Tricare: Denying our troops the best rehab care for traumatic brain injuries?

By Deborah A. Bradbard, Ph.D.
Best Defense clinical psychology department

U.S. Representative Gabrielle Giffords’ extraordinary progress has captivated the nation, and the exemplary medical care she has received this far leaves hope that she will recover from her injuries. Reportedly, she already has begun initial rehabilitation. 

Descriptions suggest her care will include what is widely considered the gold standard in rehabilitation, Cognitive Rehabilitation Therapy (CRT), which is considered the treatment of choice for traumatic brain injuries because it is comprehensive, individualized, multidisciplinary, and coordinated. The goals of CRT are to restore cognitive function to the extent possible, maximize functional adaptation to the injuries sustained, and to encourage compliance to recommended treatments. A large body of respectable scientific evidence exists to support CRT’s effectiveness.

Here’s the bad news: Thousands of military veterans who have sustained life altering traumatic brain injuries similar to Giffords’ do not receive this coordinated, holistic, and individualized rehabilitative care because the military’s insurance provider, Tricare, does not cover CRT for its beneficiaries (military personnel, veterans, and their families).

In an article published by MSNBC Jan. 10, part of the optimism regarding Giffords’ prognosis has to do with the effectiveness of the rehabilitative therapy that she is likely to receive. The article states, "Victims such as Giffords receive expert treatment because many trauma surgeons have learned from the battlefield lessons of Vietnam, Iraq, and Afghanistan. Access to comprehensive, sustained cognitive rehabilitation therapy is the key." In a second article from Politico, Dr. Gregory O’Shanick, chairman and past medical director of the Brain Injury Association of America, spoke about Representative Gifford and stated, "The acute outcome is related to the speed at which she received care." He further added, "The recovery long term is dependent on her receiving really aggressive and seamless rehabilitation." Dr. Steve Williams, rehab chief at Boston Medical Center and the Boston University School of Medicine noted that "'[o]ver the last five to 10 years, there has been a big push to getting patients rapidly to rehab,’ because research shows they recover faster and better the earlier therapy starts."

ProPublica’s T. Christian Miller and NPR’s Daniel Zwerdling recently published a series of reports that document Tricare’s stance on its coverage of CRT. A task force of 50 multidisciplinary experts unanimously agreed on the utility of the treatment for combat related traumatic brain injuries in a written document that was delivered to Tricare in 2009. Nevertheless, Tricare proceeded to hire a private contractor (ECRI) to examine CRT independently. Based on ECRI’s findings, Tricare contends that the scientific evidence is not strong enough to support its coverage of CRT. In a written statement, Tricare indicates that they support "many components of a comprehensive rehabilitation program such as physical therapy, occupational therapy, and speech therapy" and they go on to say that "more research is needed to support the effectiveness of cognitive rehabilitation for all severities of TBI."

Tricare’s position is enigmatic given the fact that there is substantial scientific evidence that both supports CRT and contradicts the ECRI study. Additional support for the therapy comes from at least 70 members of Congress, major insurance carriers who cover the treatment, the National Institutes of Health, the Brain Injury Association of America, and most recently the American Legion.

Tricare’s decision not to cover CRT limits brain-injured warriors access to the very treatment that could benefit them the most. While CRT is offered at some VA hospitals and military treatment facility locations, where Tricare authorization is not required, these sites are limited. Likewise, CRT is frequently provided in civilian rehabilitation centers, but because Tricare will not provide coverage for the treatment, many warriors for whom the treatment is recommended are unable to receive it. Congresswoman Giffords will likely continue to receive the treatment she needs and deserves. Ideally, the encouraging progress exhibited thus far will continue as Congresswoman Giffords rehabilitation unfolds.

Regrettably, Tricare’s failure to cover Cognitive Rehabilitation Therapy denies countless wounded warriors and their families the same opportunity for optimum recovery. 

Deborah Bradbard is a licensed clinical psychologist with expertise in PTSD and Trauma. She is a former director of the Norfolk Commonwealth’s Attorney Victim/Witness Assistance Program and the spouse of a career naval officer.