Tagged: veterans healthcare

Report: VA Patients 33 Percent More Likely to Die of Overmedication

Posted by Jason Van Steenwyk

militaryauthority.com VA patients more like to overdosePatients at Veterans Affairs hospitals and clinics are 33 percent more likely to die from accidental overdoses of medications than the general population, CBS News has found.

The report focused on the case of a 35-year old Army veteran, Scott MacDonald, who was proscribed a cocktail of seven different medications for pain and psychiatric conditions, including narcotics like Percocet and Vicodin – both opiate derivatives.

According to CBS’s reporting, sources within the VA are saying that VA officials have been encouraging doctors to sign off on painkiller and other medications – including narcotics – on patients they don’t see. In the short run, the practice actually saves money, because patients with enough painkillers tend to make fewer appointments and consume fewer health care services.

In the long run, however, doctors signing off on these assembly line prescriptions are putting patients at risk of opiate or prescription medicine addiction and a host of negative side effects, including accidental fatal overdose. 

The CBS report builds on earlier reporting from a local NBC affiliate in Ohio, which found that the number of unintentional drug overdose deaths in Ohio tripled between 2001 and 2011. Furthermore, an earlier study published in the Journal of Psychiatry found that veterans had a significantly elevated risk of death due to accidental overdose compared to the general population nationwide.

In 2010, Dr. Pamela Gray, then a VA physician, became concerned because, as she states, VA officials were asking her and other doctors to sign off on continuing narcotics prescriptions on patients they had not even seen, much less evaluated. She took her concerns to Senator Jim Webb (D-VA), who in turn had the VA launch an investigation. Gray subsequently lost her job – she says because she blew the whistle, though the VA cites poor communications skills as the reason she no longer practices at the VA. However, according to reporting by the Virginian Pilot, the VA’s own internal investigation mostly cleared themselves of wrongdoing, though four of the fifteen physicians interviewed said they, too, had been asked to write prescriptions for patients they had not seen. The VA Inspector General’s office wrote that there was, indeed, a perception of pressure to write narcotics prescriptions and an expectation of retaliation against any doctor who failed to do so.

At the same time media reports are highlighting the possible overreliance on psychoactive medications such as anti-psychotics in more general settings. 

VA Backlog is 443 Days in Florida

Posted by Jason Van Steenwyk

VA backlogThe current average wait time for new Veterans Administration claims in Florida is 433 days.

That’s the latest, according to a report today from WFTV News, serving Central Florida from Orlando to Daytona Beach and Melbourne. The wait time for Florida veterans is therefore nearly twice the national average, which is 273 days.

That’s the result of a mounting backlog at the VA regional office for Florida. There is only one regional office in the entire state. VA officials state the backlog is due to the large concentration of veterans within the state of Florida. However, that’s hardly news – the VA has not mentioned why it wouldn’t staff the Florida office appropriately.

Since President Obama was inaugurated in 2009, the number of veterans waiting a year or more for their benefits has exploded from 11,000 to 245,000. That amounts to a more than 2,000 percent increase, according to reporting earlier this year from the Center for Investigative Reporting. The same organization also reports this week that with the 2012 election safely over, the VA has “backed off” its promise to reduce the claims backlog.

According to WFTV’s reporting, a VA official states that the Administration has decided to devote resources to creating a paperless system, rather than create more regional offices in Florida. 

House Minority Leader Calls on Secretary Shinseki for Plan to Improve VA Services

Posted by Jason Van Steenwyk

VA services improvement planIn an open letter to the Secretary of Veterans Affairs, House Speaker John Boehner has detailed a list of failings by the VA under Secretary Eric K. Shinseki’s tenure, and requested a response to a series of questions on the VA’s plans to improve performance within the next 30 days.

Congressman John Boehner (R-OH), who also heads the Republican majority in the House of Representatives, is fed up with his contituents complaining about poor performance by the Department of Veterans Affairs. He has called upon Secretary of Veterans Affairs Eric Shinseki.

Citing an ‘alarmingly high’ backlog of unprocessed claims, Boehner made the following assertions:

  • The Cleveland VARO’s rating claims processing time is 334.2 days, as of February 15th, 2013. 
  • The current national average is 275.5 days
  • The VA has already publicly announced that they had a goal of reducing the VA rating processing time to 125 days by 2015.
  • The current nationwide average claim processing time is 272.5 days – an increase of 17.5 percent over the prior 13-month period.
  • For the Cleveland, Ohio processing center – notable because it is within Congressman Boehner’s district, wait times have actually increased by 34 percent over the past year.
  • The increase has come despite a substantial effort to modernize the Cleveland VA claims tracking and reporting system.
  • The total backlog of pending compensation claims has increased from 390,000 in 2009 to more than 821,000 today.
  • 71.5 percent of those claims have been pending for 125 days or more.
  • The VA error rate is 86.2 percent. The Secretary has announced a goal of 98 percent error free rate. Congresssman Bohner’s office calculates that this translates to about 400,000 claims having been mishandled or wrongly adjudicated on Shinseki’s watch.
  • There are currently 251,443 appeals pending, as of February 2013.

For its part, the Veterans Administration has been hit with a tsunami of claims. Nearly half of all Iraq War veterans are presenting to the VA with some issue or other. At the same time, the Viet Nam generation of veterans has entered its peak years of health care consumption. The Veterans Administration noted that it has successfully increased its throughput, processing record numbers of claims each year for the last three fiscal yearswith over a million cases resolved in each of those years. Congressman Boehner, however, points out that with an error rate of 13 percent, that creates a different problem of hundreds of thousands of cases cluttering the appeals process – and veterans waiting for their promised benefits.

The VA is also struggling with some front-end problems: Only 3 percent of claims are submitted “fully developed,” according to Tommy Sowers, the VA’s Assistant Secretary of Public and Intergovernmental Affairs. 

The VA has also created a blog, VAntage Point, to improve its image among veterans and the public at large. 

GAO: VA Reported Wait Times are Unreliable

Posted by Jason Van Steenwyk

VA CentersThe Veterans Administration has not been reporting reliable data to Congress regarding wait times for outpatient treatment. This was the conclusion of a recent study by the Government Accounting Office. The GAO also found that there was inconsistent implementation of certain elements of VHA’s scheduling policy that could result in increased wait times or delays in scheduling timely medical appointments.

The GAO visited several Veterans Affairs Medical Centers around the country, and found significant compliance problems with the appointment wait time reporting process. Several VAMCs did not ensure staffers completed required training on the appointment setting process.

At every center they visited, GAO inspectors found at least one staffer who was recording the patient’s desired appointment date incorrectly. Additionally, investigators found that staffers were actually able to change a record of a requested appointment date – in order to show a number that would meet the VA’s stated policy objectives. The result is a significant skewing of appointment time data.

The bottom line: As bad as the wait time numbers coming out of the VA these days looks, the reality is even worse. 

In addition, the GAO found that several clinics they studied were not using the electronic wait list to schedule appointments – which created an elevated risk that some patients would “fall through the cracks.”

The GAO also cited these factors impeding VA mission success: 

  • An antiquated scheduling system, VistA, which is over 25 years old, slow and cumbersome. 
  • Gaps in scheduler staffing.
  • Lack of staff dedicated to answering phones. 

The recent increase in suicides among veterans has put the VA under greater scrutiny. The GAO survey did not specifically focus on mental health care facilities and appointment wait times, but described the VA scheduling problems as “pervasive.”

VHA officials have expressed an ongoing commitment to providing veterans with timely access to medical appointments and have reported continued improvements in achieving this goal,” the GAO report stated. However, it concluded, “Unreliable wait time measurement has resulted in a discrepancy between the positive wait time performance VA has reported and veterans’ actual experiences.”


VA Modernization Effort Failing to Reduce Claims Processing Times

Posted by Jason Van Steenwyk

describe the imageDespite a massive effort to convert the Department of Veterans Affairs to a modernized, Web-based claims processing system, the VA has thus far failed to reduce wait times. In fact, they have actually made the claims process more difficult.

This was the finding of an internal investigation by the Inspector General’s office of the Department of Veterans Affairs. The IG published his report, Review of Transition to a Paperless Claims Processing Environment, earlier this month.

The VA’s goals were laudable: They intended for their massive transformation system to improve their claims processing throughput by 40 to 65 percent, while reducing their error rate. A key part of the transition was the adoption of their new Web-based automated claims processing software, VBMS.

The report faulted the VA for a failure to come up with a detailed plan for modernization or think through the system requirements. This poor planning, in combination with an incremental approach under the Agile system of software development, means that the Veterans Benefits Administration will continue to face significant problems.

Among the Inspector General’s findings:

  • The Veterans Benefits Administration’s efforts to scan and digitize veterans’ claims have not been built from a detailed plan and analysis of requirements.
  • Users stated that developers did not visit the pilot sites for the first time until August 2012 to understand their business needs and system functionality requirements.
  • Users indicated that test scenarios were not realistic because functionality in the test environments did not replicate functionality in the production environment.
  • Test cases did not process claims end-to-end within VBMS.
  • While it took approximately 4 minutes to establish a claim with multiple contentions—contentions are veterans’ disabilities or health issues—in the legacy systems, it took approximately 18 minutes to establish the same claim in the VBMS pilot system.
  • VBMS performance issues caused some documents to take 3 to 4 minutes or longer to open. On numerous occasions, inefficient system use of memory caused the system to crash and users had to reboot after opening multiple documents.
  • VBMS-generated Veterans Claims Assistance Act letters contained errors and spacing issues and did not provide capabilities to edit or modify the documents. System users complained these letters often contained the wrong VARO addresses and VBMS did not provide the capability to make the necessary corrections.
  • Ratings calculators had been deployed. However, because the calculators were not functioning properly, they were disabled and therefore not used to support disability claims determinations. A Rating Veterans Service Representative disclosed that rating an average claim in VBMS typically took 1hour in the legacy systems, but required 2 or more hours in VBMS.
  • VA began scanning and digitizing veterans’ claims before it had a detailed plan and analysis of requirements for automating claims intake.
  • VA proceeded with claims scanning and digitizing without a detailed plan outlining what this process would entail.
  • Because a methodology was not well planned, VA encountered issues in scanning and digitizing claims folders to support the VBMS pilots. Specifically, the eFolders used to store the scanned images were disorganized and VA did not ensure proper management of hard copy claims folders.

Also, the IG’s office noted that as of September 2012, it was still not possible to complete a claim entirely using the VBMS system ‘end to end.’ This is, in part, due to the Agile approach to software development and project management, which brings the system to completion gradually, in stages.

According to the VA’s own data, average processing times actually increased at the VA claims centers designated as test sites for the VBMS rollout. The Fort Harrison facility reported an increase from 78 days to 125.6 days in the amount of time it took to process a pending disability claim during the test period, from October 2011 (pre-VBMS) to September 2012 (post VBMS). The Wichita facility reported an increase of 159.2 to 172.3 days.

Data for the other two Beta sites, Salt Lake City and Providence, RI, were not yet available for comparison, according to the report.

Buffalo VA Center Exposes 700+ Veterans to HIV, Hepatitis

Posted by Jason Van Steenwyk

Buffalo vets at risk from shotsIf you received insulin injections at the VA hospital in Buffalo, New York at any time between October 19th, 2010, and last November, get in touch with the clinic, pronto.

Hospital officials have disclosed that as many as 700 veterans may have been exposed to HIV – the virus that causes AIDS – as well as hepatitis A and B from the reuse of insulin pens.

The clinic claims that it was only the pens that were reused in this case, and not the needles themselves. But that is potentially enough to taint any insulin delivered with those pens, which were not designed for reuse.

The problem came to light when inspectors visited the hospital and found a drawer full of insulin pens that were not labeled for individual patients. Some pens are reusable, but in no case should unsterilized pens be used on more than one patient. The fact that unlabeled pens were retained and not discarded indicated that some staffers were unaware that these pens were not for use on multiple patients.

VA spokespersons indicated that as many as 716 veterans may have been exposed in this way.

The VA is setting up a hotline to deal with veteran inquiries.

Meanwhile, Senator Charles Schumer (D-NY) and Representative Brian Higgins are both calling for a top-to-bottom review of medical practices at New York VA hospitals and clinics.

They are also calling for answers about why it is that the problem went undetected for two years, and why, once the problem was discovered, it took over two months for VA officials to notify veterans or Congressional representatives.

“We must evaluate the root causes of this unthinkable error, identify who is responsible for this systematic failure, better understand if it is an isolated incident or representative of widespread problems and ensure it never happens again,” said Rep. Wiggins in a statement.

The VA is providing free blood tests to those affected to rule out any infections.

This incident is not the first in which VA medical centers have accidentally exposed patients to blood-borne pathogens through incompetence. Thousands of veterans were exposed to HIV and hepatitis when staff at VA hospitals and clinics in Miami, Fla., Augusta, Ga. and Murfreesboro, Tenn. were caught reusing unsterilized colonoscopy equipment on patient after patient. At least 10 veterans later tested positive for hepatitis as a result.

In a breath-taking display of incompetence, staffers had been sterilizing colonoscopy tubes at the end of each day, according to a VA statement, rather than after each use.

VA officials then failed to inform veterans affected – claiming they couldn’t because the records were locked away in a safe that they controlled – an assertion legislators found ‘almost impossible to believe.’

At the urging of the House Veterans Affairs Committee, the Miami VA center was so poorly run that they called for the removal of the hospital’s director, Mary Berrocal, and her deputy, Nevin Weaver. The two were finally forced out in November 2012 as a result. However, the VA isn’t much on holding executives accountable: Berrocal is still a director in the Miami VA system, and Weaver is still listed on the VA Website as the director of the VA Sunshine Healthcare Network, VISN 8 as of this writing.

John Vara, another Miami VA senior executive who was ‘admonished’ with a letter of reprimand that stays in his record for up to two years, was reassigned to the Palm Beach VA system as chief of staff for education and research.

Additionally, the New York Times reported on a “rogue” cancer unit at the Philadelphia VA Center that botched 92 of 116 prostate cancer ‘seeding’ procedures, hid the matter from investigators, and falsified records to cover the problem.

The unit also continued to seed prostate patients with radioactive particles even though the equipment measuring the radioactivity dose was broken – and the radioactivity safety unit at the hospital knew this for over a year.

President Signs Burn-Pit Registry Law

Posted by Jason Van Steenwyk

US Army burn pitPresident Barack Obama signed a law last week directing the Department of Veterans Affairs to set up and maintain a ‘burn-pit’ registry. This is a list of veterans who have been exposed to potentially toxic fumes emanating from diesel fuel, human excrement, and other waste and debris in Iraq, Afghanistan and other austere areas of operation.

Although burn-pits are nothing new – they date back to ancient times – NBC News has referred to burn-pit exposure as “this generation’s Agent Orange.”

This isn’t necessarily about the small latrine pits made out of 55-gallon drums. Some contractors in Iraq actually maintained massive burn pits that were hundreds of yards wide, and did so very close to troops working and living areas, in some cases. These pits used diesel fuel to burn plastics, tires, chemicals, excrement, batteries – including rare earth and heavy metal batteries.

One study measured the cancer rate among troops stationed at Balad – a major Forward Operating Base in Iraq and home to perhaps the largest burn pit in the country – and found the cancer risk was eight times higher among those troops stationed at Balad for more than a year than among the general population, controlling for age and sex. Dioxin and particulate exposure were also each 50 times higher than acceptable levels, according to a 2007 study.

The new law follows a series of lawsuits against prominent military contractors, Kellogg, Brown and Root and Halliburton, alleging that these burn pit operators failed to properly maintain these pits, mitigate hazards or warn servicemembers of the potential harmful effects of the fumes.

One suit alleges that KBR built a large burn pit upwind of troops’ living quarters – in violation of their contract and DoD directives.

The burn-pit directory will give the Department of Veterans Affairs a database of individuals with exposure to the pits, help them track long-term medical issues among this population and compare them with other groups, and facilitate communication if effective treatments are discovered.

A series of academic studies has been undertaken, and some of them have been published within the last year. At least one study found an increase in incidents of asthma and other pulmonary disorders after deployments to Iraq and Afghanistan.

The VA has not yet issued instructions on how to sign up for the burn-pit registry. It will publish instructions when the registry is up and running.

Study: The Faster You Get Out of a VA Hospital, the Better Off You Are

Posted by Jason Van Steenwyk

VA medical careThat wasn’t quite the headline. The real headline is “Shorter hospital stays don’t mean worse care: study.” But they work out to the same thing.

“U.S. Veterans Affairs hospitals were able to reduce their patients’ length of stay without increasing the number of people who needed to be readmitted later on, according to a new study.

“As hospitals became more efficient there was this growing concern that we were discharging patients – as some would say – sicker and quicker,” said the study’s lead author Dr. Peter Kaboli.

“In fact, we found just the opposite,” said Kaboli, who works at the Iowa City VA Health Care System.”

The average VA hospital stay fell from 5.5 days in 2007 to 4 days in 2010. The study, published in the Annals of Internal Medicine, surveyed 4 million patient records at the Department of Veterans Affairs’ 129 hospitals nationwide from 2007-2010 to see if earlier discharges resulted in an increase in admission within 30 days.

The study shockingly found that when it came to readmissions, government health care added no value beyond the third day. More than that, the survey found that a five-day stay rather than a four-day stay was actually harmful to readmission rates: Reducing the length of stay from 5.5 days to 4 days actually reduced readmissions, from 16.5 percent in 1997 to 13.8 percent in 2010.

The survey also found that getting patients out of the VA hospital in four days rather than five and a half, on average, resulted in lower post-discharge mortality rates over the 90 days following discharge.

The sample was diverse: No specific diagnosis or medical condition accounted for more than 5 percent of the patient population. It is therefore unlikely that advances in treatment of a particular condition or disease accounted for a significant change in the numbers.

Why would patient outcomes improve with shorter hospital stays? Hospital-acquired infections, or HAI (also called nosocomial infections). Hospitals are hothouses for staph infections and other communicable diseases. Infection and reinfection accounts for a significant number of hospital readmissions within 30 days of discharge. The Center for Disease Control estimates that there are 1.7 million serious infections acquired in a hospital each year, killing almost 100,000 people per year. These infections can occur when hospital staffers do not disinfect exposed surfaces or diligently practice sound hygiene.

The Veterans Administration had, during the time of the study, also engaged in a massive, successful effort to improve hygiene at its hospitals and clinics. The effort resulted in a massive, 62 percent decrease in hospital-acquired staph infections. The initiative commenced in 2007 – the same year the study began.

13.6 percent of patients admitted who were screened for methicillin-resistant Staphylococcus aureus bacteria tested positive. This alerted VA staffers, who would isolate the patient from others and who would be extra diligent in practicing universal hygiene precautions, so as to minimize the risk of patient-to-patient and patient-to-staff-to-patient infection.

With screening at admission now commonplace, VA officials could effectively calculate how many patients acquired the infection while in the hospital. The VA estimated that there were 1.62 new infections per 1,000 patient days. The rate fell to 0.6 new infections per 1,000 patient-days. Not enough to hugely affect the VA’s readmission numbers, however.

The study also included the time period in which the VA had to inform more than 10,000 patients that they were potentially exposed to hepatitis and other infections because of faulty sanitation procedures at VA facilities in Florida, Georgia and Tennessee.

Troops Win Legislative Victories With New Defense Budget Deal

Posted by Jason Van Steenwyk

2013 Defense Authorization BillCongress has struck a tentative deal on the 2013 Defense Authorization Bill, at least at the committee level, and lobbyists for veterans and servicemembers groups seem to have one some important victories, sources say.

According to the Military Officers Association of America – one of the key lobbying organizations in Washington for career military and retirees – the deal contains the following provisions:

A 1.7 percent increase in base pay

The defeat of a drastic increase in TRICARE pharmacy copays proposed by the Obama Administration: Copays are capped at $17 per brand-name medication for 2013, and future increases are pegged to retirement pay increases. The Administration wanted to raise the current copay from $12 to $26, and then to $34 per medication over the next four years.

The Obama Administration also wanted to eliminate access to medications not on the current TRICARE formulary altogether. The Defense deal Congress reached this week ensures they will continue to be available, though for a $44 copay. That is substantially more expensive than the current $25 per medication, but “better than not having them available at all,” say MOAA sources.

The co-pay for mail-order generic medications remains at zero. The Administration wanted to reinstate a $9 copay for generics by 2017, but was unsuccessful in getting this included.

The bill does impose new obligations among TRICARE for Life beneficiaries: They must try using cheaper military pharmacies or mail-order for refills for at least a year, beginning, most likely, in March in 2013. After one year, beneficiaries can opt to revert back to the retail pharmacy system. Congress hopes the savings from this arrangement will offset the cost of the lower copays to the taxpayer.

The law also makes it easier for wounded medically-retired veterans to collect Combat-Related Special Compensation for those with combat-related disabilities. Those affected will see an increase in CRSC payments effective 1 January 2013.

Additionally, active duty service members will be getting a 3.8 percent increase in their housing allowance next year, on average, though allowances at some locations will actually decline.

Active duty servicemembers are also receiving an increase in basic allowance for subsistence. The new rates:

Enlisted: $352.27 per month

Officers: $242.60 per month

In other developments, the new Defense Authorization Bill makes same-sex marriages legal on military bases if they are legal in their respective states. However, military chaplains cannot be required to participate in marrying same-sex couples.

The bill also authorizes TRICARE to pay for abortions, if the patient is a victim of rape or incest.

Furthermore, the law also requires the military to discharge convicted sex offenders, and requires military officials to retain closed reports of sexual assaults for up to 50 years, in order to support disability claims against the government and possible prosecution of perpetrators, subject to the statute of limitations.

Newtown School Massacre Raises Issues for Veterans, Mental Health and Law Enforcement

Posted by Jason Van Steenwyk

veterans mental healthLast Friday, America was forced to confront the problem of evil. And we may yet again fail to recognize it where it exists.

I do not use the word ‘tragic’ or tragedy when referring to the outrage that took the lives of 20 schoolchildren and seven adults. The word applies where those who fell died because of some fault of their own – the tragic flaw of Greek and Shakespearian drama. Tragedies are, by definition, self-inflicted at some level.

This was not the case in Newtown, nor Clackamas, nor at Columbine, the Aurora Theater or Tuscon.

Tragedy has logic. This was simply murder.

The shooting has naturally resulted in calls for increased restrictions on legal gun ownership – and gun rights advocates have also resorted to the usual arguments in favor of 2nd Amendment rights.

The Newtown incident has also resulted in more calls for reforms in mental health care – a welcome development, and certainly one of interest to veterans in the VA system as well as to the general population.

But large swathes of the mental health care advocates likewise miss the target – the problem of evil.

The mental health industry – including families struggling with mental illness or personality disorders within their own homes – would argue that we need better access to mental health treatment, early intervention, up to and including involuntary commitment for individuals who have not yet committed a crime.

The mental health industry is part of the health care complex in the United States, and has adapted itself to define mental health issues in such a way as to maximize reimbursement from health insurance plans, including Medicare and Medicaid. In order to do this, it has adopted a medical treatment, documentation and financing model for mental illnesses of all stripes.

In many cases, this is absolutely appropriate. Some mental illnesses, including bipolar disorder, schizophrenia and some forms of depression respond very well to medication. The mental health industry has also adopted a medical model to treat drug and alcohol addiction – though with less success.

And then there are the so-called personality disorders: Borderline personality disorder, narcissism and sadism – a cluster of sociopathologies that the medical model continues to have trouble addressing. This is because the medical model has trouble identifying the difference between genuine mental illness and evil. If the system cannot identify evil, it cannot address it.

Public discourse on the shooting centers on keeping guns out of the hands of the “deranged,” but we fail to define our terms beyond that.

Meanwhile, we run the risk of eroding valuable constitutional freedoms.

We are already seeing that within our own community of veterans – a recent bill before Congress sought to strip veterans under VA care of their 2nd amendment rights simply on the say-so of a mental health professional, without any kind of a priori judicial review.

A VA bureaucrat social worker, under the proposed law, could refer a veteran to the FBI simply because he was bad with money.

And history is replete with state abuse of the mental health system to warehouse those who were perfectly sane, but whose ideas were considered a threat to the power structure. Imperial Japan had the Tokk? – quite literally referred to as the “thought police” between 1925 and 1945. Its function was to stamp out and suppress “dangerous thought.” Among the dangerous thoughts it suppressed: Opposition to the simultaneous war with China, the United States and Great Britain which ultimately resulted in the country’s utter devastation.

If mental health workers have a reputation for referring struggling patients to law enforcement – or committing them involuntarily to mental institutions, the potential for perverse effects is obvious: Those with enough cognizance to be extremely deadly criminals will avoid seeking care, or will say what they think the shrink wants them to say, and therefore fall outside the system’s grasp, even as the constitutional rights of less maladjusted people are eroded.

Meanwhile, the mental health field will continue to struggle with the problem of evil that cannot be medically addressed. There was nothing insane nor irrational about men like Timothy McVeigh, or MAJ Nidal Hassan. They knew exactly what they were doing. They had a goal and set about to kill to achieve it. They knew full well the devastating impact their actions would have on their victims and their victims’ families. They just did not care.

No amount of medication, nor cognitive ‘talk therapy,’ nor any number of billable hours, will correct that, no matter how skilled the practitioner.

Hassan’s case is particularly revealing: As an Army psychologist himself, Hassan was routinely in contact with many other military health care professionals – yet despite tipping his hand several times in formal presentations as an adherent of radical and violent Islam, the Army mental health care system could not identify an evil right under their noses.

In the case of the Tuscon, Arizona shootings and the Aurora. Colorado Theater shooting, we have a more ambiguous case. Clearly, neither shooter was playing with a full deck of cards. In these cases, perhaps some early intervention could have prevented the problem. The warning signs were there – and recognized by people around them at the time. James Holmes, the shooter in Aurora, was actually regularly seeing a mental health professional at the time. So access to mental health care was not the problem.

Holmes himself had actually received a degree in neuroscience, with highest honors, and had been described as a “very effective group leader” as an undergraduate. He would have had access to counseling and health care as an undergraduate student, and as a graduate student at the University of Colorado, where he was still technically enrolled at the time of the shooting. His psychological decompensation seems to have been rapid, though.

Jared Lee Loughner, the Tuscon murderer, had a long history of borderline psychosis, perhaps as a result of the chronic use of hallucinogenic drugs. Loughner had already been identified as a criminal risk, and was barred from reenrolling at Pima Community College until he received a clearance from a mental health professional stating he was not a risk for violent behavior.

Seung Hui-Cho, the murderer in the Virginia Tech Shootings who took the lives of 32 people and wounded 17 in 2007, was identified as a danger as young as 15, when he was transfixed by the Columbine murders and wrote that he wanted to repeat them. In this case, mental health care officials intervened early, and he was placed in special education with an emotional disorder and excused from a number of routine events in high school, such as group presentations. He eventually began to refuse treatment.

Privacy laws, such as HIPAA, prohibited his mental health care professionals from notifying Virginia Tech officials of his violent tendencies.

A professor of his at Virginia Tech had already removed him from her class because of menacing behavior. He was also involved in at least three incidents of stalking while enrolled at Virginia Tech, but was allowed to remain a student. Professors had already alerted the dean and campus police that Cho was a problem, but were informed that there was nothing they could do until Cho committed a crime.

In 2005, Cho was actually found by a magistrate to be a danger to himself and others around him. But the magistrate in question, Special Justice Paul Barnett, sentenced him to outpatient treatment, rather than committing him full time to an institution.

In each of these cases, mental health professionals were already involved, and clearly there was plenty of early warning in most of them. In each case, the mental health professionals and court apparatuses could not or would not take decisive action to remove these individuals from society. Access to mental health care was not an issue. The issue was the recognition of evil.

The medical model has no structural incentive to attribute to evil what it can attribute to something billable.

But that brings us back to veterans: If we adopt a system in which we are quicker to involuntarily commit those we suspect of being psychotic, or with severe personality disorders, to mental institutions, bias and prejudice against combat veterans and ignorance about PTSD will ensure that we are first in line for detention.

There are certainly reforms that can be made, both to the system that regulates firearm distribution and ownership, as well as mental health reforms.  But is the 2nd amendment that guarantees the government can never have the power to create a Tokk? of its own, and allows the weak and good to defend themselves against criminals who are strong, armed, evil and/or crazy.

There are constitutional concerns in strengthening the mental health industry’s pull – and they have powerful financial incentives to commit more and more patients to their care. Meanwhile, for every Cho, there are thousands of people who enter the system who would be harmless, yet have their freedoms abridged all the same.

We should be very cautious of broad, ham-handed measures in either field to prevent future shootings. Evil has always been among us, and while you can regulate away the ability of law abiding citizens to defend themselves against people like Cho – and more run-of-the-mill criminals – you cannot treat away nor regulate away the presence of evil.