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Military underfunding
sparks concern
(August/September
2007 Issue)
By Catherine Robertson Souter
As the physical and emotional price of war rises, the U.S. is facing
a new dilemma, one that it appears shockingly ill-prepared for:
the need for mental health care far exceeds the services readily
available for service members, veterans and their families.
According to a recent survey by a Pentagon task force, more than
one-third of military men and women in Iraq reported symptoms of
Posttraumatic Stress Disorder (PTSD), anxiety, depression or other
problems. A Department of Defense study found that nearly one-third
of returning soldiers seek mental health counseling in their first
year home.
The troop surge that by some counts has sent more than 30,000 additional
soldiers to Iraq in recent months will only increase the need for
mental health services.
Further exacerbating the problem for active duty military personnel,
the numbers of military mental health personnel has dropped in recent
years. By one American Psychological Association (APA) report, there
is a 40% vacancy in active duty slots for psychologists within the
military. Ward Casscells, the assistant secretary of defense for
health affairs, has noted that the Army's plans to hire an additional
200 mental health professionals may not be enough.
For retired military or their families, who can be overwhelmed
with grief at the loss of a family member or with concern at how
their returned soldier has changed or is distressed, finding a private
sector mental health professional is difficult, especially in rural
areas. They can spend months locating an available professional
and often find themselves traveling far outside their home region
to get to a provider who will take Tricare, the military health
plan.
Tricare's reimbursement rates are often cited as a major reason
that it is so hard to find mental health care, as many professionals
are loathe to accept lower reimbursements for their services. Tricare
rates are tied to Medicare rates and are set by Congress. And, in
a further hit, rates have gone down by 6.4% this year for some specialties.
"It seems to be a twofold problem," says Bonnie Powell, director
of public affairs for Tricare Management Activity, "especially in
rural areas where there may be a lack of access because there are
fewer providers and the ones who are there may not accept the lower
rates."
She pointed out that these same providers most likely don't accept
Medicare either which would mean it's not just a problem for the
military and their families.
Tricare has attempted to address the issue, both with medical and
mental health care, by offering higher rates in certain rural areas.
Individual providers or groups also have some room to negotiate
the rates they will accept.
"There are provisions in underserved areas where there is big
demand and low supply to reimburse above Medicare rates, up to 15%,"
says APA member Joyce Adkins, Ph.D., MPH, a US Air Force Colonel
who knows from first-hand experience in Iraq and Afghanistan what
the troops are dealing with and what types of issues they may experience.
She is the Defense Department's Program Manager for Operational
Stress and Deployment Mental Health.
"In some places, there are also managed care systems which allow
the Tricare contract providers to negotiate reimbursement rates
with the psychologist in the area."
For others, the complicated bureaucracy of a provider the size
of Tricare may be an issue. Stanley Ducharme, Ph.D., who sees several
Tricare clients as part of his Boston-based clinical practice, says
that it can be a hassle trying to work through the system to get
extra sessions approved. While he does believe there is a shortage
of psychologists who will take Tricare even in a heavily populated
area like Boston, he has no idea why others will not accept Tricare
clients since, in his experience, the reimbursement is similar to
what he would get from most managed care (about 70% per session).
"I have had to be aware of how many sessions I am seeing people
because of a sense that if I request too many sessions or provide
ongoing treatment, then they are questionable about their ability
to be deployed," he says. "There are also issues in terms of getting
further treatment sessions authorized and it took a couple of months
to get authorization. I think it's because it is a bigger bureaucracy."
Adkins has also heard these complaints.
"One of the issues in providing mental health care to the military
community is not just quantity but ensuring quality so there are
a number of measures built in to provide quality assurance. If that
process is cumbersome, they should complain to the Tricare system
because if it isn't achieving its objective of assurance quality,
if it's just 'administrivia,' they need to complain because that's
the only way that the system can be changed," she says.
"I think that many decisions about working with Tricare are based
on past experiences," Adkins says. "Tricare tells me that they have
made significant improvements in the last year, in the last few
months even. For people who are basing decisions on past experiences,
try it again and see if they have made it a better experience for
you."
Several groups have sprouted up to address the issue and offer
psychologists ways to assist with the shortage through volunteer
work. In Oregon, the Returning Veterans Resource Project NorthWest
is a non-profit organization of mental health professionals who
offer free counseling to veterans and their families. Give an Hour
is a non-profit based in Maryland that provides psychologists an
opportunity to offer one hour per week on a pro-bono basis. So far,
more than 440 psychologists have signed on to the program, which
also asks treatment recipients to give back to the community and
offers ways for others to get involved. Massachusetts has the highest
local number of participants, at 27, with the other New England
states coming in far lower with one to four participants each.
"Many people would rather give something for free and not deal
with the paperwork or the process and end up not getting a lot of
payment for their work," says Barbara Romberg, Ph.D., founder and
executive director of Give an Hour, "but they say, 'I can do this,
give back one hour a week.' I hear back from a lot of mental health
professionals who are joining because they are troubled by this
[war] and it feels good to give something, to do something rather
than watch news and feel distressed."
The good news is that a lot of attention is being paid to the issue
with stories of veterans receiving less than stellar care running
in national papers. Congress has called for a complete overhaul
of the mental health care system and has put forth a six-month deadline
for a plan that will resolve the issues coming to light.
"This is really a great opportunity to talk about mental health
in the military," says Adkins, "because we have so many things going
on right now. We are going through an entire transformation of mental
health in the military and not just in Tricare."
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