United States Senate
COMMITTEE ON VETERANS AFFAIRS
Testimony by
Michael F. Dabbs, President
May 5, 2010

Let me begin by expressing my sincere appreciation to Senator Akaka and all senators of the United States Senate Committee on Veteran Affairs for the opportunity to address you on the issue of our Association’s experience in working with the VA to provide brain injury treatment and rehabilitation to veterans.  As part of my testimony I will address how effectively state, local and private entities have been engaged by the VA to provide the best access to care and services for veterans with TBI.

Before discussing this matter, allow me to provide you with some basic information about the Brain Injury Association of Michigan and in particular, its Veterans Program.  The Brain Injury Association of Michigan was incorporated in 1981 as a 501 (c) (3) nonprofit organization by individuals with a brain injury, their families and professionals in the field of brain injury to provide support and education to one another, as well as to advocate on behalf of persons with a brain injury and their families.  Additionally, research and prevention programs were primary goals.  Our Association is one of 44 chartered state affiliates of the Brain Injury Association of America.

In 2007, with funding provided by the Health Resources Services Administration to the State of Michigan Department of Community Health (MDCH) as part of the federal government Traumatic Brain Injury State Grant program, a portion of these funds were sub-contracted to our Association to serve the needs of Michigan veterans.  Through the guidance of the MDCH’s TBI Grant Services and Prevention Council the following goals were established:
• Goal 1  Create a comprehensive and coordinated state-wide Traumatic Brain Injury (TBI) awareness and resource program for veterans, their families and friends/co-workers through implementation of a Veteran TBI Awareness Campaign.
• Goal 2  Create a working relationship with the Michigan based VA VISN 11, VA Medical Centers and subordinate VA health care providers.
• Goal 3  Survey all TBI health care providers to ascertain their interest in and capabilities of providing care for military personnel.

In order to accomplish these goals, Major Richard Briggs, Jr., USAF (Retired) was hired to manage this program and accompanies me today.  Though I would be pleased to share a more comprehensive report about our Veterans Program accomplishments, I will limit my comments to addressing our activities as it relates to Goal 2 and its relevancy to the stated purpose of this hearing.

Major Briggs developed a working relationship with the Michigan Department of Military Affairs and with their assistance was able to create partnerships with the Veterans Service Organizations’ Council and the VA County Counselors.  Also, because of this relationship with the Department of Military Affairs, he and I were invited to meet with the Veterans Integrated Service Network (VISN) 11 director and staff.  As a result of these meetings, Major Briggs was able to meet with the four VA Medical Center Directors in Michigan, as well as their respective OEF/OIF Coordinators.  These meetings afforded Major Briggs the opportunity to share with them the unique capabilities for brain injury rehabilitation available in Michigan.  These capabilities will be explained at further length below as it pertains to the Committee’s inquiry.

Finally, let me share with the Committee that the Brain Injury Association of Michigan’s Veterans Program was just recently ranked 21st out of 128 nonprofits providing support and

service to our veterans in a recently-conducted 2010 Veterans Choice Campaign special survey done by Great Nonprofits. 

The information above is provided to serve as credible evidence of our ability to address the Committee’s meeting purpose and to demonstrate our efforts to reach out and work with the VA and the main organizations that already exist that work with the VA, or collaborate closely with it.

It is my intention with the comments that follow to suggest to the Committee possible approaches or potential solutions to consider as it attempts to ensure that the intent of the federal legislation is in-fact carried forward at the local level.  Let me be clear that my comments only reflect the experiences of our Association with VISN-11 and in particular, the Michigan region of VISN-11, which is the lower peninsula of Michigan. 

In my nearly 18 years as president of the Brain Injury Association of Michigan, I have rarely seen as comprehensive a piece of legislation regarding brain injury and best practices as what was included in Title XVI, Wounded Warriors Matters of the ‘‘National Defense Authorization Act for Fiscal Year 2008.’’  In addition, the Veterans Omnibus Health Services Act of 2010 (S. 1963) also is an excellent piece of legislation as it pertains to soldiers who have sustained a traumatic brain injury (TBI).  In fact, some of the proposed approaches that I will mention address some of the provisions (sections 506, 507, 509, and 515) of this bill.

In Secretary Shinseki’s report to the Committee dated March 23, 2010 indicated a number of  “…landmark programs and initiatives that VA has implemented to provide world class rehabilitation services for Veterans and active duty Service members with TBI …”  It is my opinion that these are valuable and important developments; but here are a few concerns I have regarding this.
1. The first point mentions “…108 specialized rehabilitation sites across the VA medical centers that offer treatment by interdisciplinary teams of rehabilitation specialists …” –

I agree that the VA medical centers do offer such rehabilitation; however the VA appears to be limited in providing brain injury rehabilitation.  Our experience in
Michigan however, is that these hospitals are over-burdened and given their patient load simply are unable to provide timely care and frequency of care that is required for a person who has suffered a TBI.  Furthermore, as we have witnessed with one of the four VA medical centers in Michigan that is located in close proximity to a major hospital medical school, this VA medical center only has one doctor who is qualified to administer Neuro-psychological testing.  Neuro-psychological testing is critical to the proper and thorough screening of soldiers who have a suspected TBI.

As further evidence of the significance of this problem, let me provide you with one of the recommendations given to me by the State of Michigan Department of Military Affairs in preparation for this testimony:
“Access problems and long waits continue to be problematic despite the best attempts of the VA.”

One additional point to consider regarding this issue of adequacy of resources – it is my understanding that Michigan has over 725,000 Veterans, and only 207,000 are registered with the VA.  Yet as stated above, the current VA medical centers are seriously over-whelmed with trying to provide care to those they are servicing.  Assuming the Michigan numbers of Veterans and the Veterans who are registered with the VA are reflective of other states, this would dictate that the VA absolutely must aggressively seek outside contractors to assist them with providing care to our Veterans.  Simply put, the VA must use its financial resources to contract with public and private partners to provide care and not spend these funds trying to build facilities and staff them.  I implore this Committee and the VA to immediately take action on this issue.  Veterans who have a TBI need treatment now – not in a few years when a few more facilities might be operational.  Does it even seem reasonable to think that there are sufficient funds to build enough facilities in Michigan to meet the long-term care needs of Veterans with TBI, if the numbers above are correct; much less the rest of U.S.?

2. The second point indicates that “TBI screening and evaluation program to ensure that Veterans with TBI are identified and receive appropriate treatment for their conditions” – though this has been implemented, the current assessment that I believe is being referred to – a four question survey – is not adequate.  Another one of the State of Michigan Department of Military Affairs recommendations states:
“TBI continues to be missed when it co-occurs with other disorders.
Soldiers who are being diagnosed with disorders such as Bipolar Disorder and PTSD should be universally screened for TBI because of the similarities in their presentation.  Likewise all soldier receiving VA disability for hearing loss or Tinnitus (ear ringing) should have mandated TBI screen.”

3. Enclosure A, Page 2 notes that “…VA directed medical facilities to identify public and private entities within their catchment area that have expertise in neurobehavioral rehabilitation and recovery programs for TBI, and to ensure that referrals for services are made seamlessly when necessary.”  A similar point is made in S.1963, Section 507.  To date in Michigan, there have been only three such referrals according to the VISN-11 Cooperative TBI Agreements Patient Tracking FY09.  One of these was due to a mother’s insistence that such care be provided to her son.

This is a critical point of my testimony.  For over 37 years, Michigan, due to its unique automobile no-fault insurance system, provides comprehensive lifetime care for those sustaining injuries in an automobile crash in Michigan.  The care provided is unique to each person and provides cognitive rehabilitation care.  As a result, there are more brain injury rehabilitation providers than any other state in the U.S.  I have provided a chart that we created as an attachment to this testimony.  This information was taken directly from the Commission on Accreditation of Rehabilitation Facilities (CARF) website that indicates all certified brain injury providers in the United States.  Let me give you just a couple of the more salient points.  There are 9 brain injury residential rehabilitation providers with 78 facilities in Michigan – this is 24% of the total in the U.S.  Michigan has 8 brain injury home and community-based rehabilitation providers with 16 facilities

in Michigan – this is 33% of the total in the U.S.  Brain Injury outpatient rehabilitation providers in Michigan number 12 with 22 facilities, which represent 15% of similar providers in the nation.  And finally, there are six providers with 12 facilities, which is 24% of the total in the U.S. 

Again, these are CARF accredited providers and represent only a fraction of similar program providers within Michigan who are not certified.  A copy of the Brain Injury Association of Michigan’s Directory of Facilities and Services will be provided to the Committee’s staff to provide you with an idea of just how extensive these resources are throughout Michigan.  All of these providers are spread across Michigan, though the preponderance are located in or near the larger urban areas of the state.  Attached is a Michigan map with just the CARF accredited facilities.
 
4. Enclosure A, page 2, second paragraph also states the numbers of Veterans with TBI receiving inpatient and outpatient hospital care through public and private entities for FY 2009.  The average cost per Veteran would be $5,800. 

By way of comparison, as part of the MDCH TBI Grant from HRSA, Michigan has done an extensive analysis of its Medicaid Data for the past 10 years.  During the past four years, our analysis of a subset of TBI cases who receive Medicaid provide us a the cleanest estimate of cost (that is, Medicaid cases who had no other insurance, were not in Medicaid prior to their TBI hospitalization, had Medicaid eligibility for at least a year after the TBI hospitalization and had Fee For Service cost data) showed the following:
 Annual average cost of $28,539 just for services with a TBI diagnosis.
 Annual average cost of $41,243 for services with TBI and non-TBI diagnosis.
An issue to consider regarding this data is that I believe that Medicaid is more restrictive of services than would be available through the VA.

5. Enclosure A, page 4, #4 discusses “Programs to maximize Veterans’ independence, quality of life, and community integration, and establish an assisted living pilot.”  I believe this program could have been expedited had the VA utilized the resources available in Michigan.  I would encourage the Committee to recommend to the VA that they immediately explore and/or expand such a pilot utilizing the CARF accredited providers that I have mentioned above.  In fact, the solider mentioned above whose mother was insistent on the care outside of the VA system might be one to include in such a pilot.

RECOMMENDATIONS:
The Brain Injury Association of Michigan would readily welcome the opportunity to partner with the Veterans Administration to work expeditiously to implement the policy directives and guidance that Congress and the VA have directed.  With the collaboration of the partners that I indicated in the beginning of this testimony, I believe that we can effectively assist with demonstrating how the “new” VA can operate in the 21st Century to meet its congressionally mandated responsibility of providing care to our nation’s Veterans.
1. Create a pilot study in Michigan that utilizes the extensive continuum of care of CARF accredited brain injury rehabilitation providers.  The goal of such a pilot would be to validate Secretary Shinseki’s desire for a seamless system of care between VA and private or public partners.  Additionally, its greatest value would be to ensure the Veteran is receiving the most comprehensive program of brain injury rehabilitation that would give them the greatest opportunity to reintegrate into the community.
2. Review current legislation and possibly creating additional legislation as required creating a program that would address some of the following concerns (this is not comprehensive, simply a starting point):
• Automatically enroll a soldier into the VA upon discharge from active duty;
• Improved TBI screening;
• Comprehensive case-management;
• Increased educational offerings and support regarding their loved-ones who have a TBI pertaining to their challenges and limitations;

• Realization of “seamless transitions” and an interdisciplinary approach between health care providers across disciplines to assure that the Veterans challenges is not navigation through bureaucracy or red tape.
3. The VA should undertake a study of medical specialties that they have shortages of and what opportunities exist in their region to ensure that more timely care is rendered to Veterans who have sustained a TBI.

In conclusion, let me again express my sincere thanks to the Committee for allowing me to testify.  Brain injury is an unique injury that can be a “life-sentence” as one radio personality once called it.  It can be a needless life-sentence to the Veteran who does not receive timely, comprehensive and sufficient rehabilitative care.  I would also suggest that it is a life-sentence for their loved ones.  It impacts the family and the community.  I can personally testify to this fact as my father who served with the U.S. Marines during the assault on Guadalcanal sustained a brain injury that we learned about near the end of his life.  His undiagnosed brain injury was diagnosed in the late 1970’s, early 1980’s as PTSD.  The VA’s treatment at the time was to over-prescribe (my opinion) medication.  It wasn’t until there was a determination that there was brain injury and the medication protocol was greatly changed did he ever have the quality of life; he should have had while raising his family.  On behalf of today’s Veterans let me plead that we collectively do everything in our wisdom and power to prevent their lives having the same fate.