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  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
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
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 , met President George W. Bush and Gates, and was recently invited to the White House by President Barack Obama for a bill signing ceremony .
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
"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."
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  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
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  and Senate members 
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 .
A response letter 
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.
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 ,
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 
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 .
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
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.
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
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  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 ,
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 .
By the summer 2009, ECRI researchers had finished a draft of the study.
ECRI, later joined by Tricare, asked outside scientific experts to
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 .
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
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 ,
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
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 
said that Tricare's study "fails to represent the evidence relevant to
evaluating the effectiveness of cognitive rehabilitation after traumatic
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
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
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
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
"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
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.
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