Tag Archives: military

‘Escape Fire’ movie tells powerful patient stories

Joanne Kenen

About Joanne Kenen

Joanne Kenen, (@JoanneKenen) the health editor at Politico, is AHCJ’s topic leader on health reform and curates related material at healthjournalism.org. She welcomes questions and suggestions on health reform resources and tip sheets at joanne@healthjournalism.org.

I wrote earlier this fall about several new documentaries about health care. I’ve now had a chance to watch one of them, “Escape Fire” and talk to the filmmakers Matthew Heineman and Susan Froemke.

Joanne Kenen

Joanne Kenen (@JoanneKenen) is AHCJ’s health reform topic leader. If you have questions or suggestions for future resources, please send them to joanne@healthjournalism.org.

The film has a fairly simple basic message: The American health care system is a mess. But solutions, at least partial solutions, are there for the taking.

Part of the film focuses on the payment and delivery of health care – what those of us who write about this a lot may think of as the Dartmouth Atlas message. The fee-for-service system rewards quantity over quality and encourages all sorts of stuff to be done that doesn’t make a lot of sense and isn’t necessarily right for the patients. A part of the film looks at the – related – issue of designing a health care system around people who are sick, rather than emphasizing investment in keeping people well; Dean Ornish, Andrew Weil and Wayne Jonas all appear. We know a fair amount about keeping people well. But that’s not what our system primarily pays for.

The filmmakers, Heineman and Froemke, whose interest in the health care system was stirred when they made a film a few years ago on Alzheimer’s disease, spent more than three years on this project. The more they learned about the health system, the more astonished they became at the scope of its flaws.

“We have worse outcomes but we’re spending twice as much as other nations, “ Heineman said. And despite all that money, we don’t have a “patient-centered preventive and safe system.” The system, as he put it, is “high-tech over high-touch.”

The filmmakers weren’t alone. “We found out that no one in the medical profession is happy” about much of American medicine, they said. Doctors who want to do primary care, or who want to have a more “whole patient” approach even as a specialist, encounter all sorts of barriers. “It’s the spending structure,” Froemke said. “Medicine became a for-profit industry; we lost our moral compass.”

The film has its share of experts, some of whom like Donald Berwick, M.D., will be (I hope!) familiar to health journalists. But the heart of the film, as Froemke put it, is the stories it tells about ordinary – or maybe not so ordinary—patients and doctors.Three stories in particular stood out for me: Continue reading

Military’s spotty recordkeeping hurts veterans

Andrew Van Dam

About Andrew Van Dam

Andrew Van Dam of The Wall Street Journal previously worked at the AHCJ offices while earning his master’s degree at the Missouri School of Journalism, and he has blogged for Covering Health ever since.

At the Center for Investigative Reporting, Aaron Glantz dug deep into the widespread recordkeeping errors and lapses that are bedeviling the VA’s disability claims system and making it difficult for veterans of Vietnam, the Gulf wars, and the war in Afghanistan to prove they were in combat, exposed to harmful substances, or even injured. A few days later, ProPublica and The Seattle Times published a similar investigation, which focuses most on more recent conflicts.

According to Glantz, “A Center for Investigative Reporting review of the VA’s performance data reveals chronic errors – committed in up to 1 in 3 cases – and an emphasis on speed over accuracy that clogs the VA system with appeals, increasing delays for all veterans.”

A few more numbers from Glantz’s work:

  • “The VA acknowledges it makes mistakes on 14 percent of disability claims.”
  • “A CIR analysis of 18 audits published this year by the VA’s inspector general shows the problem could be much worse, especially in high-profile cases. The analysis found a 38 percent average error rate for claims involving disabilities like traumatic brain injury and illnesses linked to the Vietnam-era defoliant Agent Orange.”
  • One internal VA document … shows that during the first three months of 2008 … the agency failed to perform its duty to assist in nearly 11,000 cases.

Likewise, the Seattle Times/ProPublica reporters write that military historians found that “at least 15 brigades serving in Iraq at various times from 2003 to 2008 had no records on hand. The same was true for at least five brigades deployed to Afghanistan.”

Records were so scarce for 62 more units that served in Iraq and 10 in Afghanistan that they were written up as “some records, but not enough to write an adequate Army history.” This group included most of the units deployed during the first four years of the Afghanistan war.

Plenty of stories in how ACA could affect veterans’ health care

Joanne Kenen

About Joanne Kenen

Joanne Kenen, (@JoanneKenen) the health editor at Politico, is AHCJ’s topic leader on health reform and curates related material at healthjournalism.org. She welcomes questions and suggestions on health reform resources and tip sheets at joanne@healthjournalism.org.

While preparing for a veterans health panel I moderated at the recent AHCJ conference in Atlanta, I remembered an article in the Journal of the American Medical Association that AHJC’s Pia Christensen had sent me on what the health reform law would do for veterans. It’s behind a pay wall, but AHCJ members get free access. It’s written by Kenneth Kizer, who is at the University of California, Davis, but used to run the Veterans Health Administration (better known as the VA) – which is the nation’s largest health care system – when he was under secretary for health in the Department of Veterans Affairs.

There are more than 22 million veterans and the number is obviously growing. About one-third (37 percent in 2011) were enrolled in the VA, which usually means they either have a service-connected disability and/or are low income. Most (80 percent) are covered by Medicare starting at age 65. Most have some kind of coverage or mix of coverage (private insurance, Medicaid, or TRICARE, which also covers military retirees and their dependents). Only about 7 percent – well under the national average and most states’ rates – are uninsured, which in most cases means they are poor but not poor enough to get into the VA.

Joanne KenenJoanne Kenen (@JoanneKenen) is AHCJ’s health reform topic leader. If you have questions or suggestions for future resources, please send them to joanne@healthjournalism.org.

The Affordable Care Act (assuming it survives the Supreme Court) doesn’t affect the VA per se – although one could argue that some of the VA’s initiatives on care coordination and its early adoption of electronic medical records did affect the shape of the ACA. But not affecting the VA doesn’t mean it won’t affect veterans. Kizer expects that to be a mixed blessing.

For that 7 percent who are uninsured (and for those who may be paying a lot for insurance that may or may not be comprehensive in the individual or small group markets) the coverage expansion could make a big difference. Some may qualify for the expanded Medicaid. Other will be able to get insurance, often with a federal subsidy, in the new state-based insurance exchanges. And that’s a gain.

Those options will be open, too, to some veterans who are VA eligible. This is where Kizer argues the benefits aren’t so clear cut. On one hand, it gives veterans more choices, and they may be able to get care that is more convenient and timely. The drawback, though, is the care may be more fragmented and disconnected once they venture outside the VA’s closed system of coordinated care.

“Fragmentation of care is of concern because it diminishes continuity and coordination of care, resulting in more emergency department use, hospitalizations, diagnostic interventions, and adverse events. The VA serves an especially large number of persons with chronic medical conditions or behavioral health diagnoses – populations especially vulnerable to untoward consequences resulting from fragmented care,” Kizer wrote.

There is even some data suggesting that vets who get some care in the VA and some outside are more likely to be rehospitalized and die within a year than VA-only users, although the data is limited. The new choices by expanded coverage options could also mean more veterans end up getting care outside the VA system – from doctors who may not be as well-versed in the medical problems prevalent among vets (including PTSD) or the resources available to help them. There could be some good local stories on this aspect – and on the broader issue of whether mental health providers in the community are plugged into the needs of veterans, whether or not they are eligible for the VA itself.

There are also a bunch of questions about financing – and these too are worth a local look. If more vets seek care outside the VA, will that mean that some low-volume rural VA services will be cut back? How will that affect the remaining vets who want to get those services from the VA? Will coverage expansion in general – not just for vets – lure more doctors and nurses and physical therapists etc out of the VA to meet the higher demand for health providers among the newly insured? And will the increased options for vets cost the government money? For instance, the government may be making redundant payments now – think about a vet over age 65 who gets some care in the VA and is also enrolled in a government-subsidized Medicare Advantage plan, or is a dual-eligible getting subsidized Medicare, Medicaid – and VA care. Will this kind of duplicative payments rise if vets get subsidized coverage through Medicaid or the exchange – and also draw on VA services? Is anyone in your state even thinking about this? Kizer suggests research needs to be done on this, and says Florida, Texas and California – together home to nearly one in four vets – would be good places to start.

He raises other questions about the health care work force, the safety net, the oft-neglected needs of women vets but concludes with a call to recognize that “providing health care for veterans is an ongoing cost of foreign policy foreign policy and national defense strategies and that the nation has a long-standing social contract with veterans to ensure that those who have experienced harm during military service have ready access to health care.”

Medical, support network lacking for returning National Guard, reservists

Pia Christensen

About Pia Christensen

Pia Christensen (@AHCJ_Pia) is the managing editor/online services for AHCJ. She manages the content and development of healthjournalism.org, coordinates social media efforts of AHCJ and assists with the editing and production of association guides, programs and newsletters.

National Guardsmen and reservists returning from duty in Iraq and Afghanistan “have been hastily channeled through a post-deployment process that has been plagued with difficulties, including reliance on self-reporting to identify health problems,” according to an investigation by graduate students in Northwestern University’s Medill School.

nat-guard-iraq

Photo by The National Guard via Flickr

Hidden Surge” found members of the National Guard must navigate disparate health care and support providers, made more difficult by the fact that many of them live in rural areas. Three of the stories were published in The Washington Post.

The reporters also found that, in the immediate aftermath of 9/11, most reservists were medically unready to deploy – an assessment made by a private contractor. “More than 2,400 Army Reserve soldiers were held back, at least temporarily, because of inaccurate assessments by the contractor, according to data provided by the Army Reserve Medical Command.”

Meanwhile, some soldiers with behavioral problems that could be aggravated by the stress of deployment and combat were improperly sent overseas.

The project, done by 10 students, was directed by faculty member Josh Meyer, who covered national security for the Los Angeles Times for 20 years. Students used video and interactive graphics to help tell the stories. A “How We Did It” sidebar says the students interviewed more than 150 people, reviewed documents and reports and traveled to nine states to do the reporting.

According to a press release, the Hidden Surge project is part of Medill’s National Security Journalism Initiative, funded by the McCormick Foundation.

DoD spent nearly $363 million on weight-loss surgeries in past decade

Andrew Van Dam

About Andrew Van Dam

Andrew Van Dam of The Wall Street Journal previously worked at the AHCJ offices while earning his master’s degree at the Missouri School of Journalism, and he has blogged for Covering Health ever since.

Reporting for KIRO-Seattle, Chris Halsne used FOIA requests to find out how much the military’s TriCare plan is paying for weight-loss surgeries for soldiers and their dependents. Including post-surgery tummy tucks, Halsne calculates (PDF) that the government was on the hook for at least $362,971,831 for such procedures over the past decade.

The military defends the expenditures by pointing to the long-term savings of having healthier TriCare enrollees, though Halsne found those savings difficult to prove, as 86 percent of soldiers and their families leave the plan before they qualify for lifetime benefits.

Halsne found that even some active-duty personnel are getting bariatric procedures, which are officially off limits to them as they are required to stay fit through diet and exercise to remain in the military.

While analyzing Defense Department records on health-related costs, KIRO Team 7 Investigators also discovered the military continues to pay for some weight loss surgery for active duty personnel. Records show $2,400,000 worth since 2001. The military banned bariatric procedures for active duty soldiers and sailors in 2007, yet it appears they approved around 57 of them after that.

Tricare, the military’s health insurance program funded by federal taxpayers, declined KIRO’s repeated questions for an interview.

Reporter FOIA’s database further exposing the toll war takes on returning vets

Andrew Van Dam

About Andrew Van Dam

Andrew Van Dam of The Wall Street Journal previously worked at the AHCJ offices while earning his master’s degree at the Missouri School of Journalism, and he has blogged for Covering Health ever since.

Writing for the Bay Citizen and The New York Times, Aaron Glantz brings a new, data-based take on the mental and physical toll the wars in Iraq and Afghanistan have taken on returning veterans, thanks to what he calls “an obscure government database called the Beneficiary Identification Records Locator Subsystem death file,” which he obtained via FOIA.

The database, which reveals a high rate of suicide and fatally risky behavior, lists all veterans who earned Veterans Affairs benefits since 1973.

Records from that database, provided to The Bay Citizen under the Freedom of Information Act, show that the VA is aware of 4,194 Iraq and Afghanistan veterans who died after leaving the military. More than half died within two years of discharge. Nearly 1,200 were receiving disability compensation for a mental health condition, the most common of which was post-traumatic stress disorder.

Names were redacted, but Glantz nonetheless managed to identify a number of veterans, including a troubled 26-year-old man who threw himself under a train just three days after being turned away by the VA. In the course of his investigation, Glantz has managed to fill in some of the gaps in the federal records, a process which has shown just how lacking the VA’s data can be.

In October, The Bay Citizen, using public health records, reported that 1,000 California veterans under 35 died from 2005 to 2008 — three times the number killed in Iraq and Afghanistan during the same period. At the time, the VA said it did not keep track of the number of Iraq and Afghanistan veterans who died after leaving the military.

The VA database does not include veterans who never applied for benefits or who were not receiving benefits at the time of their death, according to the agency. The VA said it also did not keep track of the cause of death.

When confronted with his agency’s shortcomings, a VA representative responded in a manner that belied his agency’s lack of focus on recordkeeping.

David Bayard, a VA spokesman, said the agency was working hard to treat veterans with mental health issues. “VA has some pretty fine programs,” Mr. Bayard said, “but unfortunately we aren’t always successful.”

Dallas Morning News explores effects of war on military families

Andrew Van Dam

About Andrew Van Dam

Andrew Van Dam of The Wall Street Journal previously worked at the AHCJ offices while earning his master’s degree at the Missouri School of Journalism, and he has blogged for Covering Health ever since.

For the paper’s series on military families, Dallas Morning News reporter Dave Tarrant has spent four months investigating what he calls the “relentless cycle of crisis and stress” that affects soldiers’ loved ones. The broad series touches on everything from the Fort Hood suicides to the Army’s preventative measures to Tarrant’s latest, “Wife faces life-or-death decision for her war-injured husband.”

Most of the content is behind the Morning News paywall, but there’s enough on the landing pages to, at the very least, help you understand where Tarrant’s investigation has taken him and just how wide-ranging the health effects of prolonged war can become.

Pentagon reluctant to provide therapy for TBI

Andrew Van Dam

About Andrew Van Dam

Andrew Van Dam of The Wall Street Journal previously worked at the AHCJ offices while earning his master’s degree at the Missouri School of Journalism, and he has blogged for Covering Health ever since.

After a lengthy investigation, ProPublica’s T. Christian Miller and NPR’s Daniel Zwerdling found that, in their words, 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.”

They’re writing, of course, about traumatic brain injury, a consequence of roadside bombs in Afghanistan and Iraq. Their work revolves around a method of treating TBI and rehabilitating victims that has gained wide acceptance among civilian physicians and health plans but has not been embraced by the military’s insurance provider.

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.

Tricare provides health insurance for about 4 million active duty and retired soldiers, and “despite pressure from Congress and the recommendations of military and civilian experts,” it still refuses to cover cognitive rehabilitation therapy for the thousands of American soldiers afflicted by TBI.

Five of the 12 largest insurers cover the therapy, and an expert panel has recommended that the military do the same.

For its part, Tricare points to an assessment it conducted that put the effectiveness of cognitive rehabilitation therapy into doubt. I’ll let Miller and Zwerdling take it from there.

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.

The therapy would cost $15,000 to $50,000 per soldier, and the reporters found that, in private, Pentagon officials had expressed concerns about the massive cost of providing it to every suffering soldier. A few soldiers with political connections or ultra-motivated family members have managed to get the therapy, but its essentially off limits for most folks covered by Tricare.

Finally, a quick parenthetical mention answers a question that most health reporters are asking at this point. How did they get those internal studies and documents?

HINT: It involved finding a slightly less formal way to fulfill some of their FOIA requests.

(NPR and ProPublica obtained a copy of the ECRI reports through the Freedom of Information Act. 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.)

Bagram airfield a leading lab for trauma medicine

Andrew Van Dam

About Andrew Van Dam

Andrew Van Dam of The Wall Street Journal previously worked at the AHCJ offices while earning his master’s degree at the Missouri School of Journalism, and he has blogged for Covering Health ever since.

NPR’s Quil Lawrence reports that Afghanistan’s Bagram airfield, the primary stop for seriously wounded soldiers before they’re stabilized and transported to Germany or America for long-term care, has served as an opportunity for forging broad advances in emergency medicine.

“At the beginning of this conflict, we were taking the best trauma medicine from the civilian sector, and we brought it to Iraq and Afghanistan,” says U.S. Air Force Col. Chris Benjamin, the hospital commander. He says now his doctors tell him it’s the other way around.

“Here we are seven, eight years later, taking what we’ve learned in these conflicts to teach them the advances that we’ve made with this data collection here in theater,” he says.

Thanks to body armor and advances in battlefield trauma like the increased use of tourniquets, more soldiers are arriving alive, but with serious, traumatic injuries. When they pass through Bagram, the volume and severity of their wounds “continues to yield new data that are helping to save lives in ways that were impossible only a few years ago,” Lawrence writes.

DoD: No condolence letter if soldier committed suicide

Andrew Van Dam

About Andrew Van Dam

Andrew Van Dam of The Wall Street Journal previously worked at the AHCJ offices while earning his master’s degree at the Missouri School of Journalism, and he has blogged for Covering Health ever since.

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Photo by Chris_Lott via Flickr

Writing on the NPR health blog, Whitney Blair Wyckoff writes that while American soldiers who commit suicide receive full military honors, their families don’t receive a letter of condolence from the White House. It’s a substantial omission because, as Wyckoff notes, “the number of soldiers who committed suicide in the U.S. military rivaled those who were killed on the battlefield in Afghanistan this year.”

Suicide prevention and mental health advocates are circulating petitions to reverse the policy, which is gaining media attention at a time when the military’s attempting to destigmatize mental illness. The administration’s only reply was an e-mail from the Department of Defense stating that “Under the current program, the Secretary of Defense does not send condolence letters to next-of-kin of members who commit suicide.”