Treating Our Wounded Warriors for Mental Health and Traumatic Brain Injuries

The Wounded Warrior Project® (WWP) began some 10 years ago when some fellow veterans and friends took action to provide comfort items at Walter Reed Army Medical Center to wounded service members returning home from Afghanistan and Iraq. Ten years later, with a stated mission to honor and empower our wounded warriors, WWP has grown into a holistic rehabilitative effort to assist wounded warriors recover and transition back to civilian life. Tens of thousands of wounded service members, their family members, and caregivers receive support each year through 19 separate WWP programs.

Some of you may know of the WWP through its national fund raising efforts, such as the Billy Casper Golf’s (BCG) fourth-annual “World’s Largest Golf Outing” – a simultaneous event played at more than 110 BCG-managed golf courses in 28 states on Monday, August 11 – which raised more than $875,000, a record high, for WWP. Over 12,000 golfers, including 439 injured service members, participated in this largest, single-day golf fundraiser in the history of WWP. Former President Bill Clinton, the 2014 recipient of the PGA of America’s Distinguished Service Award, supported the World’s Largest Golf Outing in his suburban New York City community.

Several WWP programs provide assistance for veterans who are suffering with mental health problems or traumatic brain injuries (TBI). They include:

  • Combat Stress Recovery Program addresses mental health needs of injured service members through innovative programming and therapeutic options for the stages of the readjustment process.
  • Project Odyssey® uses the healing power of nature, along with support from mental health professionals and staff, to help wounded service members gain perspective on life through outdoor activities and retreats.
  • Restore Warriors® (org) is a website for warriors and families looking for information and practical advice about living with combat stress and post-traumatic stress disorder (PTSD).
  • The Independence Program offers the opportunity for warriors who have suffered TBI, spinal-cord injury, or other neurological conditions to engage in social, recreational, wellness, education, volunteer, and other activities.
  • Physical Health & Wellness programs serve all Alumni (including those with amputations, spinal cord injuries, burns, visual impairments, TBI, PTSD, and other cognitive or mental health conditions) and are designed to optimize the physical and psychological well-being of Alumni through comprehensive recreation and sports programs, physical rehabilitation, and nutrition programs.

 Mental Health Needs

The WWP has provided testimony at 16 congressional hearings on mental health issues since 2011. As part of its government advocacy efforts, on July 10, 2014, WWP Alumnus Josh Renschler, testified before the House Committee on Veterans Affairs on the VA’s mental health care programs. Renschler, Sergeant U.S. Army (Retired), served as an infantryman for five and half years before being medically retired following a mortar blast in Iraq in 2004, where he sustained severe back injuries and subsequently developed PTSD. Renschler testified that “access” to mental health care alone will not solve the problems facing injured service men and women. According to Renschler, “Access to a system where I go to three different buildings to see three different providers for health issues that are all related to my mental health – pain, lack of sleep, and relationship issues – is a real problem when those providers aren’t working as a team, and aren’t even given the time needed to coordinate their observations and treatment approaches with one another. In other words, access to mental health care isn’t enough unless that mental health care is also effective.”

Renschler also cautioned that proposals to expand veterans’ access to non-VA mental health care provide no “silver bullets,” given a national shortage of mental health care providers. While he believes “there are VA facilities that are providing veterans’ timely access to effective, patient-centered mental health care, that is not the case systemwide. Unfortunately there are no measures in place to assess patient outcomes.”

Renschler’s claim that there are “no measures in place [at the DoD and VA] to assess patient outcomes” is supported by a June 20, 2014 Institutes of Medicine (IOM) Report Brief. The IOM brief notes that between 2004 and 2012, the percentage of all active-duty service members with a diagnosis of PTSD increased from 1 to 5 percent. In 2012, more than half a million veterans of all eras sought care for PTSD through VA health care services—making up 9.2 percent of all VA users. Almost 24 percent of these veterans (119,500) had served in the Afghanistan and Iraq conflicts.

The IOM brief found that neither DoD nor VA has a mechanism for the systematic collection, analysis, and dissemination of data for assessing the quality of PTSD care. The report also found that: (1) many of the DoD and VA PTSD care programs and services are under different commands and authorities, which makes it difficult to identify and evaluate them; (2) neither DoD nor VA is in a position to provide high value care, primarily because of the lack of outcome data, but also due to the absence of cost information for certain treatments; and (3) although the DoD and VA have taken the important first step to increase access to care, the referral process to purchased care providers appears to be ad hoc rather than thoughtful clinical decision making, questions remain about providers’ adherence to the VA/DoD Clinical Practice Guideline for Management of Post-Traumatic Stress, adequacy of training in evidence-based treatments for both direct care and purchased care providers, and the ability of providers to deliver that treatment.

The WWP’s 2013 Annual Alumni Survey further supports the existence of a problem in providing access to and adequate mental health care for our veterans. For example, the survey shows that 75.4 percent of WWP alumni reported having experienced PTSD, but only 55.2 percent of WWP alumni said they had visited a professional to get help. The survey also found that 34.2 percent of WWP alumni said they had difficulty in getting mental health care, put off getting such care, or did not get the care they needed. The reasons reported included inconsistent treatment or lapses in treatment, and feeling uncomfortable with existing resources within the DoD or VA. In fact, only 9.8 percent of WWP alumni reported they have not had any mental health concerns since deployment.

 Traumatic Brain Injuries

On July 29, 2014, after lobbying by WWP, the U.S. Senate and House Committees on VA Affairs included a three-year extension of the VA’s Traumatic Brain Injury (TBI) Assisted Living pilot program in their compromise VA legislation. This extension provides a reprieve for wounded veterans who would have otherwise been evicted from their rehabilitation programs and reopens the program for those who were locked out since February 2014. Specifically, H.R. 4276, the Veterans Traumatic Brain Injury Care Improvement Act of 2014 – amends the National Defense Authorization Act for Fiscal Year 2008 to extend the VA’s Traumatic Brain Injury (TBI) Assisted Living pilot program to assess the effectiveness of providing assistance to eligible veterans with traumatic brain injury to enhance their rehabilitation, quality of life, and community integration.

On August 7, 2014, when President Obama signed into law the $16.3 billion landmark reform of the troubled VA (the Veterans Access, Choice and Accountability Act (H.R. 3230)), it included the provisions of H.R. 4276 in Title V of the Act.

WWP has announced that it is pleased not only with the VA bill’s extension of the TBI Assisted Living Pilot Program, but also the emergency funding for VA staff and facility expansion, and the prospect that “wounded warriors will benefit from a requirement that public colleges and universities limit the tuition costs to post-9/11 GI-bill beneficiaries to in-state tuition rates regardless of the veteran’s state of residence.”

However, while the WWP is pleased with the congressional compromise and passage of the VA overhaul bill, it continues to be concerned that with a “national shortage of primary care physicians and mental health providers, and a culture that allows access issues and cover-ups to fester, the promise of this legislation may not be realized.”

 Other WWP Programs

Fourteen additional WWP programs also focus on engagement of the wounded warrior, the nurturing of his or her mind and body, and encouraging economic empowerment. These WWP programs include:

  • The Alumni program offers assistance, communication, and camaraderie for injured service members through educational sessions, sporting, and social events.
  • Benefits Service provides Alumni and their families with information and access to government benefits and a full range of programs and the community resources necessary for successfully transitioning to life after injury.
  • International Support supports warriors at Germany’s Landstuhl Regional Medical Center (LRMC), the Ramstein Air Base, and those in the Warrior Transition Battalion (WTB) in Europe.
  • WWP Packs contain essential care and comfort items designed to make wounded service members’ hospital or poly-trauma center stay more comfortable.
  • The WWP Resource Center responds to specific internal and external resource requests and proactively reaches out to Alumni and their family members to engage them in available programs and services.
  • Peer Support mentors are trained to be resources and listeners who can share their understanding and perspective with Alumni and their family members.
  • Family Support reaches out to the family members who suddenly find they are serving as full-time supporters or caregivers.
  • Soldier Ride® is an initiative that provides adaptive cycling opportunities across the country to help Alumni restore their physical and emotional well-being.
  • Education Services provides outreach, information, and self-advocacy skills training to Alumni interested in attending or returning to school or who need support while in school. WWP also provides information and resources to help colleges, universities, and vocational programs support, accommodate, and retain student warriors.
  • TRACK™ is the first whole-life approach to education for Alumni. This one-year program focuses on academic and vocational needs, including the ability to earn up to 24 credit hours at a local college, health and wellness training, and individualized performance and goal-setting training.
  • Transition Training Academy™ (TTA) provides the opportunity for WWP Alumni to learn valuable information technology (IT) career skills with future employment opportunities. TTA has perfected a unique, blended learning environment designed expressly for wounded service members, and allows WWP Alumni to explore the IT field as a career.
  • Warriors to Work™ provides career guidance and support services to wounded service members interested in transitioning to the civilian workforce. Warriors to Work specialists assist Alumni with individualized goal setting, building an effective resume, preparing for an interview, networking, access to internships, and assistance with job placement.
  • Policy & Government Affairs provides a voice to the thousands of wounded service members we represent at the Federal level. WWP creates, advocates for, and helps to implement legislation that will maintain wounded service members and their families far into the future and keep them informed about changes in laws and programs that will impact them.
  • Community Integration Grants provide grants to organizations dedicated to honoring and empowering Wounded Warriors. By providing these grants, WWP is able to increase the breadth and scope of programs and services offered to wounded service members while continuing to reach out on a local level.

Cardiologist Accused in $7.2M Overbilling Scheme

Dr. Harold Persaud, a Westlake, Ohio cardiologist has been indicted for performing unnecessary catheterizations, tests, stent insertions and causing unnecessary coronary artery bypass surgeries as part of a scheme to overbill Medicare and other insurers by $7.2 million, of which Medicare and the private insurers paid approximately $1.5 million. The scheme allegedly took place from February 16, 2006, through June 28, 2012. The indictment seeks forfeiture of $93,446 from an account in the name of Harold Persaud and $250,188 from an account in the name of his wife, Roberta.

The 16 count indictment, announced by U.S. Attorney’s Office for the Northern District of Ohio included one count of health care fraud, 14 counts of making false statements and one count of engaging in monetary transactions in property derived from criminal activity.

Allegations

According to the indictment, Dr. Persaud: (1) selected the billing code for each patient and used codes that reflected a service that was more costly than that which was actually performed; (2) performed unnecessary nuclear stress tests; (3) knowingly recorded false results of nuclear stress tests to justify unnecessary cardiac catheterization procedures; (4) falsely recorded the existence and extent of blockage; (5) recorded false symptoms in patient records to justify testing and procedures; (6) inserted cardiac stents in patients who did not have 70 percent or more blockage and who lacked symptoms of blockage; (8) placed a stent in a stenosed artery that already had a functioning bypass; (9) improperly referred patients for coronary artery bypass surgery; and (10) performed medically unnecessary aortograms, renal angiograms, and other procedures and tests.

Other Legal Actions

Dr. Persaud had a private medical practice at 29099 Health Campus Drive in Westlake and had hospital privileges at Fairview Hospital, St. John’s Medical Center and Southwest General Hospital, according to the indictment. The Cleveland Plain Dealer reports that Dr. Persaud has been sued for medical malpractice at least 14 times in Cuyahoga County Common Pleas Court since 2012. The Plain Dealer also reported on August 29, 2013, that Dr. Persaud sued St. John Medical Center in Westlake, its chief medical officer Dr. Michael Dobrovich and unnamed others for more than $10 million claiming they made false statements about him, defamed his character and interfered with his ability to do business when they accused him of unnecessarily placing stents in the hearts of some of his patients.

Court Appearance

Dr. Persaud pleaded not guilty to the indictment during his initial appearance in U.S. District Court and was ordered to surrender his passport, avoid contact with any potential witnesses, and released on a $25,000 personal bond, according to the Plain Dealer.

An indictment is only a charge and is not evidence of guilt.

CMS Continues to Monitor the Relative Cost of the MA Program

Concerns about overpayment as a result of favorable risk selection of healthier-than-average beneficiaries have confronted the Medicare program throughout its history of contracting with Medicare Advantage (MA) plans. The goal of the MA risk adjustment system is to use risk scores to assure that MA plans that enroll sicker-than-average beneficiaries are paid appropriately, but not to increase payment for an average beneficiary. A Medicare and Medicaid Research Review (MMRR) paper, titled “Measuring Coding Intensity in the Medicare Advantage Program,” used recent data and improved methodology to estimate the effects of coding intensity on MA risk scores.

MA Risk Adjustment System

The MA payment system creates incentives for MA plans to find and report as many diagnoses as can be supported by the medical record. For example, the MA payment system uses diagnostic information to assign a risk score to each beneficiary, where the average beneficiary in Medicare fee-for-service (FFS) has a risk score of 1.0. MA plans are paid the product of their plan bid multiplied by the enrollee’s risk score. Therefore, if an MA plan bids $1,000/month for an enrollee with a risk score of 1.0, and then enrolls a beneficiary with a risk score of 1.2, the plan gets paid $1,200/month for that enrollee.

The implicit assumption in the design of the MA payment system is that a beneficiary will have the same risk score of 1.0 whether they are enrolled in FFS or MA. As such, if a FFS beneficiary had a risk score of 1.1 if enrolled in MA, then the MA plan would be overpaid. The term “coding intensity” is the difference between the scores that a group of beneficiaries would have if enrolled in MA and their scores in FFS.

The Challenge

The Government Accountability Office (2012) estimated that in 2010 MA beneficiary risk scores were at least 4.8 percent and perhaps as much as 7.1 percent higher than they would have been if the same beneficiaries had been enrolled in FFS.

  • According to the MMRR paper, the mean risk scores in MA increased faster than in FFS from 2004 to 2013—by 0.305 in MA, compared to 0.106 in FFS. As measured using the 2004 risk model, MA risk scores grew from 90.2 percent of FFS risk scores in 2004 to 109.1 percent in 2013, an increase of 18.9 percentage points. From 2004–2013, the mean MA risk score increased 2.2 percentage points per year more quickly than the mean FFS score using the 2004 risk model and 1.6 percentage points more quickly using the 2014 risk model. According to the paper, the main reason that MA risk scores increased more quickly than FFS scores appeared to be due to increases in relative coding intensity.
  • CMS and the Congress have responded to the increase in risk scores over time in several ways.
  • Starting in 2010, CMS lowered payment by 3.41 percent by applying an across-the-board coding adjustment. This coding intensity adjustment will increase to 4.91 percent in 2014 and to at least 5.91 percent in 2018.
  • Starting in 2013, CMS set the four most severe diabetes Hierarchical Condition Categories (HCCs) (HCC15-HCC18) to have the same payment coefficient. As a result, recording diagnoses that move enrollees from HCC18 (diabetes with ophthalmologic or unspecified manifestation) into HCC15 (diabetes with renal or peripheral circulatory manifestation) will no longer increase revenue for MA plans.
  • CMS made further changes to the model in 2014, removing some of the HCCs that were the subject of MA efforts at increasing coding intensity.
  • The legislated increase in coding intensity adjustment is 0.25 percent per year from 2014 through 2018.
  • The President’s Budget for 2015 proposes increasing the minimum adjustment to 0.67 percent per year through 2020, topping off at 8.51 percent in 2020, which is much closer to the expected increase in relative risk scores.

Paper’s Conclusion

The paper concludes that it is challenging to accurately measure the effects of coding intensity on MA risk scores and even more challenging to devise optimal policy responses. It notes that HHS is continuing its analysis of the relative risk of MA and FFS enrollees in order to improve the ability of the Medicare program to accurately pay for MA beneficiaries.

Childhood Cancer Research: We Must Do Better

Every summer about this time I play golf in a pediatric cancer research fundraiser where the parents, family, and friends of Jeffrey Pride raise money for pediatric cancer research. Jeff died of acute lymphoblastic leukemia (ALL) at age seven, and for the last 12 years The Jeffrey Pride Foundation for Pediatric Cancer Research has raised money for the pharmacological research of new chemotherapeutic agents and to subsidize clinical trials so that children will be able to receive new and potentially breakthrough therapies.

Like many charitable organizations that have sprung up after such a tragedy, The Jeffrey Pride Foundation is an all-volunteer, tax-exempt, Internal Revenue Code Sec. 501(c)(3) organization whose sole mission is to raise funds, 100 percent of which go directly to pediatric cancer research. In addition, because the foundation’s board wanted its funds to have the greatest impact, it chose, with the help of Jeff’s doctors, to contribute to the Children’s Oncology Group (COG), the world’s largest pediatric cancer research organization. And as one of the larger donors to COG, the foundation has a designated fund called The Jeffrey Pride Fund for Targeted Therapy Discovery in Childhood Acute Lymphoblastic Leukemia. COG, a National Cancer Institute (NCI) supported clinical trials group, oversees more than 90 percent of all pediatric cancer research done in North America, Australia, New Zealand, Sweden, and the Netherlands, and writes all treatment protocols for children’s chemotherapy regimens. According to the NCI, each year approximately 4,000 children who are diagnosed with cancer enroll in a COG-sponsored clinical trial.

Outlook for Survival

Despite the best efforts of the NCI, COG, private fundraising foundations, and clinical researchers, cancer is still the leading cause of disease-related death among children (ages 1-19) in the United States. In 2014, it is estimated that 15,780 children will be diagnosed with cancer and 1,960 will die of the disease. There is some good news, however. According to the NCI, survival rates have improved for some childhood cancers. For instance, in 1975, just over 50 percent of children diagnosed with cancer survived at least 5 years. However, by 2004-2010, more than 80 percent of children diagnosed with cancer survived at least 5 years.

Pediatric Regimens Needed 

Some evidence suggests that children may have better treatment outcomes if they are treated with pediatric treatment regimens rather than adult treatment regimens. For instance, it is possible that the improvement in the 5-year survival rates for 15- to 19-year-olds with ALL, from approximately 50 percent in the early 1990s to 78 percent in 2003-2007, reflects the greater use of pediatric treatment regimens. This evidence underscores the need for more pediatric cancer clinical trials and the development of pediatric treatment regimens. Unfortunately, this can only happen through greater funding from the government, private donations, and a greater commitment from drug manufacturers. In fiscal year 2012, the NCI’s funding of pediatric cancer research was only 208.1 million, which was approximately 3.5 percent of its $5.87 billion budget.

Long-Term Outlook and Follow-Up Care

While 5-year survivor rates are up for certain childhood cancers, surviving for 5-years is not a lifetime cure. In addition, childhood cancer survivors need follow up care and ongoing medical surveillance because of the risk of complications steming from their treatment. An analysis of childhood cancer survivors treated between 1970 and 1986 has shown that cancer survivors remain at risk for complications and premature death as they age, with more than half experiencing a severe complication or death by the age of 50.

In addition to regular medical follow-up examinations for childhood cancer survivors, the NCI underscores the importance of parents keeping an accurate record of cancer treatments, including: the type and stage of cancer; date of diagnosis and dates of any relapses; types and dates of imaging tests; contact information for the hospitals and doctors who provided treatment; names and total doses of all chemotherapy drugs used in treatment; the parts of the body that were treated with radiation and the total doses of radiation that were given; types and dates of all surgeries; any other cancer treatments received; any serious complications that occurred during treatment and how those complications were treated; and the date that cancer treatment was completed.

The NCI booklet Facing Forward: Life After Cancer Treatment contains a list of organizations that can help parents keep track of this information. The NCI also provides a handbook for parents of children with cancer.