Before Deployment | Military Health Care

WASHINGTON — As the war on terror began, the Pentagon needed a way to quickly assess the medical readiness of thousands of National Guard and Reserve members before deployment and turned to the private sector for help.

At the center of that effort was Wisconsin-based Logistics Health, Inc. Called upon to provide pre-deployment fitness screenings to help mobilize the reserve component, LHI has grown over the last decade to become a major player in military health care contracting. Its portfolio has grown to include the Reserve Health Readiness Program, pre-enlistments physicals and veterans’ disability examinations.

LHI’s portfolio of federal contracts attracted the attention of major defense contractors. Earlier this year, the company was acquired by a subsidiary of health care giant UnitedHealth Group.

LHI was founded in 1999 by Donald Weber, a former Marine who still serves as CEO. Based in La Crosse, Wis., the company’s first federal contract, for the FEDS-HEAL program, was providing anthrax immunizations to the military and other federal employees.

In 2001, FEDS-HEAL, a program of the defense, health, and veterans affairs departments, was expanded to cover health screening of reservists being deployed overseas.

The program created “a national…services network that provides required medical and dental readiness services to military members who are not entitled beneficiaries of TRICARE and the military health system,” said Don Donahue, an industry expert who has worked for both LHI and QTC, a California firm that provides similar services.

Donahue said the programs were an attempt to avoid the problems of the Gulf War, when many reserve troops who were activated had medical problems.

“It became a hindrance to the combat operations,” he said. “People weren’t getting where they needed to go in time.”

The reserves needed a medical program created specifically for them, Donahue said. The active component’s medical procedures are provided by their services, but reserves are largely on their own until deployed.

LHI provided pre-deployment medical screenings including physicals, dental exams, x-rays, mental health evaluations and paper surveys filled out by each troop.

In 2007, the program was reorganized into the Reserve Health Readiness Program, directed solely by the Department of Defense. The five-year, $790 million contract was awarded to LHI.

Yet for all its importance in getting the reserves ready, RHRP is not a required program. The decentralized nature of the National Guard, for example, means that each state and territory gets to make its own decisions about who they choose to provide the medical services.

“You wind up having 54 little fiefdoms each kind of doing what they want to do,” Donahue said.

Currently, about 30 states are enrolled in the Reserve Health Readiness Program and rely on Logistics Health for medical providers, according to Donahue and other experts. One state that spurned the program was the Illinois National Guard, opting for a local company because it was dissatisfied with LHI.

“I just wasn’t happy with the program,” said Lt. Col. David Beatty, deputy state surgeon of the Illinois National Guard. “They had so many states that they were just overburdened.”

Beatty said there were times when many of his soldiers would be ready to deploy, but LHI had not placed that information in the medical system, delaying their deployment.

LHI held back several thousand Army Reservists over concerns about their health. About 2,500 of those holds were overturned after a review by the Defense Department.

To address low deployment numbers, the military implemented the Periodic Health Assessment in 2006, requiring reserve troops to get annual checkups evaluating their physical, dental, and mental health. Since then, readiness rates for the National Guard and Reserve have jumped to their highest levels yet.

Also responsible for providing mental health screenings upon a soldier’s return from duty, LHI has been criticized for not properly ensuring that all troops filled out the post-deployment evaluations. The surveys are part of an initiative to treat post-traumatic stress disorders by flagging soldiers who may be suffering from mental problems.

Yet a 2009 report by the Government Accountability Office found that almost 72,000 troops who returned from deployment in 2007 and 2008 had not filled out the mental health questionnaires, hindering the Pentagon’s ability to determine if a soldier’s mental health needs were being adequately served.

The GAO report found the Defense Department was not doing an adequate job in its required oversight of LHI’s operations. Instead “an unsystematic, improvised approach for documenting potential problems” had been created.

“In addition, should LHI’s performance diminish – for example, if LHI was not resolving identified problems,” the report said, “the lack of readily available documentation could compromise DOD’s ability to take appropriate action.”

Capt. Diedre Presley, head of the military office charged with overseeing LHI, would not disclose the results of her office’s evaluations of LHI, but said the process was working effectively.

LHI declined numerous requests for an interview, citing the “sensitive nature” of its business. LHI spokeswoman Tracey Armstrong released a statement describing the company’s role in providing care. “Over the past 10 years, we have provided millions of health care services to hundreds of thousands of Service members, ensuring their fitness to serve before they deploy and supporting their physical and emotional health needs when they return,” the statement said. “As an organization, we are inspired every day by the opportunity to serve our nation’s heroes.”

The statement also said, “As our outstanding Department of Defense annual performance evaluations attest, we regularly exceed the requirements and regulations of individual Service Components and of our contractual obligations.”

The first generation of the RHRP contract is coming to a close, and the Pentagon already has begun work on the next round, estimated to cost several hundred million dollars more than its predecessor. The higher price tag can be explained by the fact that all of the reserve component troops still will be required to get annual checkups, and the Defense Department no longer will be paying the costs of deployed reservists as the wars wind down, Donahue said.

The expanding contract may explain LHI’s acquisition by UnitedHealth Group as well as the purchase of QTC by Lockheed Martin in August.

Glenn Kurowski, head of the division that bought QTC, said Lockheed Martin was attracted by the company’s use of information technology, health care expertise and strong physician network.

He declined to comment on whether the company would be pursuing the next round of RHRP bids, but said Lockheed Martin has a lot of expertise in the field that would enable it to provide effective health services for the reserves.

Donahue said he is not surprised larger companies have entered the fray.

“The entry of the big integrators is reflective of the value of the program,” he said, “both in what it serves the military and the money that can be made doing that.”

This story has been updated to include an additional line from the statement released by LHI.

WASHINGTON — The National Guard and Reserve have played a critically important role in the wars in Afghanistan and Iraq, deploying in unprecedented numbers and enduring repeat tours of duty to combat zones where they fight alongside active duty troops.

But this unforeseen surge has been hampered by significant problems from the start.

Many stem from the fact that most of the more than 665,000 who deployed were working men and women who were part of a civilian “strategic reserve” that trained one weekend a month and two weeks a year.

“When you’re a strategic reserve… you think that you’re not going to be a day one player, you’re going to be used later on and that you’ll have time” to get ready, said Gen. Craig R. McKinley, the chief of the National Guard Bureau, which oversees and coordinates operations among the 54 state and territorial Guard units.

“What Sept. 11 taught me is that you may not have time, you may need to be ready today and you have to do today what you might not have been prepared to do, but you’ve got to get in the game anyway,” said McKinley, who assumed the Guard post in November 2008.

In the immediate aftermath of the Sept. 11 attacks, most reserve component soldiers — the National Guard and the Reserves for each military branch — were medically unready to deploy. In response, the Pentagon turned to a private company for help in creating a massive pre-deployment pipeline to quickly assess the medical status of the reserves and shore up readiness rates.

From the start, many units went through the mobilization process so quickly that there wasn’t enough lead time to fix some health problems, holding up deployments despite the military’s critical need for additional troops to support its growing combat effort. More than 2,400 Army Reserve soldiers were held back, at least temporarily, because of inaccurate assessments by the contractor, according to data provided by the Army Reserve Medical Command.

The number could be even higher as the command looks closely at the records of medically non-deployable soldiers, according to Maj. Gen. Richard Stone, the Army’s deputy surgeon general for mobilization, readiness and reserve affairs.

And an unknown number of other reserve soldiers were sent overseas who should not have been, including some with behavioral problems that could become aggravated by the stress of combat and lead to depression, post-traumatic stress disorder and even suicide, according to interviews with current and former officials, troops and experts, and a review of government documents and studies.

“In a time of crisis when they needed so much manpower, nobody wanted to identify problems,” said Dr. Remington Nevin, who worked with the military’s main health surveillance wing. “If we had a robust screening process, we wouldn’t have had enough people to fight the surge.”

In recent years, the military has taken steps to more thoroughly prepare and assess the reserves before deployment. In response, readiness rates among the reserves are at a little over 60 percent and at over 70 percent for the Guard, the highest numbers ever, according to Stone.

The Pentagon has also placed a greater focus on behavioral issues in an effort to weed out those unfit to serve due to potentially debilitating mental health problems.

But reservists have reported suffering from mental health problems, including post-traumatic stress disorder, at a higher rate than their active duty counterparts, based on data maintained by the Armed Forces Health Surveillance Center. “We were deploying sick soldiers who got broken [more] when something happened to them, and we end up picking the costs for decades to follow,” said Nevin, who said he was not speaking in his official capacity as an epidemiologist at Fort Polk in Louisiana.

The extent of the problem is still becoming known as many of their injuries go undiagnosed because the reserves lack the same access to care and support as their active-duty counterparts, according to Nevin and others.

As a result, military officials still do not know whether they are fully vetting the reserves before sending them to war, especially those who have already deployed, experts say.

Responding to urgent need

The massive mobilization began three days after the Sept. 11, 2001 attacks, when President George W. Bush declared a state of emergency that authorized the Defense Department to issue a mandatory call-up of the reserve component for duty related to terrorism.

After the first Gulf war, the Government Accountability Office had said the medical readiness process needed improvement if the reserve components were to meet the nation’s security needs.

To ramp up deployment of the reserves, the government expanded a joint venture known as FEDS-HEAL, in which the departments of defense, health and veterans affairs had been paying a private contractor to provide medical services since 1999.

FEDS-HEAL required reservists to undergo a series of tests and screenings when called up to active duty. The contractor, LHI of La Crosse, Wis., evaluated reservists on their physical and mental health, using a combination of doctor examinations and self-administered questionnaires designed to catch medical problems.

The new program was getting underway just as 75,000 reserve members were activated during the first major combat operations in Afghanistan. And soon, reservists were being sidelined for minor and easily correctable problems by LHI’s rapidly expanding network of contract health-care workers, said Lt. Col. Ross Waltemath, director of civil military affairs at the Indiana National Guard.

“We had a bad problem in the beginning with the contract company,” Waltemath said. “No one wanted to talk anymore. Every single screening you went through, ‘I am perfect’ was all you heard.”

Stone agrees that there were problems, but said LHI was only trying to err on the side of caution.

“The profiling was done in a very liberal manner to protect the service member,” Stone said.

LHI, also known as Logistics Health Inc., declined repeated requests for an interview and for a response to the specific criticism, citing the “sensitive nature” of their business. But a statement released by the company’s official spokeswoman, Tracey Armstrong, said, “We regularly exceed the requirements and regulations of individual service components and of our contractual obligations.”

Tackling mental health concerns

Gaps in the screening process caused other serious repercussions, in part because identifying physical problems was much easier than behavioral ones, especially those starting to surface among those on their second or third deployments.

The Pentagon relies on reserve members to report their own health problems because they have no way of tracking their medical care when the reserves are not called up for active duty.

“Study after study has shown self-administered surveys are the best way to get information,” Stone said. But the military lacks a central record-keeping system capable of maintaining complete health records of those in the reserves, undermining its ability to spot and manage medical conditions, according to Waltemath and other experts.

Medical documents of guardsmen at an Evansville, Ind., readiness screening event. Self assessment surveys play a crucial role in evaluating the health of reservists. (Bob Spoerl/Medill)

Some of the reserve members missed the initial warning signs that they were suffering from depression and post-traumatic stress disorder. Others reported not seeking care due to concerns that getting mental health treatment would hurt their career, according to Terri Tanielian, director of RAND Corporation’s Center for Military Health Policy Research.

“The soldier can seek civilian care for mental problems and his unit may never come to know,” Nevin said. Because of confidentiality, the reserve members’ commanding officers also can’t get access to their medical records, depriving the military of another avenue for identifying problems.

And the pre-deployment screenings administered by LHI did not have adequate controls in place to catch potential behavioral problems, according to some military officials and experts.

Those deploying between 2001 and 2006 only had to answer one question related to mental health on their pre-deployment surveys: “During the past year, have you sought counseling or care for your mental health?”

“For me to find out someone has a problem, the soldier has to come to me with the problem or I have to find out by accident,” Waltemath said. “That’s a challenge the active-duty soldiers don’t face.”

Since 2003, when the Armed Forces Health Surveillance Center began keeping statistics, the reservists reported mental health problems at significantly higher rates than their active duty counterparts.

After media reports asserted that the military was sending mentally unfit service members into combat zones, the Pentagon in 2006 developed minimum mental health standards for those deploying. That included a special pre-deployment questionnaire focusing exclusively on potential behavioral problems.

Waltemath said that helped, but only so much.

“How much time do you get with those clinicians–five minutes?” he said. “I don’t want someone dictating if I have a behavioral health issue with a five minute talk.”

In September 2007, the Pentagon awarded LHI a new $790 million, five-year contract to run what was now called the Reserve Health Readiness Program.

That year, Ryan Kohlheim’s brother Spencer had just returned home after spending six months in Afghanistan, his sixth deployment with the military. He said his problems coping with civilian life were getting worse.

“He was involved in an incident where he freaked out on some people,” Kohlheim said. After his brother spent a night in jail, he took him to a Veterans Affairs facility for counseling sessions and treatment for substance abuse and mental health problems.

Less than a year later, Spencer again deployed to Iraq. Two weeks after returning home in December 2008, he hanged himself in their grandmother’s house.

Kohlheim said he didn’t know what kind of screening process his brother went through. But, he said, “I don’t think he was in any shape or form to deal with everything going on there. I absolutely think they should have stopped him from going.”

Spencer Kohlheim (second from left) was deployed to Iraq in 2008, even though he was undergoing counselling sessions at a Veterans Affairs facility for mental health problems. (family photo from Ryan Kohlheim)

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Looking to the future

Nevin and others remain concerned that the screening process is inadequate, especially for the reserves.

Annual statistics from October 2010 showed that only one in 300 reservists had been identified for mental health referrals based on the pre-deployment health assessment forms they filled out — significantly fewer than the one in 100 among full-time soldiers, according to the Armed Forces Health Surveillance Center.

Some states have put in place additional measures designed to improve the pre-deployment process.

Waltemath’s Indiana National Guard, for instance, ensures that its members spend a significant amount of time, face to face, with a specialist to discuss mental health issues before deployment and at a VA facility after deployment something that is not required on the federal level.

Even though the two wars are winding down, officials in the National Guard and Reserve say they need to continue to improve the screening system because the reserves have now become fully integrated into the active duty military’s operational plans for the future, and they will need to be ready.

Next year, the Pentagon is expected to issue a new RHRP contract, and estimates it to be worth more than $1 billion.