by Art Levine
In charge of both the Community Care contracts and the newer Choice program, the $9.5 billion combined VA windfall for Tri-West and Health Net had disastrous impacts on the health and well-being of veterans, according to the VA’s Inspector General, The Arizona Republic and NPR, among others. Reveal demonstrated how the VA’s top-down, outsourced approach to the Choice program caused horrific problems in Alaska without a full-time VA hospital in the state. The Reveal investigation focused on those needing vital medical care, but the same roadblocks clearly affected those requiring specialized mental health care in a system so short of clinicians. Although the state had a well-run, informal network of non-VA providers, after Tri-West took over, it continually bungled getting treatment authorizations to community doctors. As a result, a disabled Alaskan veteran like Daryl (who didn’t give his last name on air) suffering with PTSD and chronic pain had to wait months for medical care and physical therapy for his back and arm. His arm became so weak that he lost his job as an airplane mechanic. Daryl aptly dubbed the program, “No Choice.”
The Choice contractors also came under fire from NPR and some state officials for delays in funding and arranging timely mental health care. Clinical psychologist Cher Morrow-Bradley in Jacksonville, North Carolina, for instance, found that Health Net delayed paying her for the sessions with vets for close to a year; the company refused to answer NPR’s questions. With Health Net in charge of much of the eastern and central US, at least two states, Maine and Montana, have withdrawn mental health services from the VA Choice program and scrambled to find other funds to pay for them, NPR reported.
Amazingly, the VA has continued to pay close to a billion dollars a year each to Tri-West and Health Net while only recently making some improvements in the Choice program. In fact, as noted by the conservative Daily Caller, Tri-West paid a $10 million fine in 2012 to settle Justice Department charges that it defrauded the Pentagon by not passing along its savings on provider costs to the government. Despite the fraud charges—disputed by Tri-West—the VA signed up the company in 2013 to that multibillion-dollar contract to help oversee the Community Care program that was a “precursor,” also poorly run, to Choice, according to multiple Inspector General reports.
This time around, objections from the Alaskan members of Congress led the VA to scale back Tri-West’s role in interacting with veterans—first in Alaska, then in a few other locations. But even as the contractors remain responsible for paying claims, the VA is planning to return far more of the scheduling authority back to the VA centers that generally got away scot-free with rigging wait times in the first place.
When he headed the VHA overseeing this mess, Dr. David Shulkin, although conceding some problems, told NPR in 2016 that the program was “working well” in many places. But instead of effectively resolving the disaster, first as the head of VHA and now as Secretary, he has touted instead a few dozen contract changes and four minor congressional amendments, while pinning his hopes on a broader legislative package that will create “Choice 2.0” that’s still stalled in Congress, although a short-term extension passed early in 2017. As late as a March 2017 congressional hearing and in interviews, Shulkin and his top deputies were still disputing blistering recent reports by the GAO and the VA’s Inspector General that found months-long waits for Choice enrollees and a stark absence of any meaningful oversight of these outsourced programs; the VA leaders claimed that the reports used faulty assessment methodology and were based on outdated information that doesn’t reflect the most recent reforms. “The VA has no reliable data to measure how long the entire [appointment] process takes,” the GAO’s director of health care, Randall Williamson, told the House Veterans Affairs Committee in March 2017.
In response to these reports, Dr. Baligh Yehia, the Deputy Undersecretary for Health for Community Care, doubled down on the claim that the watchdogs’ findings were mistaken, used obsolete methodology and were outdated. He only concedes, “This program has design flaws and we’re redesigning Veterans Choice.”
As media accounts of the Choice fiasco increased, though, the VA, echoing some VA Commission on Care findings on expanding civilian-sector care, still sought other ways to restrict the sort of outside help veterans can seek. The agency proposes to oversee an integrated, “high-performing network,” but it would still limit veterans with mental illnesses from going outside the VA if their nearest facility offered timely access to “specialized behavioral services.”
One such haven of purported excellence is the Phoenix VA’s Outpatient PTSD Clinical Team. Yet this VA system still has far to go in terms of quality and outreach: In May 2015, yet another troubled veteran killed himself in the parking lot of the Phoenix VA.
Other improvement initiatives don’t offer much more grounds for hope. Senator Baldwin’s opiate prescription reform proposal, cited in the previous chapter, could limit medication excesses if enacted, but it doesn’t address most of the abuses in psychiatric drug prescribing, especially involving antipsychotics. For example, years after the FDA in 2011 added new warnings about heightened cardiac risk posed by the antipsychotic Seroquel in interactions with at least seven categories of drugs, the VA still hasn’t bothered to warn its clinicians about those dangers in any high-profile alerts. In short, the VA has done nothing in practice to truly limit off-label prescribing of Seroquel despite the troubling number of deaths linked to the medication, often in combination with other prescription drugs.
Those were essentially the same mild, unenforced off-label policies in place when Eric Layne, an Iraq veteran who had served with his wife Janette in the National Guard overseas, started his regimen of Seroquel, Paxil and Klonopin in the summer of 2007 to deal with his increasingly tempestuous PTSD symptoms. “Eric was told that he would get his life back once the VA got his medications right,” Janette remembers. But that never happened. By October, he was suffering from incontinence, severe depression and continuous headaches as he became more listless and gained weight. He even fell asleep with food in his mouth. He lost his job later in the fall and entered an eight-week residential program for PTSD in Cincinnati where his high doses of medications were supposedly monitored. When he finally returned from the VA hospital, they talked about possibly seeing a doctor to investigate the side effects of the medications.
He never got the chance. Three months later, after he came back disoriented and drugged from the special PTSD program at the Cincinnati VA in January, he was dead.
The surviving West Virginia family members hoped that the federal government would learn from the experiences of veterans such as Eric Layne and rein in the use of psychiatric medications. But it soon became clear that neither the FDA nor the VA was really influenced by such tragedies. Looking back, it sometimes seems as if agency officials were trying out in small markets a scenario for hiding scandals and deaths, with sham Inspector General reports, pro forma expressions of regret and a reluctance to hold anyone accountable or to change prescribing practices. These tactics all played starring roles in West Virginia before they took the production national in response to the furor over Phoenix and Tomah.
CHAPTER 5
A Marine’s Descent into PTSD Hell
CORPORAL ANDREW WHITE, A MARINE CORPS VET FROM CHARLESTON, West Virginia, wasn’t supposed to end up like this. At twenty-three, he’d gone from leading his Junior ROTC color guard in his spiffy dress blues to skillfully defusing explosives and serving as a lead Humvee gunner in Iraq to becoming another traumatized veteran scrambling for help.
When Andrew decided to join the Marines shortly after graduating high school with honors in May 2003, he was following the example of his two older brothers: William, a non-commissioned officer in the Navy now in his forties, and Robert, who was based in Fort Bragg, North Carolina. His father Stan White says, “His brothers were both career military, and Andrew really looked up to Bob and he chose the Marines. I think because he could prove himself as a Marine,” marking out his own path. That strength clearly derived in part fr
om his father, a formidable retired high school administrator whose pain and anger over his son’s death can still be traced in his long, determined face that seems even more resolute with his white Fu Manchu-style mustache.
When in battle, with his brother as a role model, despite the danger and without complaint, Andrew jutted through the roof of the vehicle and exposed himself to enemy fire in the desolate, windswept deserts of western Iraq, handling the mounted machine gun with steely resolve.
In May 2005, though, whatever outward coolness he displayed in battle couldn’t conceal his shock at the violence he encountered when he took part in the massive Marine campaign known as “Operation Matador” to retake control of insurgent-held areas. Flooding the area with 1,000 soldiers, supported by helicopter gunships and jets, the Marines swept through surrounding towns, largely going after elusive foreign insurgents allied with Abu Musab al-Zarqawi, an Al Qaeda leader behind many suicide bombings in Iraq and the founder of what later became known as ISIS. During the Matador campaign, Andrew was part of a large convoy leaving Al Qaim on patrol. While standing with his machine gun at the top of the Humvee, he was ordered to fire on muzzle flashes from near the roadway. A rocket-propelled grenade, or RPG, then came whistling past his head. “This was terrifying, and he felt he was almost killed and still might be killed. He believed he should return fire in the direction of the RPG firing, but he didn’t,” the VA psychologist noted in Andrew’s 2007 medical chart. “He had a flashback related to this on July 4th this year, and experiences intrusive thoughts and images as well as trauma dreams related to this trauma.”
But the fighting only got worse, searing more horrifying memories into Andrew. The next day, an armored personnel AmTrac carrier near the town of Haban was carrying a squad of reservists from Lima Company in Ohio when the vehicle ran over an explosive device that turned it into an inferno. Four Marines were burned to death inside. Ten other men were seriously wounded, and Andrew saw it all from his perch as a Humvee gunner. The hellish vista was even more disturbing because inside the AmTrac, undergirded with tank-style treads, were rounds of explosives that were “cooking off,” sending weaponry and orange flames skyward. White was deeply shocked, feeling both horrified and powerless at once because all he could do was watch; he later told a VA psychologist that for years afterward, he at times experienced vivid flashbacks about the incident.
He also remained forever plagued by one night mission in his Humvee. As a gunner and combat engineer, his confusion in the dark, bleak desert was compounded by night-vision goggles as his team provided protection for an eight-wheeled Stryker fighting vehicle in their convoy. The Humvee was about one hundred meters ahead of the Stryker when that vehicle was blown to pieces by an IED that Andrew and others had apparently missed. A GI in the Stryker was killed, and the shock was so great that White continued having intrusive thoughts about it for years.
Even so, everything seemed fine at first when Andrew and his two closest buddies from the reserve unit that served in Iraq, Jacob Towner and Seth Montgomery, came back to Camp LeJeune. It was September 2005, and the southern weather was still warm enough so that when they were given a twenty-four-hour leave from the base, they headed straight to Topsail Island in North Carolina to unwind. Years later, when Shirley White, a short, sweet-tempered woman with a voice still husky from loss and regret, looks at the early photo of Andrew, broadly smiling in his green fatigues moments after they first saw him come back to Camp LeJeune, she points out: “You can see he’s in good spirits. He’s glad to be home.”
The good feelings didn’t last long. He came home to Cross Lanes on a Saturday evening. On Monday, the Whites were at an IHOP in Charleston, talking about how pleased they were that Andrew was home safe, when they got the phone call no parent ever wants to hear. Shirley’s cell phone rang, and Cathy White, Bob’s wife, said, “We lost Bob.” Reeling from the shock, they could only ask, “Are you sure?” Stan and Shirley rushed back home, placed some calls and started making arrangements to drive down to Fort Bragg, where Bob’s family was located. Andrew White took the news very hard, but he didn’t say much about it. Bob’s death at age thirty-four came so suddenly after Andrew’s return that visitors in those first days couldn’t help but notice that he hadn’t even finished unpacking: his Marine duffel bag was still on the screened-in front porch.
Ten days later, when Bob’s body was returned to Fort Bragg and funeral services held, Andrew was so upset by it all that he had to leave the chapel several times. He never really got over his brother’s death and gradually unraveled. By the time he joined a veterans’ support group in February 2007, it quickly became apparent to social worker Debbie Linzmaier and some others there that he could benefit from a professional evaluation at the nearby Kanawha City clinic. After one of those early visits, he got his first psychiatric medications.
Within a year, he was dead.
• • •
ANDREW ULTIMATELY RECEIVED NINETEEN DIFFERENT PSYCHIATRIC, PAINKILLING and other drugs during the months he sought help. By the end, there wasn’t much left of the six-foot-one young man with short-cropped black hair, six-pack abs and laconic manner who had once been filled with so much promise.
Initially, the prescriptions seemed reasonable enough. He was given the antidepressant Paxil and a low dose of an older generation antidepressant, trazodone, used for its non-addictive sedating effects.
Soon enough, though, Andrew became yet another victim of the military’s clueless health practices and the corporate marketing that promoted Seroquel’s off-label use with PTSD patients—and even for active-duty soldiers. The VA was in the early stages of an initiative to cut down on prescribing for PTSD patients receiving potentially addictive benzodiazepines, such as Klonopin, Xanax and Restoril. Yet it was also allowing the mostly off-label use of Seroquel, the most sedating of antipsychotics, to skyrocket more than 770 percent between 2001 and 2010, although the number of patients covered by the VA increased only 34 percent, the Associated Press reported.
For active-duty troops, the growth in antipsychotic use, including Seroquel, was even more astonishing. Dr. Richard Friedman, a professor of clinical psychiatry at Weill Cornell Medical College and a regular op-ed contributor to The New York Times, revealed as part of a series of important columns on military drugging that antipsychotic prescriptions increased by 1,083 percent between 2005 and 2011. He noted in 2013 that it was probable that almost all such prescribing was off-label, because the military is supposed to screen out enlistees with the serious psychiatric disorders treated by antipsychotics. Doctors may be prescribing different types of psychotropics, he theorized, “for off-label use as sedatives, possibly so as to enable soldiers to function better in stressful combat situations,” joined by a fifteen-fold increase in stimulant prescribing to wake them up for battle the following day. Yet this roller-coaster prescribing pattern may well have contributed—with the addition of such stimulant drugs as Adderall—to a rise in these medication-addled soldiers of the brain chemical norepinephrine, which is released by stimulants. This chemical also naturally surges during combat as part of the fight-or-flight response, he pointed out, helping sear memory of a traumatic combat event in the brain. The upshot: “A soldier taking a stimulant medication,” he suggested in 2012, “could be at higher risk of becoming fear-conditioned and getting PTSD in the setting of trauma.”
His research showed that the prevalence of PTSD within the US military increased over a thousand-fold to 22 percent by 2009, although he made clear that no causal link had yet been firmly established between stimulant use and the skyrocketing PTSD rates. Yet his hypothesis was apparently confirmed in 2015 when Pentagon researchers studying nearly 26,000 soldiers reported that those prescribed stimulants were five times more likely to have PTSD. So it seemed likely that all the off-label use was actually helping create a new market of PTSD sufferers primed for using antipsychotics after they were discharged.
Seroquel also became the VA’s second-largest drug expenditu
re—after the blood-thinner Plavix—in 2007, the year Andrew was first prescribed it back home. More than four years after his death in 2008—and the deaths over time of hundreds of other veterans and soldiers taking Seroquel for PTSD symptoms, usually with other medications—the VA was spending $150 million annually for mostly off-label uses of Seroquel while the drug was under a patent. Costs dropped for the medication after it lost its patent protection in 2013. Even so, the number of VA prescriptions written for the drug dipped only slightly even in the face of FDA warnings about Seroquel’s cardiac risk; a damning 2011 Journal of the American Medical Association (JAMA) study on the ineffectiveness of antipsychotics for PTSD; and payouts of over $1 billion by AstraZeneca in settlements by 2011. (These resulted from nearly 30,000 lawsuits against the company for allegedly hiding the drug’s health dangers, including diabetes, along with several federal and state anti-fraud settlements.) Despite all that, Seroquel still remains the most heavily prescribed antipsychotic in the VA system, with nearly 800,000 prescriptions annually—more than twice as many as Abilify, the nation’s most prescribed antipsychotic.
As purchases of antipsychotics by the VA and the Defense Department exploded after 2001—overwhelmingly for medically unapproved uses—so have the number of state-side young soldiers and veterans found “dead in bed” or “dead in barracks” who have often been taking Seroquel along with other prescriptions. These incidents have been chronicled by advocates for veterans in updated spreadsheets, but no government agency tracks them. Especially in the VA, there have been no major initiatives yet to halt or even to systematically study these preventable deaths. (One exception: in 2012, DOD’s US Central Command decided doctors needed a waiver to prescribe Seroquel to soldiers in combat zones.)