginning of the wars in Afghanistan and Iraq, many of them caused by blasts from roadside bombs, a common insurgent weapon. Nearly 50,000 others have suffered more severe brain injuries. Previous ProPublica and NPR stories [4] cited studies showing that as many as 40 percent of mild traumatic brain injuries go undiagnosed.

Overall, the survey presented a bleak picture of an increasingly dangerous war in Afghanistan. One extraordinary statistic: Near the peak of violence in Iraq in 2006, from 12 percent to 15 percent of troops responding to a similar survey reported killing an enemy. In Afghanistan last year, 48 percent to 56 percent of combat troops surveyed reported being “directly responsible” for killing a combatant—a more than threefold increase.

In addition, about 50 percent to 60 percent of soldiers and Marines in Iraq in 2006 reported that a comrade had suffered a casualty. In Afghanistan, 73 percent of soldiers and almost 80 percent of Marines reported having a buddy who was wounded or died.

The Army has struggled to keep up with flood of soldiers suffering from so-called invisible wounds of war, such as traumatic brain injury and post-traumatic stress disorder. Last month, ProPublica and NPR reported [5] the Army is facing a “critical” shortage of neurologists to implement its new initiative to improve diagnosis and treatment of mild traumatic brain injuries.

At a hearing last June [6], Gen. Peter Chiarelli, the Army’s vice chief of staff, told Congress that the Army had a total of 52 neurologists, though only 40 were practicing—a figure, he said, that included child neurologists. “We’re an Army that’s in uncharted territory here,” Chiarelli recently told USA Today [7]. “We have never fought for this long with an all-volunteer force that’s 1 percent of the population.”

Please see the original here

ProPublica Honored With Two George Polk Awards

by Minhee Cho at ProPublica

ProPublica is pleased to announce that it has won two George Polk Awards this year, in collaboration with our partners NPR and Frontline, for the series “Brain Wars” and “Law & Disorder.”

A collaborative project by ProPublica’s T. Christian Miller and NPR’s Daniel Zwerdling and Susanne Reber, “Brain Wars ” found that the U.S. military was failing to diagnose and treat traumatic brain injuries suffered by soldiers. It has been selected for the George Polk Award for Radio Reporting.

ProPublica’s A.C. Thompson along with our partners Raney Aronson and Tom Jennings at Frontline and Laura Maggi and Brendan McCarthy at The Times-Picayune won the George Polk Award for Television Reporting for “Law & Disorder ,” which took an in-depth look at the controversial and often brutal actions taken by the New Orleans Police Department in the aftermath of Hurricane Katrina.

The George Polk Awards are conferred every year to honor special achievement in journalism, particularly investigative and enterprise reporting. ProPublica’s Abrahm Lustgarten was among the winners last year for his reporting on the dangers of drilling for natural gas.

Congratulations to all of the winners Please see the original here

Scientific Review Kicks Off to Weigh Treatment for Brain-Injured Soldiers

Perhaps one day diagnoses and treatment options will be made available to Injured Contractors.

by T. Christian Miller, ProPublica, and Daniel Zwerdling, NPR Feb. 7, 2011

The Institutes of Medicine kicked off its yearlong study of cognitive rehabilitation therapy on Monday, a process that will help the Pentagon decide whether its health plan will cover the treatment for troops who have suffered brain injuries in Iraq and Afghanistan.

We’ve previously reported [1] that Tricare, which covers troops and many veterans, relied on a controversial study to deny coverage for the treatment, which helps rewire soldiers’ brains to perform basic tasks such as memorizing lists and following orders. Tricare said the study showed there wasn’t enough evidence to support paying for the treatment, which can cost more than $50,000 per soldier. The Pentagon says nearly 200,000 troops have suffered traumatic brain injuries since the wars began, though our own reporting [2] shows the numbers are probably a lot higher.

The IOM panel of experts will review scientific literature and ultimately render a decision on whether it supports the efficacy of cognitive rehabilitation therapy. If the experts reach this conclusion, they will hardly be the first to do so. In April 2009, a consensus panel assembled by the Pentagon said the therapy works, especially for soldiers suffering more severe forms of brain injury. Other groups, such as the Brain Injury Association of America, have weighed in to support it. Even some major private insurance companies pay for it.

The head of the IOM panel, Georgetown University neurologist Ira Shoulson, pointedly quizzed Tricare on this issue at Monday’s session, asking what the current review would produce that previous reviews had not.

Capt. Robert DeMartino, Tricare’s director of behavioral health, said he hoped the panel would be able to pinpoint what types of cognitive rehabilitation works best, and what kind of civilian doctors and clinicians were best qualified to provide it. He noted that stories published last year by ProPublica and NPR have cast a “shadow” over the issue, prompting congressional committees and lawmakers to pressure Tricare to provide cognitive rehabilitation therapy.

“For us, we know that we’re in a field like a gray zone,” said DeMartino, who addressed the panel by speakerphone. “We want to make sure the [treatments] that work are the ones we are going to use.”

The IOM review will continue through the end of the year, and the panel expects to convene other public sessions to help them arrive at a determination.

Congress to Investigate Pentagon Decision to Deny Coverage for Brain Injured Troops

By T Christian Miller  ProPublica and Daniel Zwerdling NPR

WASHINGTON, D.C.–A key congressional oversight committee announced [1] today that it was opening an investigation into the basis of a decision by the Pentagon’s health plan to deny a type of medical treatment to troops with brain injuries.

Sen. Claire McCaskill, D-Mo., the chairman of the subcommittee on contracting oversight, said she wanted to examine a contract issued by Tricare, an insurance-style program used by soldiers and many veterans, to a private company to study cognitive rehabilitation therapy for traumatic brain injury. Such injuries are considered among the signature wounds of the wars in Afghanistan and Iraq.

The study, by Pennsylvania-based ECRI Institute, found insufficient or weak evidence to support the therapy. Often lengthy and expensive, cognitive rehabilitation programs are designed to rewire soldiers’ brains to conduct basic life tasks, such as reading books, remembering information and following instructions. ECRI’s findings ran counter to several other studies, including ones sponsored by the Pentagon and the National Institutes of Health, which concluded that cognitive rehabilitation was beneficial.

In a letter to Defense Secretary Robert Gates, McCaskill cited an investigation [2] by ProPublica and NPR in December, which found that top scientific experts had questioned the Tricare-funded study in confidential reviews, calling it “deeply flawed” and “unacceptable.”

“If true, these reports raise significant questions regarding the Department’s award and management of the contract with ECRI Institute, and may have profound implications for hundreds of thousands of injured service members and their families,” McCaskill wrote. “We owe it to our brave service members to find the truth.”

The ProPublica and NPR investigation also found that senior Pentagon officials have worried about the high price of the care, which can cost more than $50,000 per patient. Some studies estimate that as many as 400,000 troops have suffered traumatic brain injuries in the war zones, though only a small percentage of them would need a full-scale program of cognitive rehabilitation therapy.

McCaskill joins a growing chorus demanding that Tricare reconsider its decision to deny coverage for cognitive rehabilitation. In recent weeks, the American Legion, the nation’s largest veterans’ organization, called [3] on Tricare to provide treatment. Sen. Bob Casey, D-Penn., chairman of the Senate Foreign Relations subcommittee with oversight of the Middle East, sent a letter [4] to Gates asking for an explanation of Tricare’s stance.

McCaskill was also one of the senators who signed a letter [5] in 2008 asking Gates to direct Tricare to begin providing cognitive rehabilitation to troops. This November, the Pentagon sent a response [6] to Congress informing them of the Tricare study’s findings. George Peach Taylor Jr., then-acting assistant secretary of defense for health affairs, said the Pentagon would continue to study the treatment, with another report expected later this year.

In strongly worded response [7] on Jan. 19, McCaskill said that the senators who signed the original letter believed that enough evidence existed on the treatment’s benefits to justify covering the cost for brain-damaged soldiers.

She asked for Gates to provide her committee with a series of documents on the contract and critical scientific reviews by Feb. 18.

“While we agreed that further research on cognitive rehabilitation therapy was appropriate, we also called on the Defense Department to err on the side of providing this proven treatment to service members,” McCaskill wrote.

ProPublica and NPR have filed a similar request under the Freedom of Information Act, but Tricare has denied access to the documents, giving contradictory explanations [8] for why. ProPublica and NPR have appealed.

Tricare officials have said their decision to deny cognitive rehabilitation is based on regulations requiring scientific proof of the efficacy and quality of treatment. They have said that the study by ECRI highlighted a lack of rigorous evidence proving the therapy’s benefits.

Tricare officials also noted that the agency does cover some types of treatment considered part of cognitive rehabilitative therapy. For instance, Tricare will pay for speech and occupational therapy, which plays a role in cognitive rehabilitation. Tricare officials deny that cost played any role in their decision. In a statement [9], Tricare said the care of troops was their “utmost” concern.

Tricare did not immediately return requests for comment on McCaskill’s investigation.

ECRI defended its study. The non-profit institute, which has carried out numerous health reviews for Tricare, other agencies and hospital and medical groups, said they applied standard protocols in reviewing scientific literature about the efficacy of cognitive rehabilitation therapy. ECRI provided a document explaining its review here [10].

“The issue of how well cognitive rehabilitation therapy works for traumatic brain injury is important,” said Jeffrey C. Lerner, the president and CEO of ECRI Institute. “ECRI Institute is fully committed to providing information to the U.S. Senate on our report and methodology.”

New Year’s Toast 2011

Cheers

Again this year to

T Christian Miller for his continued investigative work on issues vital to Injured Military, Veterans, and Civilian Contractors at ProPublica and with NPR.  Your Traumatic Brain Injury coverage will benefit soldiers and contractors as well.

Last year we predicted you would win an award of  “some kind” for your efforts.   It wasn’t long before they started piling up and all well deserved.

Our sincerest Thanks for your many years of listening to story after story.

MsSparky !!  Can’t say enough, not here anyway.  Pedal to the metal.

Veterans Today for your support and help in promoting issues vital to Injured Veterans and Civilian Contractors everyday, every year.

Our Big Advocate Bruce H Nicholson for countless “unbilled” hours.  Your support has been over the top.  We look forward to an even more productive year this year.

Our “A” Team at American Contractors in Iraq and Afghanistan for your unrelenting research and DBA claim decision database.  We haven’t seen anything yet, so we are told, can’t wait.

Much of the work done here at DefenseBaseActComp is not yet published and many of the people who do the work choose to remain anonymous.

To all of you who support our Injured Civilian Contractors and the families of those who were killed, named and unnamed

We wish you a Very Happy New Year !!

Cheers !

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

By T Christian Miller Propublica and Daniel Zwedling NPR

Versions of this story were co-published with NPR [1] and Stars and Stripes [2]. For more coverage, listen to NPR’s All Things Considered [3] starting today at 4 p.m.

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)

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 [4] 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 [5], met President George W. Bush and Gates, and was recently invited to the White House by President Barack Obama for a bill signing ceremony [6].

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 [7] 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 [8] and Senate members [9] 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 [10].

A response letter [11] 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 [12], 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 [13] 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 [14].

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 [15] 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 [4], 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 [16].

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 [17]. 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 [18], 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 [19] 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.

Inform our investigations: Do you have information or expertise relevant to this story? Help us and journalists around the country by sharing your stories and experiences [20].

This Year, Contractor Deaths Exceed Military Ones in Iraq and Afghanistan

by T. Christian Miller Propublica  Disposable Army

More private contractors than soldiers were killed in Iraq and Afghanistan in recent months, the first time in history that corporate casualties have outweighed military losses on America’s battlefields.

More than 250 civilians working under U.S. contracts died in the war zones between January and June 2010, according to a ProPublica analysis of the most recent data available from the U.S. Department of Labor, which tracks contractor deaths. In the same period, 235 soldiers died, according to Pentagon figures.

This milestone in the privatization of modern U.S. warfare reflects both the drawdown in military forces in Iraq and the central role of contractors in providing logistics support to local armies and police forces, contracting and military experts said.

Steven Schooner, a professor of government contracting at George Washington University Law School, said that the contractor deaths show how the risks of war have increasingly been absorbed by the private sector. Private contractors in Iraq and Afghanistan provide fuel, food and protective services to U.S. outposts — jobs once performed by soldiers.

“It’s extremely likely that a generation ago, each one of these contractors deaths would have been a military death,” Schooner said. “As troop deaths have fallen, contractor deaths have risen. It’s not a pretty picture.”

Schooner, who conducted a recent study of contractor fatalities published in Contractor Services [1] (PDF), an industry newsletter, said contractors now make up more than 25 percent of total deaths in Iraq and Afghanistan — a proportion that has grown steadily throughout the conflicts. Official figures show that 5,531 troops and 2,008 civilian contract workers have died in Iraq and Afghanistan between the beginning of hostilities in 2001 and June 2010.

Many working under U.S. contracts are local civilians, often working as translators for troops, or are hired from third world countries to do basic labor, such as cleaning kitchens and toilets.

Previous ProPublica stories [2] have noted that companies employing such workers often fail to report their deaths and injuries to the Labor Department, as required by law. Government figures likely understate the total number civilian contractor deaths.

The rising fatalities have received little public attention, concealing the full human cost of the war, Schooner said. When President Obama spoke of troop deaths in Afghanistan earlier this month, he made no mention of fatalities among the private workforce that feeds and fuels U.S. forces.

“I’m not accusing either the Bush or the Obama administration of intentionally deceiving the public,” Schooner said. “But when a president applauds a reduction in military deaths but fails to acknowledge the contractor personnel now dying in their place, someone isn’t telling the whole story.”

The wars in Iraq and Afghanistan are the most privatized in American military history. Today, there are 150,000 troops in Afghanistan and Iraq. As of March 2010, there were more than 200,000 private contractors, though that number is believed to have declined with the drawdown of U.S. forces.

Defense Secretary Robert Gates announced [3] a plan last month to sharply reduce the number of contractors, saying the Pentagon has become overly dependent on private workers to carry out jobs once done by soldiers.

A recent Congressional Research Service report [4] (PDF) found that the heavy use of contractors had exposed troops to supply shortfalls, wasted taxpayer money, and stirred anger among locals. In several high-profile incidents, heavily armed private security contractors have killed unarmed Iraqi and Afghan civilians.

“Some analysts believe that poor contract management has also played a role in abuses and crimes committed by certain contractors against local nationals, which may have undermined U.S. counterinsurgency efforts in Iraq and Afghanistan,” the report found.

Marcie Hascall Clark, an advocate for contract workers, said that contractor deaths and injuries reflected contractors’ importance in fighting the wars.

Labor Department figures [5] show that more than 44,000 contractors have reported injuries since 2001, compared to about 40,000 U.S. troops. The figures are not entirely comparable, since contractor injuries include minor workplace injuries.

“I don’t think most contractors expect to be treated as nobly as our soldiers, but they don’t expect to be forgotten, either,” said Hascall Clark, who runs a group called American Contractors in Iraq and Afghanistan [6]. “I think there should definitely be some recognition of what they do.”

Soldiers With Brain Trauma Denied Purple Hearts, Adding Insult to Injury

by T Christian Miller ProPublica and Dan Zwerdling NPR

The U.S. Army honors soldiers wounded or killed in combat with the Purple Heart, a powerful symbol designed to recognize their sacrifice and service.

Yet Army commanders have routinely denied Purple Hearts to soldiers who have sustained concussions in Iraq, despite regulations that make such wounds eligible for the medal, an investigation by NPR and ProPublica has found.

Soldiers have had to battle for months and sometimes years to prove that these wounds [1], also called mild traumatic brain injuries, merit the honor, our reporting showed. Commanders turned down some soldiers despite well-documented blast wounds that wrenched their minds, altered their lives and wracked their families.

The Army twice denied a Purple Heart for Sgt. Nathan Scheller, though the aftereffects from two roadside explosions in Iraq have left him with lasting cognitive problems, according to the Army’s own records.

Please see the entire presentation here

High Profile Suicide in Iraq: Deeply Disturbed by Abuses Carried Out by American Contractors in Iraq

Greg Mitchell at Huffington Post

The scourge of suicides among American troops and reservists (which I’ve covered since 2003) remains a serious and seriously under-reported problem. One of the most high-profile cases involves a much-admired Army colonel and ethicist named Ted Westhusing — who, in his 2005 suicide note, pointed a finger at rising U.S. general named David Petraeus.

Westhusing’s widow, asked by a friend what killed this West Point scholar, had replied simply: “Iraq.”

Before putting a bullet through his head, Westhusing had been deeply disturbed by abuses carried out by American contractors in Iraq, including allegations that they had witnessed or even participated in the murder of Iraqis. His suicide note included claims that his two commanders tolerated a mission based on “corruption, human rights abuses and liars. I am sullied — no more. I didn’t volunteer to support corrupt, money grubbing contractors, nor work for commanders only interested in themselves.” One of those commanders: the future leader of American forces in Iraq, and then Afghanistan, Gen. David Petraeus.

Westhusing, 44, had been found dead in a trailer at a military base near the Baghdad airport in June 2005, a single gunshot wound to the head. At the time, he was the highest-ranking officer to die in Iraq. The Army concluded that he committed suicide with his service pistol and found his charges against the commanders unfounded. Petraeus would later attend Westhusing’s memorial service back in the U.S.

Ted Westhusing was an unusual case: “one of the Army’s leading scholars of military ethics, a full professor at West Point who volunteered to serve in Iraq to be able to better teach his students. He had a doctorate in philosophy; his dissertation was an extended meditation on the meaning of honor,” as Christian Miller explained in a major Los Angeles Times piece.

Please read the full article here