Wednesday, August 18, 2010

Why is a civilian hospital preffered over a VA Medical Center for traumatic brain injuries? Read on and you will understand.

Last month, a 24-year-old veteran received his first treatment for trauamtic brain injury from the Veterans Affairs Department — more than a year after he was discharged from the Marine Corps.

“The hand-off from [the Defense Department] to VA was very slow,” Jonathan Barrs told the Senate Committee on Veterans’ Affairs on Wednesday. “So far, the VA care has been good, but this whole time of waiting was very hard, and I had to keep asking my primary care doctor for a consult, which took a very long time.”

His TBI was diagnosed in November 2008. He medically retired in May 2009. He began receiving care in April 2010.

“The injuries get worse with time,” said Michelle LaPlaca, associate professor of biomedical engineering at the Georgia Institute of Technology. “The longer you wait, the less beneficial it will be for veterans.”

Though panelists at the hearing agreed that VA care has greatly improved since the early days of the wars in Iraq and Afghanistan, they also agreed that much work needs to be done.

Barrs’ case served as an example of service members and veterans still slipping through the cracks with “invisible” injuries. Not only did Barrs have to wait for a year for treatment from VA, he also eluded an initial diagnosis of TBI by not telling anyone about his injuries when an improvised explosive device blew up 30 feet from his vehicle in 2006, slamming him into his gunner turret and leaving him with glass embedded in his head. Symptoms showed themselves when he finally was screened for TBI in November 2008 by the Defense Department.

“I’m a United States Marine,” Barrs said. “I was still walking. I never wanted to get out of the Marines. But I had these horrible migraines.”

What about testing?

Military officials said that should no longer happen.

“What are you doing to ensure they get treatment?” asked committee chairman Daniel Akaka, D-Hawaii.

Air Force Col. Michael Jaffee, the national director for the Defense and Veterans Brain Injury Center, said testing for the troops is no longer subjective — “even if you are being strong and denying treatment.”

“What we’re really concerned with is people in the margins,” said Sen. Richard Burr, R-N.C. “How are we going to catch it if we don’t have a baseline?”

Jaffee told Burr he was “proud to say” there is a baseline — a pre-deployment cognitive assessment, the results of which people in theater could access by calling a special help line. What he did not say is that there is no post-deployment follow-up using the same test.

That was the subject of a brief debate at a recent House hearing in April in which lawmakers questioned the value of doing a baseline test if no post-deployment comparison is done to see if a service member’s cognitive functioning has changed. The senators at Wednesday’s hearing did not ask questions about a follow-up exam.

Burr also said he is concerned that few veterans with TBI seem to be accessing care in private assisted-living facilities under a pilot program created by Congress.

Lucille Beck, chief consultant for rehabilitative services for VA, said VA treated 3,700 veterans for TBI in fiscal 2009. Four went to residential programs, and 26 are expected to do the same in 2010.

“Why are so few being served under this pilot?” Burr asked. “This is 2010. We passed this in 2007. And we have four veterans?”

Beck said veterans prefer to get their care in their homes with their families. However, VA initially identified 168 veterans who said they would be interested at some point in assisted-living care.

Michael Dabbs, president of the Brain Injury Association of Michigan, said only three veterans had been referred to private care for TBI in the lower part of the state.

“There is totally inadequate access of care within VA to address the problem,” he said.

Sen. Patty Murray, D-Wash., cited a 2008 Government Accountability Office report that cited concerns with how veterans and service members were being screened for TBI, and she asked what has been done to address the problem. Beck said three research projects were in the works, and the first would be completed in 2011.

“Are we doing anything in the interim, or are we just waiting for a study?” Murray asked.

Beck said everyone who screens positive on the existing exams is receiving a “full and complete” evaluation. She also said a telehealth screening pilot would be in place by the end of the year.

Jaffee said several research projects involving brain scans are also in place. The scans would allow doctors to actually see if an injury has occurred.

Roadblocks to care

Karen Bohlinger, wife of Montana Lt. Gov. John Bohlinger, took issue with that research. She has spent most of the past 4½ years caring for her son, a former Special Forces officer who has a severe head injury, in Seattle because care is not available in their home state. Her family paid for a private brain scan to determine what care her son needed.

She said all troops should automatically receive those scans, rather than having doctors rely on symptoms or asking people questions to determine their cognitive abilities. She also asked for bio-marker baseline testing.

“Self- and counselor assessments are not always accurate,” she said. “Neuroimaging is critical.”

She said she often hears of cases where a service member is given a 10 percent disability rating based on a doctor’s assessment, but have their ratings shoot up to 100 percent after a brain scan, when doctors can see how much damage was actually done.

“Scans are available in the private sector,” she said. “Our veterans deserve no less.”

She also said care should be made convenient for the veterans, not the providers, and cited group therapy sessions that coincided with rush hour in Seattle, as well as providers who are reimbursed by the number of diagnoses made, rather than how well the provided treatment works. She said, clinics also provide fewer services during the holiday season, so there are few group sessions or therapy appointments.

Frustration in private sector

Bruce Gans, executive vice president and chief medical officer for the Kessler Institute for Rehabilitation, said there are diagnostic tools the military and VA could be using. But he also said very few people train to take care of people with brain injuries because it’s such a difficult field.

Therefore, it’s frustrating to him that the private facilities see so few veterans, mostly because they don’t get referrals from Tricare or VA. He compared the “trickle” of brain-injury veterans to the 97 percent of amputees who receive care through private contractors for VA. He said case management has improved greatly, but that case managers can’t get their veterans the care they need because it’s still not available through VA.

LaPlaca, of Georgia Tech, also expressed frustration. She said there is no FDA-approved treatment for TBI, each case is different, most clinical trials are done by industry so doctors don’t know which ones can be trusted, and it’s difficult to work with VA because all research has to be done offsite to access VA records.

“There is a lot of bureaucracy,” she said.

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