VA Inconsistent in Delivery of Mental Health Services

Two internal annual VA reports that have been obtained by McClatchy Newspapers reveal that in some parts of the country mental health services are not getting the resources they need, and in several areas, they are failing to meet the VA's own goals. The reports used to be readily available to the public, but in the last year, the VA has removed them from its Web site. McClatchy obtained the reports for FY 2006 via a Freedom of Information Act request.

In fiscal year 2006, the reports show, some of the VA's specialized PTSD units spent a fraction of what the average unit did. Five medical centers — in California, Iowa, Louisiana, Tennessee and Wisconsin — spent about $100,000 on their PTSD clinical teams, less than one-fifth the national average.

The documents also show that while the VA's treatment for PTSD is generally effective, nearly a third of the agency's inpatient and other intensive PTSD units failed to meet at least one of the quality goals monitored by a VA health-research organization. The VA medical center in Lexington, Ky., failed to meet four of six quality goals, according to the internal reports.

An official at the VA dismissed the findings and played down the significance, insisting that Veterans are receiving adequate care. He insisted that the spending disparity is not as extreme as the numbers make it sound, and besides that, they are working to improve resource allocation for mental health services anyway. Spending varies widely among the units, however, from more than $2,000 per treated veteran in centers in The Bronx, N.Y., and Boise, Idaho, to about $300 per treated veteran in Augusta, Ga., and about $200 in Palo Alto, Calif., one of the reports says.

The VA is bracing for an onslaught of veterans returning from Iraq and Afghanistan experiencing PTSD, and at a time when the department is under scrutiny for shortfalls in staffing and funding for mental health units. The VA insists that they deliver high-quality care and that when comparisons are made across facilities in the system, the results are uniformly positive.

The data shows that the number of veterans who utilize the VA's specialized outpatient PTSD services is growing much faster than the number of appointments the VA is providing. The reports reveal that the number of veterans treated grew by more than 4% from 2005 to 2006, while the number of appointments scheduled grew by only 1%. This translates to veterans receiving fewer visits.

"It is the task of thoughtful planning, performance assessment and clinical care to assure that, as VA passes through a period of major change during the years to come, the treatment provided to veterans with PTSD is equitably distributed, accessible, effective and efficient," the report concludes.

Paul Sullivan, a former VA official who works for the advocacy group Veterans for Common Sense, said the numbers indicated that the VA wasn't prepared to treat the number of soldiers who were coming home with PTSD.

"If the ominous trend continues or if all our Iraq soldiers return home quickly, VA's crisis may deteriorate into a full-blown catastrophe," he said.

The influx of veterans returning from Iraq and Afghanistan needing services is already taking its toll as the agency struggles to meet demands for care. Depending on the severity of symptoms, the services provided by the VA range from inpatient intensive therapy to outpatient group therapy. Services available are split between general mental health services and individual counseling to specialized, largely group therapy programs, that deal with specific focused issues and symptoms (i.e. PTSD.) "The availability of specialized PTSD programs is an important indicator of the quality of health care provided by VA," it says.

The VA health system consists of 153 medical centers, 103 of which have special PTSD clinical units, but only 40 have specialized inpatient units for the treatment of PTSD.

Assessing the efficacy of PTSD treatment is subjective rather than objective, but by and large, programs can be evaluated for effectiveness by tracking the symptoms of veterans receiving the services. Are they abusing drugs or alcohol ('self medicating')? Are they able to hold a job? What are their work habits? Is the veteran coming into contact with law enforcement as a result of their behaviors? Are there instances of domestic violence? Other episodes of violence?

Overall, the results show, the VA offers effective treatment for PTSD, with most beneficiaries of treatment reporting that they experience a decrease of symptoms.

The VA is managing to keep it together for now, but there is only so much belt tightening and streamlining that can be done. There are only so many hours in the day and a finite number of appointments can be made. The time is long since past to fully fund the VA, and provide the care to our returning Soldiers, Sailors, Airmen and Marines that is part of the bargain when they agree to serve. They have lived up to their end of the bargain. It is time for American society to reciprocate.

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I'm getting published, and on a pretty important issue

Pardon me for tooting my own horn a bit, but ...

This February, I wrote an op-ed column in my newspaper about how the mentally ill often get "warehoused" in the Texas prison system. It caught the eye, online, of Chris Salazar, publisher of DOCTalk, a nationally-distributed, Texas-based physician advocacy quarterly magazine. (The current issue's cover story is an in-depth interview with Michael DeBakey; inside stories include an interview with the director of Houston's M.D. Anderson cancer center; you can learn more about the mag here.)

So, he's running the column in his next issue, as part of a series on mental health issues. On this particular issue, the "advocacy" part includes getting parity on mental health insurance coverage and many other issues, which of either state or federal legislative action in many cases.

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This is tragic, that vets aren’t getting better mental health insurance

The biggest problem, other than Tricare’s stinted coverage and lack of therapists in its coverage, is that Guard and Reserve troops called to active duty aren’t getting active-duty level mental health insurance coverage.

Soldiers returning from war are finding it more difficult to get mental health treatment because military insurance is cutting payments to therapists, on top of already low reimbursement rates and a tangle of red tape.

Wait lists now extend for months to see a military doctor and it can takes weeks to find a private therapist willing to take on members of the military. The challenge appears great in rural areas, where many National Guard and Reserve troops and their families live.

Tricare itself needs to be improved, and Guard and Reserve on active duty should get 100 percent payment of premiums while called up.

Cross posted at SocraticGadfly.

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Vindication for a long-running hissy-fit

I have a long history of writing about mental health issues and repatriated soldiers. (More here, here, and here)

Sometimes it has felt like I was shouting down the well. Thank goodness these issues are finally getting some traction. Yesterday I got one more bit of vindication when the Institute of Medicine, which advises the federal government on issues of medical science, released their long awaited report on the treatment returning soldiers are not getting.

The report suggested changes to VA policies, but the panel could not say whether those changes would result in more or fewer PTSD diagnoses, or in greater or lesser expense for taxpayers. "PTSD has become a very serious public health problem for the veterans of current conflicts and past conflicts," said psychiatrist Nancy Andreasen of the University of Iowa, who chaired the panel. Noting the shortcomings of the VA system, Andreasen added that "a comprehensive revision of the disability determination criteria are needed."

She said the current VA system, in which PTSD compensation is limited to those who are unable to hold a job, places many veterans in a Catch-22.

"You can't get a disability payment if you get a job -- that's not a logical way to proceed in terms of providing an incentive to become healthier and a more productive member of society," she said.

The practice is especially wrong, she added, because it is at odds with VA policies for other kinds of injuries. To determine the compensation a wounded veteran should get, the government assigns one a disability score. Veterans who are quadriplegic, for example, can be assigned a disability level of 100 percent even if they hold a job, whereas veterans with PTSD must show they are unable to work to get compensation.

Andreasen said the policies are "problematic, in the sense that they require the person given compensation to be unemployed. This is a disincentive for full or even partial recovery."

I personally favor adopting the suggestions offered by Linda Bilmes of Harvard. She has offered the most troop-centric approach to offering services to those who need and deserve those services. Her notion is so simple it hurts: Give the troops who apply for benefits the benefit of the doubt!

The Institute of Medicine panel said the scale used to evaluate veterans is outdated and largely designed for people who suffer from other mental disorders. Andreasen and other members also said they had heard from veterans who had received wildly different kinds of evaluations -- some lasting 20 minutes while others took hours. The scientists said VA should standardize the evaluations using state-of-the-art diagnostic techniques.

While VA requires its experts to determine what proportion of a veteran's disabilities were caused by particular traumatic experiences, and to what extent overlapping symptoms are related to particular disorders, the IOM said there is no scientific way to classify symptoms in this manner.

Frankly, if you aren’t mad as hell about the way our troops are being treated – if you aren’t pissed off about the fact the VA is still not fully funded – don’t be mouthing platitudes about supporting the troops around me.



[Cross-posted from Blue Girl, Red State]

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Unconscionable

This ABC news piece by Bob Woodruff is why the GAO needs to act swiftly on the request by the bipartisan Senate group that has asked for an in-depth evaluation of the mental health services our returning troops are not getting.

[Outrage Alert Warning: Red]

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Which is worse? When outrages occur, or when they stop surprising you?

There is an insidious abuse of troops taking place in the shadows, and it needs to be exposed to strong overhead light.

It is the use of the 5-13 discharge to cull injured troops from service and deny them future benefits through the VA. A 5-13 is a psych discharge. It brands the veteran as having a personality disorder, an Axis II disorder in the Diagnostic and Statistical Manual of the American Psychological Association. Personality disorders are deemed pre-existing conditions, and therefore the military is absolved of all future responsibility to those veterans.

Take the story of Specialist Jon Town, reported by Joshua Kors in the April 9 issue of The Nation.

Jon Town has spent the last few years fighting two battles, one against his body, the other against the US Army. Both began in October 2004 in Ramadi, Iraq. He was standing in the doorway of his battalion's headquarters when a 107-millimeter rocket struck two feet above his head. The impact punched a piano-sized hole in the concrete facade, sparked a huge fireball and tossed the 25-year-old Army specialist to the floor, where he lay blacked out among the rubble.

"The next thing I remember is waking up on the ground." Men from his unit had gathered around his body and were screaming his name. "They started shaking me. But I was numb all over," he says. "And it's weird because... because for a few minutes you feel like you're not really there. I could see them, but I couldn't hear them. I couldn't hear anything. I started shaking because I thought I was dead."

Eventually the rocket shrapnel was removed from Town's neck and his ears stopped leaking blood. But his hearing never really recovered, and in many ways, neither has his life. A soldier honored twelve times during his seven years in uniform, Town has spent the last three struggling with deafness, memory failure and depression. By September 2006 he and the Army agreed he was no longer combat-ready.

But instead of sending Town to a medical board and discharging him because of his injuries, doctors at Fort Carson, Colorado, did something strange: They claimed Town's wounds were actually caused by a "personality disorder." Town was then booted from the Army and told that under a personality disorder discharge, he would never receive disability or medical benefits.

Town is not alone. A six-month investigation has uncovered multiple cases in which soldiers wounded in Iraq are suspiciously diagnosed as having a personality disorder, then prevented from collecting benefits. The conditions of their discharge have infuriated many in the military community, including the injured soldiers and their families, veterans' rights groups, even military officials required to process these dismissals.

The number of 5-13’s coming down has ballooned. It has reached the point where they would have us believe that the Army took an entire Division of hinky, psychologically damaged troops in recent years. Even with the number of waivers that have been issued to meet recruiting quotas (17%) that stretches credulity.

Not surprisingly, Fort Carson is at the vanguard of soldier abuse and neglect. Again. For cryin’ out loud, can we get an IG on-post please? Preferably a hardass. I mean, what the hell is it going to take? You hear a tale of soldiers being abused by the system, you won’t have to listen long before you hear “Fort Carson” in that conversation. And this scandal is no exception. The command culture there once again sets the bar for fecklessness and mendacity as low as it has ever been.

Inspector General.

Fort Carson.

Now.

Got that?

Okay.

Now that we have settled that, let’s talk about Feres v U.S., the 1950 Supreme Court decision that protected military medical professionals from civil suit. Because of this ruling, there is no recourse of accountability for mental health professionals who mislead vulnerable and compromised troops.

Who will be the courageous congressperson who will sponsor the legislation that gives the troops the right to seek civil remedy for professional malfeasance at the hands of military health professionals?

In the meantime, since legislation moves slowly, Senator Bond needs to move forward with his threat and launch a congressional investigation into the abuse of 5-13 discharges to avoid fulfilling responsibilities to wounded and damaged troops. And every single 5-13 discharge that has been processed in the last four years should be thoroughly reviewed, and those found to have been misdiagnosed should have their benefits restored, retroactively.

We have 535 elected officials. Will just one stand up for what is right here?

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Filner Fires Senior Dem Staff of Veterans' Affairs

I posted last week about the importance of the work that Representative Bob Filner (D-CA) would be doing as the new Chairman of the Committee for Veteran's Affairs; it appears that not only is Representative Filner replacing the staff director, but he seems to be replacing all of the senior staff on the Democratic side of the committee. The wisdom of this, when the Republicans will have an experienced senior staff, escapes me. Here's more info about what's at stake in combating Representative Buyer (R-IN) and his Republican staff [to clarify, the Navy provides counseling and mental health care to the Marines]:

An experienced Navy psychologist warns that the U.S. military does not have enough mental health professionals to meet the growing number of emotionally damaged war veterans.

Moreover, Navy Cmdr. Mark Russell says, many of the mental health professionals on staff lack formal training in core therapies for post-traumatic stress syndrome. Russell predicts a "perfect storm" of dire health care consequences.
...
Military mental health officials downplay Russell's grim assessment, noting that training is increasing, aggressive mental health programs are being created, and civilian mental health professionals are being hired to provide additional resources.

"Mark really has a tremendous amount of compassion and a real desire to make sure that everyone gets what they need," says Navy Capt. Warren Klam, a psychiatrist and senior medical officer for mental health at the Naval Medical Center in San Diego and a member of the Mental Health Task Force. "I just think if you look at the bigger picture, it's not nearly as much of a concern as it might sound. I think DOD (Department of Defense) is very sensitive to this issue and is trying to work very hard."

In my opinion yes, the military cares about this problem, but I also think they could use some help prioritizing this issue in the grand scheme of things that they have on their collective plate. Both the military and the nation's track record of caring for veterans (particularly those suffering from PTSD) could be better:

...the VA estimates that nearly 200,000 veterans are homeless on any given night. And nearly 400,000 experience homelessness over the course of a year. Conservatively, one out of every three homeless men who is sleeping in a doorway, alley or box in our cities and rural communities has put on a uniform and served this country. According to the National Survey of Homeless Assistance Providers and Clients (U.S. Interagency Council on Homelessness and the Urban Institute, 1999), veterans account for 23% of all homeless people in America.

We need to do better this time. And Representative Filner needs to keep that foremost in his mind. It's too early to say whether his firing of the senior staff was a mistake, but he's stumbling a bit getting out of the blocks.

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