[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]
THE U.S. DEPARTMENT OF VETERANS AFFAIRS
SCHEDULE FOR RATING DISABILITIES
=======================================================================
HEARING
before the
SUBCOMMITTEE ON DISABILITY ASSISTANCE
AND MEMORIAL AFFAIRS
of the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED TENTH CONGRESS
SECOND SESSION
__________
FEBRUARY 26, 2008
__________
Serial No. 110-71
__________
Printed for the use of the Committee on Veterans' Affairs
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COMMITTEE ON VETERANS' AFFAIRS
BOB FILNER, California, Chairman
CORRINE BROWN, Florida STEVE BUYER, Indiana, Ranking
VIC SNYDER, Arkansas CLIFF STEARNS, Florida
MICHAEL H. MICHAUD, Maine JERRY MORAN, Kansas
STEPHANIE HERSETH SANDLIN, South HENRY E. BROWN, Jr., South
Dakota Carolina
HARRY E. MITCHELL, Arizona JEFF MILLER, Florida
JOHN J. HALL, New York JOHN BOOZMAN, Arkansas
PHIL HARE, Illinois GINNY BROWN-WAITE, Florida
MICHAEL F. DOYLE, Pennsylvania MICHAEL R. TURNER, Ohio
SHELLEY BERKLEY, Nevada BRIAN P. BILBRAY, California
JOHN T. SALAZAR, Colorado DOUG LAMBORN, Colorado
CIRO D. RODRIGUEZ, Texas GUS M. BILIRAKIS, Florida
JOE DONNELLY, Indiana VERN BUCHANAN, Florida
JERRY McNERNEY, California VACANT
ZACHARY T. SPACE, Ohio
TIMOTHY J. WALZ, Minnesota
Malcom A. Shorter, Staff Director
______
Subcommittee on Disability Assistance and Memorial Affairs
JOHN J. HALL, New York, Chairman
CIRO D. RODRIGUEZ, Texas DOUG LAMBORN, Colorado, Ranking
PHIL HARE, Illinois MICHAEL R. TURNER, Ohio
SHELLEY BERKLEY, Nevada GUS M. BILIRAKIS, Florida
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
official version. Because electronic submissions are used to prepare
both printed and electronic versions of the hearing record, the process
of converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
current publication process and should diminish as the process is
further refined.
C O N T E N T S
__________
February 26, 2008
Page
The U.S. Department of Veterans Affairs Schedule for Rating
Disabilities................................................... 1
OPENING STATEMENTS
Chairman John J. Hall............................................ 1
Prepared statement of Chairman Hall.......................... 53
Hon. Doug Lamborn, Ranking Republican Member, prepared statement
of............................................................. 54
WITNESSES
U.S. Department of Veterans Affairs, Bradley G. Mayes, Director,
Compensation and Pension Service, Veterans Benefits
Administration................................................. 42
Prepared statement of Mr. Mayes.............................. 104
U.S. Department of Defense, Major General Joseph E. Kelley, M.D.,
USAF (Ret.), Deputy Assistant, Secretary of Defense for
Clinical and Program Policy (Health Affairs)................... 44
Prepared statement of Dr. Kelley............................. 108
______
American Academy of Disability Evaluating Physicians, Mark H.
Hyman, M.D., FAADEP, Presenter, and Mark H. Hyman, M.D., Inc.,
F.A.C.P., F.A.A.D.E.P., Los Angeles, CA........................ 22
Prepared statement of Dr. Hyman.............................. 79
American Legion, Dean F. Stoline, Assistant Director, National
Legislative Commission......................................... 31
Prepared statement of Mr. Stoline............................ 89
American Psychiatric Association, Sidney Weissman, M.D., Member,
Committee on Mental Healthcare for Veterans and Military
Personnel and Their Families................................... 24
Prepared statement of Dr. Weissman........................... 83
Center for Naval Analyses (CNA) Corp., Alexandria, VA, Joyce
McMahon, Ph.D., Managing Director, Managing Director, Center
for Health Research and Policy................................. 12
Prepared statement of Dr. McMahon............................ 75
Disabled American Veterans, Kerry Baker, Associate National
Legislative Director........................................... 34
Prepared statement of Mr. Baker.............................. 93
Institute of Medicine, The National Academies:................... 69
Lonnie Bristow, M.D., Chair, Committee on Medical Evaluation
of Veterans for Disability Benefits, Board on Military and
Veterans Health............................................ 7
Prepared statement of Dr. Bristow............................ 58
Dean G. Kilpatrick, Ph.D., Member, Committee on Veterans'
Compensation for Posttraumatic Stress Disorder, and
Distinguished University Professor and Director, National
Crime Victims Research and Treatment Center, Medical
University of South Carolina, Charleston, SC............... 9
Prepared statement of Dr. Kilpatrick......................... 66
Jonathan M. Samet, M.D., M.S., Chairman, Committee on
Evaluation of the Presumptive Disability, Decision-Making
Process for Veterans, Board on Military and Veterans
Affairs, and Professor and Chairman,, Department of
Epidemiology, Johns Hopkins Bloomberg School of Public
Health, Johns Hopkins University, Baltimore, MD............ 11
Prepared statement of Dr. Samet.............................. 71
National Veterans Legal Services Program, Ronald B. Abrams, Joint
Executive Director............................................. 26
Prepared statement of Mr. Abrams............................. 85
Veterans' Disability Benefits Commission, Vice Admiral Dennis
Vincent McGinn, USN (Ret.), Member, on behalf of Lieutenant
General James Terry Scott, USA (Ret.), Chairman................ 4
Prepared statement of Admiral McGinn......................... 54
Veterans of Foreign Wars of the United States, Gerald T. Manar,
Deputy Director, National Veterans Service..................... 36
Prepared statement of Mr. Manar.............................. 100
SUBMISSION FOR THE RECORD
American Medical Association, statement.......................... 110
MATERIAL SUBMITTED FOR THE RECORD
Reports:
``VA Benefits: Fundamental Changes to VA's Disability
Criteria Need Careful Consideration,'' GAO-03-1172T,
Testimony Before the Senate Committee on Veterans' Affairs,
September 23, 2003, Statement of Cynthia A. Bascetta,
Director, Education, Work force, and Income Security
Issues, U.S, General Accounting Office..................... 114
Post-Hearing Questions and Responses for the Record:
Hon. John J. Hall, Chairman, Subcommittee on Disability
Assistance and Memorial Affairs, Committee on Veterans'
Affairs, to Vice Admiral Dennis Vincent McGinn, USN (Ret.),
Member, Veterans' Disability Benefits Commission, letter
dated February 29, 2008, and Admiral McGinn's response
letter dated March 31, 2008................................ 117
Hon. John J. Hall, Chairman, Subcommittee on Disability
Assistance and Memorial Affairs, Committee on Veterans'
Affairs, to Lonnie Bristow, M.D., Chair, Committee on
Medical Evaluation of Veterans for Disability Benefits,
Institute of Medicine, letter dated February 29, 2008, and
Dr. Bristow's responses.................................... 119
Hon. John J. Hall, Chairman, Subcommittee on Disability
Assistance and Memorial Affairs, Committee on Veterans'
Affairs, to Dean Kilpatrick, Ph.D., Committee on Veterans
Compensation For Posttraumatic Stress Disorder, Institute
of Medicine, letter dated February 29, 2008, and Dr.
Kilpatrick's responses..................................... 121
Hon. John J. Hall, Chairman, Subcommittee on Disability
Assistance and Memorial Affairs, Committee on Veterans'
Affairs, to Jonathan Samet, M.D., Chair, Committee on
Evaluation of the Presumptive Disability Decision-Making
Process for Veterans, Institute of Medicine, letter dated
February 29, 2008, and response letter dated March 18, 2008 124
Hon. John J. Hall, Chairman, Subcommittee on Disability
Assistance and Memorial Affairs, Committee on Veterans'
Affairs, to Joyce McMahon, Ph.D., Managing Director, Center
for Health Research and Policy, Center for Naval Analysis
Corporation, letter dated February 29, 2008, and Dr.
McMahon's responses........................................ 126
Hon. John J. Hall, Chairman, Subcommittee on Disability
Assistance and Memorial Affairs, Committee on Veterans'
Affairs, to Mark Hyman, M.D., American Academy of
Disability Evaluating Physicians, letter dated February 29,
2008, and Dr. Hyman's responses............................ 128
Hon. John J. Hall, Chairman, Subcommittee on Disability
Assistance and Memorial Affairs, Committee on Veterans'
Affairs, to Sidney Weissman, M.D., Committee on Mental
Healthcare for Veterans and Military Personnel, American
Psychiatric Association, letter dated February 29, 2008,
and response letter dated April 4, 2008.................... 130
Hon. John J. Hall, Chairman, Subcommittee on Disability
Assistance and Memorial Affairs, Committee on Veterans'
Affairs, to Ronald Abrams, Joint Executive Director,
National Veterans Legal Services Program, letter dated
February 29, 2008, and response letter dated March 24, 2008 132
Hon. John J. Hall, Chairman, Subcommittee on Disability
Assistance and Memorial Affairs, Committee on Veterans'
Affairs, to Dean Stoline, Assistant Director, National
Legislative Commission, American Legion, letter dated
February 29, 2008, and response letter dated March 20, 2008 135
Hon. John J. Hall, Chairman, Subcommittee on Disability
Assistance and Memorial Affairs, Committee on Veterans'
Affairs, to Bradley Mayes, Director, Compensation and
Pension Service, Veterans Benefits Administration, U.S.
Department of Veterans Affairs, letter dated February 29,
2008, and VA responses..................................... 136
Hon. John J. Hall, Chairman, Subcommittee on Disability
Assistance and Memorial Affairs, Committee on Veterans'
Affairs, to Major General Joseph Kelley, M.D., USAF (Ret.)
Deputy Assistant Secretary of Defense for Clinical and
Program Policy, U.S. Department of Defense, letter dated
February 29, 2008, and DoD responses....................... 138
THE U.S. DEPARTMENT OF VETERANS AFFAIRS
SCHEDULE FOR RATING DISABILITIES
----------
TUESDAY, FEBRUARY 26, 2008
U.S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Disability Assistance
and Memorial Affairs,
Washington, DC.
The Subcommittee met, pursuant to notice, at 2:02 p.m., in
Room 334, Cannon House Office Building, Hon. John J. Hall
(Chairman of the Subcommittee) presiding.
Present: Representatives Hall, Rodriguez, Lamborn, and
Bilirakis.
OPENING STATEMENT OF CHAIRMAN HALL
Mr. Hall. Good afternoon. The Committee on Veterans'
Affairs, Subcommittee Disability Assistance and Memorial
Affairs, hearing on the U.S. Department of Veterans Affairs
(VA) Schedule for Rating Disabilities will come to order.
Before I begin my opening statement, I would like to call
attention to the fact that the American Medical Association
(AMA) has asked to submit a written statement for the hearing
record. If there is no objection, I ask for unanimous consent
that this statement be entered for the record. Hearing no
objection, so entered.
[The statement of the American Medical Association appears
on p. 110.]
Mr. Hall. Could we all please rise for the Pledge of
Allegiance. Flags are at both ends of the room.
[Pledge of Allegiance.]
Thank you and thank you for being here. We will be
expecting Congressman Bilirakis at some point to be joining us.
Minority Counsel is here and we are going to proceed with his
agreement to go ahead and hope to get through as much of this
hearing as possible without putting it on autopilot.
This is the third hearing of the Subcommittee regarding the
VA's claims processing system. As we have discussed before,
this system has not lived up to expectations and has left many
disabled veterans without proper and timely compensation and
other benefits.
At the heart of this system is the VA Schedule for Rating
Disabilities or VASRD. The rating schedule as we know it today
is divided into 14 body systems, which incorporate
approximately 700 codes that describe illness or injury
symptoms and levels of severity. Ratings range from zero to 100
percent and are in increments of ten. This schedule was
uniquely developed for use by the VA, but the U.S. Department
of Defense (DoD) has also mandated its use when the service
branches conduct evaluation boards on servicemembers who are
unfit for duty. Otherwise, it is not used by any other
governmental agencies or private-sector disability plans.
In its study, the Veterans' Disability Benefits Commission
(VDBC) concluded that the VA rating schedule had not been
comprehensively updated since 1945. Although sections of it
have been modified, no overall review has been satisfactorily
conducted, leaving some parts of the schedule out of date,
relying on arcane medical practices, and not in sync with
modern disability concepts.
The notion of a rating schedule was first crafted in 1917,
so that returning World War I veterans would be cared for when
they could no longer function in their pre-war occupations.
At the same time, the American economy was primarily
agricultural based and labor intensive. Today's economy is
different and the effects of disability are understood to be
greater than the average loss of earning capacity.
Many disability specialists agree that quality of life,
functionality, and social adaptation are just as important.
Our Nation's disabled veterans deserve to have a system
that is based on the most available and relevant medical
knowledge.
There are several issues pertaining to the rating schedule
I hope to have us discuss today. First would be the need to
remove out-of-date and archaic criteria that are still part of
the schedule for some conditions and replace them with current
medical and psychiatric evaluation instruments for determining
and understanding disabilities.
The medical community relies on codes from the
International Classification of Disease (ICD) and the
Diagnostic and Statistical Manual of Mental Disorders (DSM).
Should the Veterans Benefit Administration (VBA) be relying on
these and other AMA Guides as well?
Individual Unemployability, IU, as a rating gives VA an
alternative means by which to compensate veterans who cannot
sustain gainful occupation, but might not otherwise be rated
100 percent.
The U.S. Government Accountability Office (GAO) found that
the use of IU was ineffective and inefficient since it relies
on old data, outdated criteria, and lacks guidance.
[See ``VA Benefits: Fundamental Changes to VA's Disability
Criteria Need Careful Consideration,'' GAO-03-1172T, Testimony
Before the Senate Committee on Veterans' Affairs, September 23,
2003, Statement of Cynthia A. Bascetta, Director, Education,
Work force, and Income Security Issues, U.S, General Accounting
Office, which appears on p. 114.]
The VDBC, Institute of Medicine (IOM), and the Center for
Naval Analyses (CNA) Corp., also studied IU and expressed their
concerns over how it is utilized instead of scheduled ratings.
I look forward to hearing from them today.
The criteria for psychiatric disabilities, especially for
post traumatic stress disorder or PTSD, are in dire need of
expansion. The current rating schedule has only one schedule
for all of mental health which is based on the Global
Assessment of Functioning scale, or GAF.
The IOM noted that one of the many problems with GAF is
that it was developed for schizophrenia, and therefore, not as
accurate for other disorders, and recommended that VA replace
it as a diagnostic tool. I am especially concerned about this
issue and how it pertains to PTSD and other mental disorders.
The VDBC also recommended that traumatic brain injury or
TBI, in case you have not had enough initials yet, be a
priority area of concentration, and for VA to improve the
neurological criteria for TBI, which has become one of the
signature injuries of this war.
I know there has been much discussion on how to compensate
veterans for their quality of life losses. Both the VDBC and
Dole-Shalala reports recommended that this be a new category
added to the rating schedule in some fashion, but they did not
necessarily agree or provide clear guidance on how to do this
or whether the current system does so implicitly. So next steps
are still needed.
Presumptions have had a major impact on VA compensation
over the last few decades for conditions related to ionizing
radiation, Agent Orange, and the Gulf War. The IOM, therefore,
engaged in a lengthy study for the VDBC on presumptions and
recommended that there be evidence-based criteria which could
impact the rating schedule.
I commend Secretary Peake for changing the regulation on
PTSD, but we might also want to add a presumption that combat-
zone service is a stressor when evaluating PTSD.
I look forward to the testimony today on these complex
rating schedule issues. I know there is a lot to be done to
improve the VA claims processing system. But with the rating
schedule at the core of the process, it seems that the
centerpiece is in need of immediate comprehensive repair, which
we intend to advocate.
I look forward to working with Ranking Member Lamborn and
the Members of the Subcommittee in providing oversight for the
VA's schedule for rating disabilities. The VA needs the right
tools to do the right thing so our Nation's disabled veterans
get the right assistance.
[The prepared statement of Chairman Hall appears on p. 53.]
Mr. Lamborn, our Ranking Member, was unable to be here.
Will he have a statement for the record?
Mr. Lawrence. Yes.
[The prepared statement of Congressman Lamborn appears on
p. 54.]
Mr. Hall. It will be made a part of the record. Whenever
Mr. Bilirakis arrives, then he will be afforded the chance to
make an opening statement and also to ask questions.
I would like to first of all welcome our panels, all of our
panelists today, and to remind you that your complete written
statements have been made part of the hearing record.
Please limit your remarks so that we can have sufficient
time to followup with questions once everyone has had the
opportunity to provide their testimony.
Joining us on our first panel is Vice Admiral Dennis
Vincent McGinn, Member of the Veterans' Disability Benefits
Commission.
Admiral McGinn, I first want to express my deepest
sympathies to you, the rest of the Commission, and its staff on
the passing of Commissioner Butch Joeckel. Butch was a true
American hero, a great Marine, and a veterans' advocate to the
end, who understood all too well why we are here today trying
to improve the qualify of life for our disabled veterans.
I understand that Butch was known for saying, ``You just
have to do the right thing.'' And I think it is apropos that we
keep that spirit in mind as we move forward on improving the VA
claims processing system.
We also welcome Dr. Lonnie Bristow, Chair of the Committee
on Medical Evaluation of Veterans for Disability Benefits for
the Institute of Medicine; Dr. Dean Kilpatrick, Member of the
Committee on Veterans' Compensation for Post Traumatic Stress
Disorder for the Institute of Medicine; Dr. Jonathan Samet--is
that the correct pronunciation?
Dr. Samet. Samet.
Mr. Hall. Samet. Thank you. Dr. Jonathan Samet, Chair of
the Committee on Evaluation of Presumptive Disability,
Decision-Making Process for Veterans for the Institute of
Medicine; and Dr. Joyce McMahon from the Center for Health
Research and Policy of the CNA Corp.. Thank you all for joining
us.
And, Admiral McGinn, you are now recognized for 5 minutes.
STATEMENTS OF VICE ADMIRAL DENNIS VINCENT MCGINN, USN (RET.),
MEMBER, VETERANS' DISABILITY BENEFITS COMMISSION, ON BEHALF OF
LIEUTENANT GENERAL JAMES TERRY SCOTT, USA (RET.), CHAIRMAN;
LONNIE BRISTOW, M.D., CHAIR, COMMITTEE ON MEDICAL EVALUATION OF
VETERANS FOR DISABILITY BENEFITS, BOARD ON MILITARY AND
VETERANS HEALTH, INSTITUTE OF MEDICINE, THE NATIONAL ACADEMIES;
DEAN G. KILPATRICK, PH.D., MEMBER, COMMITTEE ON VETERANS'
COMPENSATION FOR POSTTRAUMATIC STRESS DISORDER, INSTITUTE OF
MEDICINE, THE NATIONAL ACADEMIES, AND DISTINGUISHED UNIVERSITY
PROFESSOR AND DIRECTOR, NATIONAL CRIME VICTIMS RESEARCH AND
TREATMENT CENTER, MEDICAL UNIVERSITY OF SOUTH CAROLINA,
CHARLESTON, SC; JONATHAN M. SAMET, M.D., M.S., CHAIRMAN,
COMMITTEE ON EVALUATION OF THE PRESUMPTIVE DISABILITY,
DECISION-MAKING PROCESS FOR VETERANS, BOARD ON MILITARY AND
VETERANS AFFAIRS, INSTITUTE OF MEDICINE, THE NATIONAL
ACADEMIES, AND, PROFESSOR AND CHAIRMAN, DEPARTMENT OF
EPIDEMIOLOGY, JOHNS HOPKINS BLOOMBERG SCHOOL OF PUBLIC HEALTH,
JOHNS HOPKINS UNIVERSITY, BALTIMORE, MD; AND JOYCE MCMAHON,
PH.D., MANAGING DIRECTOR, CENTER FOR HEALTH RESEARCH AND
POLICY, CENTER FOR NAVAL ANALYSES (CNA) CORPORATION,
ALEXANDRIA, VA
STATEMENT OF VICE ADMIRAL DENNIS VINCENT MCGINN, USN (RET.)
Admiral McGinn. Thank you, Mr. Chairman and Members of the
Committee. I am pleased to appear before you today on behalf of
the Chairman of the Veterans' Disability Benefits Commission,
General Terry Scott, to discuss the findings, conclusions, and
recommendations of the Commission related to revising the VA
rating schedule.
The Commission was tasked to examine and make
recommendations concerning the appropriateness of benefits, the
appropriateness of the level of benefits, and appropriate
standards for determining whether a disability or death of a
veteran should be compensated. We completed our work and
submitted our report on the 3rd of October 2007.
Mr. Chairman, I appreciate your comments concerning
Commissioner Joeckel. You may note that we dedicated our report
to him and he was the conscience of our Commission and a
continuous reminder of the tremendous debt our Nation owes to
disabled veterans.
For almost 2\1/2\ years, the Commission conducted an
extensive and comprehensive examination of issues related to
veterans' disability benefits. This was the first time that the
subject had been studied in depth by an independent body since
the Bradley Commission in 1956.
We identified 31 key issues for study and made every effort
to ensure that our analysis was evidence based and data driven.
And we engaged two well-known organizations to provide medical
expertise and analysis. First the Institute of Medicine of the
National Academies and the CNA Corporation. Both of those
organizations are represented today in this panel.
Of the many issues the Commission examined, one of the most
important was determining the effectiveness of the VA rating
schedule.
You will be hearing from four panels today, including to my
left Drs. Bristow, Kilpatrick, Samet representing their IOM
Committees, and Dr. McMahon from CNA, independent experts,
Veteran Service Organizations, and later Admiral Dan Cooper and
Mr. Mayes representing the Department of Veterans Affairs.
I will keep my remarks brief and focus on the conclusions
and recommendations of our Commission related to the rating
schedule.
Our Commission is most appreciative of the outstanding work
of the IOM Committees and CNA. We believe that their efforts
were exceptionally complementary of each other and that the
results were remarkably consistent.
The Commission's report summarizes the analysis and
recommendations of CNA and the IOM Committees in some detail.
However, the reports to the Commission are rich in detail with
extensive analysis and each should be carefully reviewed by the
Committee.
I would like to highlight a few of their key findings that
our Commission found especially helpful. For example, Dr.
Bristow's Committee emphasized that the rating schedule should
achieve horizontal and vertical equity.
Vertical equity means that the VA ratings of severity of
disability assigned in 10 percent increments from zero to 100
percent should be accurately assigned so that those assigned
more severe ratings should be those veterans whose disabilities
impact their earnings more than those assigned less severe
ratings.
CNA's comparison of the earnings of veterans who are not
service disabled with service-disabled veterans demonstrated
that disability causes lower earnings in employment at all
levels of severity and types of disabilities and that the
earnings loss of the disabled veteran increases as the percent
rating increases. Thus, VA ratings using the rating schedule
are generally achieving vertical equity.
Horizontal equity means that assigning ratings of severity
should reflect average loss of earnings among the nearly 800
diagnostic codes and across the 16 body systems. CNA's analysis
generally confirmed horizontal equity as well. Overall, their
analysis confirmed that the VA rating schedule and VA's
assignment of ratings using the rating schedule results in
compensation paid to veterans that is generally adequate to
offset average impairment of earnings.
Taken as a whole, the rating schedule is doing its job
reasonably well. The detailed and comprehensive analysis
demonstrated that even veterans with less severe ratings do, in
fact, have loss of earnings.
However, the key word in the aforementioned paragraph is
generally. The CNA analysis also identified very pronounced
disparities for some veteran cohorts in which vertical and
horizontal equity are not being achieved.
The amount of compensation is not sufficient to offset loss
of earnings for three specific groups of veterans, those whose
primary disability is post traumatic stress disorder, PTSD, or
other mental disorders, those who are severely disabled at a
young age, and those who are granted maximum benefits because
their disabilities make them unemployable.
For these veteran groups, horizontal and vertical equity is
not being achieved. Those severely disabled at a young age have
greater loss of earning, especially over their remaining lives
since they did not have established civilian careers or
transferable job skills and have more of the normal working
years ahead of them.
The analysis also clearly demonstrates that veterans with
PTSD and other mental disorders experience much greater loss of
employment and earnings than those with physical disabilities,
particularly those more severely disabled.
These disparities should be addressed by a careful but
prompt revision to the rating schedule leading to a more
equitable level of payment to disabled veterans in the severely
disabled category.
Concerning PTSD and mental disorders, the reasons for
insufficient compensation may lie partly in the criteria in the
rating schedule itself and partly in how the VA raters
interpret or apply the criteria.
The rating schedule was revised a few years ago to
eliminate separate criteria for diagnoses such as PTSD and in
order to have a single set of criteria for all 67 diagnoses
contained in the body system known as mental disorders.
The Commission asked the IOM to provide advice as to
whether a single set of criteria is effective. IOM recommended
that separate criteria should be established for PTSD and CNA's
survey of VA raters and VSO service officers found agreement
with that advice.
Concerning the interpretation of the criteria by raters,
the Commission learned that almost \1/2\ of 223,000 veterans
granted individual unemployability or IU as being unable to
work due to their service-connected disabilities had a primary
diagnosis of PTSD, that would constitute 31 percent, or other
mental disorders, 16 percent.
To be granted IU, the veteran must be rated at 60 to 90
percent disabled and also be found unable to work due to the
service-connected disability.
Mr. Hall. Excuse me, Admiral.
Admiral McGinn. Yes.
Mr. Hall. I am sorry. Could you summarize, please?
Admiral McGinn. I certainly will. Yes, sir.
Our Commission concluded that there has been an implied but
unstated congressional intent to compensate disabled veterans
for impairment to quality to life due to their service-
connected disabilities. And this is a key area that the
Committee can make a real difference.
I would also like to point out before I make my concluding
remarks that since the reports of the IOM that indicated the
need to update the rating schedule, there has been very, very
limited progress by the VA. And this should be looked at both
in terms of what is the sense of urgency and other adequate
resources available to do this rating schedule update as a
matter of priority.
As I reflected in my written statement and partially in the
oral statement I have just made, only by keeping the rating
schedule current with the best up-to-date medical knowledge and
by adjusting the payment levels to offset both loss of earnings
and quality of life can we be assured that disabled veterans
and their families are adequately compensated.
This was the clear consensus of our Commission. The
specific recommendations in our report should be used to guide
needed legislative actions by Congress as well as the policy
and resource allocations by the departments and agencies needed
to update and improve disabled veterans' benefits.
Mr. Chairman, I would be glad to answer any questions the
Committee may have.
[The prepared statement of Admiral McGinn appears on p.
54.]
Mr. Hall. Thank you, Admiral.
And next, Dr. Bristow, you are recognized for 5 minutes.
STATEMENT OF LONNIE BRISTOW, M.D.
Dr. Bristow. Thank you. Good afternoon, Chairman Hall and
Ranking Member Lamborn and Members of the Committee.
My name is Lonnie Bristow. I am a physician and I have
served as the President of the American Medical Association.
And I am joined this day on this panel by Drs. Dean Kilpatrick
and Jonathan Samet who will introduce themselves shortly.
But on their behalf, we want to thank you for the
opportunity to testify about the work of our Institute of
Medicine Committees, our three Committees from the IOM.
My task today is to present to you the recommendations of
the IOM Committee, which I chair, which was asked to evaluate
the VA's schedule for rating disabilities and related matters.
Dr. Kilpatrick will follow me to speak about his
Committee's work which focused on post traumatic stress
disorder, a particular challenge for the VA to evaluate. And
Dr. Samet will conclude our panel's presentation from the IOM
by briefing you on the findings of his Committee which was
asked to offer its perspective on the scientific considerations
underlying the question of whether a health outcome should be
presumed to be connected to military service.
We submitted testimony, written testimony for the record
and we will summarize our presentations here. I only have a few
minutes, so let me quickly list our key findings and
recommendations concerning the VA rating schedule. And I will
be glad to go into more detail about any of them during the
question period.
Our Committee found that the statutory purpose of
disability compensation which is to compensate for an average
loss of earning capacity is, in fact, an unduly restrictive
rationale for the program and it is inconsistent with the
current modern models of disability.
The Committee recommends that the VA compensate for three
consequences of service-connected injuries and diseases. First,
for work disability which it currently does. And, second,
however, for loss of ability to engage in usual life activities
other than work, what disability experts today call functional
limitations. And, third, for loss in quality of life.
Concerning the rating schedule, the Committee found that
the schedule is not as current medically as it could be or
should be. The relationship of the rating levels to average
loss of earning capacity is not known at the time of our
evaluation. The schedule does not evaluate impact on a
veteran's ability to function in every-day life and the
schedule does not evaluate for loss in quality of life.
The Committee, therefore, recommends that VA immediately
update the current rating schedule medically beginning with
those body systems that have gone the longest without a
comprehensive update and adopt a system for keeping that
schedule up to date medically.
Second, establish an external Disability Advisory Committee
to provide advice during the updating process.
And, third, as a part of updating the schedule, we
recommend moving to the ICD and DSM diagnostic classification
systems.
Fourth, we recommend investigating the relationship between
the ratings and actual earnings to see the extent to which the
rating schedule is compensating for loss of earnings on average
and make adjustments in the rating criteria to reduce any
disparities that are found.
Fifth, compensate for functional limitations on usual life
activities to the extent that the rating schedule does not.
And, sixth, develop a method of measuring loss of quality
of life and where the schedule does not adequately compensate
for it, VA should adopt a method for doing so.
The Committee also reviewed individual unemployability or
IU and our main finding concerning IU is that it is not
something that can be determined on medical grounds alone.
Therefore, the Committee recommends that the VA conduct
vocational assessments as well as medical evaluations whenever
they are determining IU eligibility.
This concludes my remarks. And I want to thank you again
for the opportunity to testify, and I will be happy to address
any questions you might have about our report.
[The prepared statement of Dr. Bristow appears on p. 58.]
Mr. Hall. Thank you, Doctor.
And as you heard, the bell buzzer was sounding indicating
that votes have been called. So I am going to have to ask you
to be patient once again, and this Subcommittee will be in
recess until this stack of votes are over.
[Recess.]
Mr. Hall. The Subcommittee is called back to order. And we
apologize for the delay. You will be happy to know our
legislative business is over for this afternoon, so we will be
able to continue uninterrupted.
Dr. Kilpatrick, your written statement is in the record.
You are now recognized for 5 minutes, please.
STATEMENT OF DEAN G. KILPATRICK, PH.D.
Mr. Kilpatrick. Thank you very much, and I appreciate the
opportunity to testify on behalf of the Committee on Veterans'
Compensation for PTSD.
Last June, our Committee completed its report entitled
``PTSD Compensation and Military Service,'' which addresses
several potential revisions to the schedule for rating
disabilities in the context of a larger review of how the VA
administers its PTSD compensation program. Our Committee's
review of the scientific literature led it to draw the
following conclusions:
First, there are two primary steps in the VA's disability
compensation process. The first of these is a compensation and
pension or C&P exam.
Testimony presented to our Committee indicated that
clinicians often feel pressured to limit the time they devote
to conducting a PTSD C&P exam, sometimes to as little as 20
minutes, even though the protocol suggested in a best practice
manual developed by the VA National Center for PTSD can take 3
hours or more to complete.
Our Committee felt very strongly that the key to a proper
administration of the VA's PTSD compensation program is a
thorough C&P clinical examination conducted by experienced
mental health professionals. Many of the issues that arise
could be dealt with nicely if the resources needed for a
thorough examination were provided.
The Committee also recommended that a system-wide training
program be implemented for the clinicians who conduct these
exams in order to promote uniformity and consistent
evaluations.
The second step in the VA compensation process is rating
the level of disability associated with service-connected
disorders. This rating is performed by a VA employee using
information gathered in the C&P exam and the criteria set forth
in the schedule for rating disabilities.
Currently the same set of criteria are used for rating all
mental disorders and they primarily focus on symptoms from
schizophrenia, mood and anxiety disorders.
The Committee found that these criteria are, at very best,
a crude and it is an overly general instrument for the
assessment of PTSD disability. We recommend that the new
criteria be developed and applied that specifically address
PTSD symptoms and that are firmly grounded in the standards set
out in the DSM used by mental health professionals.
A third point is that our Committee suggested that the VA
take a broader and more comprehensive view of what constitutes
disability for PTSD. There is a special emphasis and some might
say a total emphasis on occupational impairment in the current
criteria that unduly penalizes veterans who may be capable of
working but who are significantly symptomatic or impaired in
other dimensions and, thus, the current system may serve as a
disincentive to both work and recovery.
Under this framework, the psychosocial and occupational
aspects of functional impairment would be separately evaluated
and the claimant would be rated on the dimension upon which he
or she is more affected.
In order to promote more accurate, consistent, and uniform
PTSD disability ratings, the Committee recommended that the VA
establish a specific certification program for raters who deal
with PTSD claims and to have training along with that as well.
Finally, at the VA's request, the Committee addressed
whether it would be advisable to establish a set schedule for
reexamining veterans receiving compensation for PTSD. The
Committee concluded that this was not appropriate to require
across-the-board, periodic reexaminations and instead
recommended that it be done on a case-by-case basis when there
is some reason to believe that maybe the disability status had
changed.
Our reasoning for that was that the resources that the VA
has are finite and they would be better spent focusing on doing
a really first-class and timely initial evaluation than
diverting the resources to do periodic rereviews.
The second point about that is that if only PTSD is singled
out, it says to the veteran that there is something suspect
about this so that we have to reexamine you over and over
again. And we did not find any data that suggests that there
was a need for that.
I realize that there has been some differences of opinion
between various committees about the extent to which
reexamination should happen and I think honest people could
disagree on that. And we would just urge that, you know, the
Congress as well as that the VA, consider carefully the merits
of each of those approaches.
And, finally, I really would say, and this is my opinion,
but I think it is consistent with what our Committee thought,
that if we are going to do periodic PTSD reexaminations and we
are going to implement that, we should not do so until there
are adequate resources to ensure that every veteran gets a
first-rate initial C&P exam that is done in a timely fashion.
We have several other recommendations in our report. I
understand that each of you have that, and so I would be happy
to answer any questions when the time comes.
[The prepared statement of Mr. Kilpatrick appears on p.
66.]
Mr. Hall. Thank you, Doctor.
Dr. Samet, you are now recognized for 5 minutes.
STATEMENT OF JONATHAN M. SAMET, M.D., M.S.
Dr. Samet. Thank you. Good afternoon. I am pleased to speak
with you today on behalf of our 16-member Committee about the
report, improving the presumptive disability, decisionmaking
process for veterans. You have the report and we have also made
the executive summary available.
We were charged with describing the current process for how
presumptive decisions are made for veterans and with proposing
the scientific framework for making such presumptive decisions
in the future.
As you know, presumptions are made in order to reach
decisions in the face of unavailable or incomplete information.
And presumptions have been made since 1921 around matters of
exposure and causation.
To address our charge, we met with the full range of
involved stakeholders. We completed a series of ten in-depth
case studies to look at lessons learned from past presumptions.
We also looked at how information is obtained on the health of
the veterans and how exposures during military service are
evaluated and potentially linkable to health events in the
future. We also looked at how scientists synthesize information
to judge what is known about association and causation.
To the first part of our charge, the present approach to
presumptive disability, decisionmaking largely flows from the
``Agent Orange Act of 1991.'' In that law, Congress asked the
VA to contract with an independent organization to review
scientific evidence for Agent Orange, that organization being
the Institute of Medicine.
The Institute of Medicine provides its reports to the VA
which then acts with its own internal decisionmaking process to
determine if a presumption is to be made.
Our case studies pointed to a number of difficulties in
this current approach that need to be addressed in any future
approach, lack of information on exposures received by military
personnel, insufficient surveillance of veterans for service-
related illness, gaps in information because of secrecy,
varying approaches to bringing information together, and
variation in classification of evidence in different
presumptions sometimes around association and sometimes around
causation, and a general lack of transparency of aspects of the
process.
We proposed a new approach that we feel will address these
deficiencies when implemented. We call for an approach that is
outlined in the figure attached to my testimony. Elements of
this approach include an open process for nominating exposures
and health conditions for review involving all stakeholders who
are interested in the outcome of the presumptive disability,
decisionmaking process.
We recommend a revised process for evaluating scientific
information on whether a given exposure causes a health
condition in veterans. We offer a new set of categories to
assess the strength of evidence for causation and propose that
in a second step of the scientific evaluation of the evidence,
an estimate be made of the numbers of exposed veterans who are
at risk from the exposure.
We call for a consistent and transparent decisionmaking
process by the VA and a system for tracking the exposures of
military personnel and for monitoring health conditions while
in service and after separation and an organizational structure
to support this process.
Two elements of the organizational process include creating
two panels. One we called the Advisory Committee would be
advisory to the VA. This Committee would monitor information as
it comes in on the exposures and health of veterans. It would
assess nominations made for consideration for presumptions and
give recommendations to the VA.
The second panel would be a Science Review Board, an
independent body that would evaluate the evidence, the strength
of the evidence, and do the quantitative estimations if
appropriate. The recommendations of this group would go to the
VA as well.
We propose a set of principles, including stakeholder
inclusiveness, evidence-based decisions, a transparent process,
flexibility and consistency, and, finally, use of causation and
not just association as the target for decisionmaking.
We offer a set of categories around how certain the
evidence is for causation and suggest that for the purpose of
causation that the benefit always goes to the veterans and that
the evidence should be at least 50 percent or more pointing
toward causation for making presumptive decisionmaking.
This implementation of this approach will call for action
by Congress. Legislation would be needed to create the two
panels and the resources would be needed to create and sustain
exposure and health tracking for service personnel and
veterans.
Elements of this system we recommend could be implemented
at present even as steps are taken to move the DoD and VA
toward implementing the full model.
Thank you.
[The prepared statement of Dr. Samet appears on p. 71.]
Mr. Hall. Thank you, Doctor.
Dr. McMahon, you are now recognized.
STATEMENT OF JOYCE MCMAHON, PH.D.
Ms. McMahon. Thank you. Chairman Hall, Representative
Lamborn, and distinguished Members, I appreciate the
opportunity to testify before the House Subcommittee on
Disability Assistance and Memorial Affairs of the House
Committee on Veterans' Affairs today on the subject of revising
the VA schedule for rating disabilities.
This testimony is based on the findings reported in the CNA
final report for the Veterans' Disability Benefits Commission.
We were asked to provide analysis to the Commission
regarding the appropriateness of the current benefits program
for compensating for loss of average earnings and degradation
of quality of life resulting from service-connected
disabilities for veterans.
Pertinent to today's topic is that we were asked to examine
the evidence regarding the individual unemployability rating,
to evaluate the quality of life findings for disabled veterans,
and to conduct surveys of raters and Veterans Service Officers
with regard to how they perceive the process of rating claims
and assisting applicants.
Our primary task was to focus on how well the VA
compensation benefits served to replace the average loss in
earnings capacity for service-disabled veterans. We defined
subgroups of disabled veterans by body system of the primary
disability and on the total combined disability rating in four
groups, 10 percent, 20 to 40 percent, 50 to 90 percent, and 100
percent disabled.
Within this, we further stratified the 50--to 90-percent
disabled group into those with and without individual
unemployability status.
Our overall finding is that for male veterans, there is
general parity overall at the average age of entry. When we
looked at various subgroups, we found some differences as has
been mentioned before. In particular, those with a primary
mental disability have lower earnings ratios than those with a
primary physical disability and many of the rating subgroups
for those with a primary mental disability had earnings rates
below parity. In addition, entry at a young age with severe
disability is associated with below parity earnings ratios.
We were asked to look at veterans' quality of life
degradation, and we did this by conducting a survey using
health-related questions taken from a standardized bank of
questions used to survey the general population. This allowed
us to compare results for service-disabled veterans to widely
used population norms.
We found that as the degree of disability increased,
generally overall health declined, and that there were
differences between those with physical and mental primary
disabilities. Physical disability led to lower physical health,
but in general did not lead to lowered mental health except for
the most severely disabled.
On the other hand, mental disability led not only to lower
mental health scores but was also associated with lower
physical health in general. For those with a primary mental
disability, physical scores were well below the population
norms for all rating groups and lowest for those with PTSD.
In general, we did not find that there were any implicit
quality of life payments being made to the disabled veteran
population since most veterans were at parity with the
exception of the subgroups we have mentioned. Overall, there is
no quality of life payment implicitly being provided by the
current compensation schedule.
There are groups that are below parity and these would
include those entering as severely disabled veterans at a young
age and, in particular, those with a mental primary disability.
Since these people are below parity, that implies a negative
implicit quality of life payment for these groups. However, it
is worth noting that in general the loss of quality of life
appears to be the greatest for those with a mental primary
disability.
Turning to the survey of raters and Veterans Service
Officers that we conducted, I will make a few points quickly.
Many raters indicated that the criteria for IU are too broad
and that more specific decision criteria or evidence regarding
IU would be helpful in deciding IU claims.
They reported that claims are becoming more complex, that
mental claims are harder to evaluate than physical claims, and
that they would appreciate more specific criteria to help them
resolve mental health issues, especially PTSD.
Turning to IU, we were asked specifically to look at this
in the context of the system and how it works. We have a figure
that 8 percent of those receiving VA disability compensation
have IU, but 31 percent of those with PTSD as their primary
diagnosis have IU status. This may indicate that the rating
schedule does not work well for PTSD.
We were asked to comment on the rapid growth in the number
of disabled veterans categorized as IU from 2000 to 2005. The
data suggests that the vast majority of the increase in the IU
population is explained by demographic changes, specifically
the aging of the Vietnam cohort.
We also looked at mortality rates to determine if there
were clinical differences for those with IU, and we found that
those with IU status have higher mortality rates than those who
were rated 50 to 90 percent disabled without IU. IU mortality
rates were, however, less than was observed for those who are
100 percent disabled.
Finally, we would make a couple of comments about rating
system implications. If the purpose of the IU designation is
primarily related to employment, there could be a maximum
eligibility age reflecting typical retirement patterns. But if
it is to correct for rating schedule deficiencies, an option
might be to simply correct the rating schedule so that fewer
disabled veterans would need to be classified as IU.
In particular, I do not think you will ever find that you
can get away from the rating system using an IU designation
completely, but you might well be able to limit the number of
veterans who receive this designation each year by changing the
schedule or considering other options such as a greater use of
retraining programs.
Thank you.
[The prepared statement of Ms. McMahon appears on p. 75.]
Mr. Hall. Thank you, Doctor.
Thank you to all of our panelists.
At this time, I want to acknowledge Congressman Rodriguez
and Congressman Bilirakis who have joined us.
I will ask a few questions first. Admiral McGinn, as a
Member of the Commission and participant in its deliberations,
what is your sense of the priority of revising the rating
schedule from the perspective of the veteran? In other words,
what do veterans need most?
Admiral McGinn. I think the comments by some of my
colleagues at the panel here reflected the priority that should
be placed on PTSD, TBI or traumatic brain injury, and other
mental conditions as areas in which the VA should start their
review of the rating schedule. Those are all very, very
compelling in terms of numbers and the effects it has on
veterans and their families. And from a veteran's perspective,
that is a good place to start.
That said, the entire rating schedule should be approached,
and updated with a much greater sense of urgency. And if that
requires more resources, those should be applied.
Thank you, sir.
Mr. Hall. In your testimony, you called for VA's response
to be urgent and expedient, but then pointed out that this has
never been the case with the VA's reaction to recommendations
such as those made by Omar Bradley's Commission in 1956.
So if we want this done now, what is the best way for
Congress to ensure your call to action?
Admiral McGinn. I know we made a recommendation in our
report on establishing an oversight group comprised of DoD and
the VA to track the progress of the various recommendations
that we made.
I will say that given the fact that we are at war, we are
seeing terribly injured veterans come back and into the system,
tremendous effect on their families, and various spotlights
have been put on how we treat those veterans.
The VA and DoD, for example, have made tremendous progress,
more in the past couple of months, 6 months say, than in the
previous 10 years on addressing the so-called seamless
transition from uniform member to disabled veteran.
I think that same type of focus needs to be applied in
updating the rating schedule and we will see the results that
we need.
Mr. Hall. And would you consider the 25-percent quality of
life payment as recommended by the Commission sufficient to
correct the horizontal and vertical equity issues described by
CNA? Should the maximum payment of 25 percent only pertain to
the most severely disabled or for the three groups you
described as below parity?
Admiral McGinn. I think that horizontal and vertical equity
issues should be dealt with separately than quality of life.
And quality of life should be applied as we are developing
standards for measuring quality of life or decrement to quality
of life and what appropriate compensation should be.
I think that immediately those veterans who are most
severely disabled should benefit first from a quality of life
increase.
Mr. Hall. Thank you.
Dr. Bristow, could the rating schedule be simplified and
still be an effective tool for VA to use in compensating
veterans?
Dr. Bristow. That is a very difficult question, Mr.
Chairman. I believe the rating system needs to be clarified. I
am not sure if simplified is the term that I would use. But I
think it certainly needs to be clarified so that it has logic.
It currently fails to have the sort of logic, at least from
the point of view or from the perspective of medicine or
science, that it should have and can have. It has a lack of
logic because it has not progressed during the last five
decades at the rate that it should have. In some areas, it has
been abysmally behind the times. Others, there have been fitful
starts in an effort to become more modernized. But its problem
is a lack of being up to date rather than being too complex.
Mr. Hall. Do you agree with the Commission's recommendation
to begin with mental health, specifically PTSD and TBI?
Dr. Bristow. Yes, sir, although my Committee recommended
that the updating take place approaching those particular
systems that have had the longest lag of inattention.
This actually dovetails with the Commission's
recommendation, particularly if you look at traumatic brain
injury, which is a part of the neurological system, which would
be one of the first systems that needs to be upgraded.
The addition of PTSD that the Commission is recommending
for early and urgent attention, I think, is based on pragmatism
and it makes eminently good sense. And I am quite certain that
no one on my Committee would disagree or dispute or find fault
with that.
Mr. Hall. Thank you.
In a hearing last month, Dr. Randy Miller from Vanderbilt
University testified that the rating schedule was too vague and
ambiguous. He suggested that if it had better definitions and
clear-cut key words, it could be automated.
What is your opinion on these observations and would you
advocate for the automating of the rating schedule using
software, artificial intelligence, et cetera?
Dr. Bristow. I think it is key that the rating system begin
to use as rapidly as can be accomplished DSM and ICD codes. The
reason is because that would bring the greatest clarity to what
the medical condition or surgical condition is of a particular
individual. And clarity is essential if you are going to do any
sort of epidemiologic approach to a given population.
The rating system currently has been using only 700 plus
codes and whenever a condition does not fit a particular code,
the raters are encouraged or advised that they should use an
analogous code. That is a matter of administrative convenience.
But when one attempts to look back and decide what is going on
with a given population of diseases or injuries, there is a
mishmash that has been created in that fashion.
And so it is important that although the ICD codes are far
more numerous, parenthetically, we are talking about an
alternative with the potential use, the use of potentially
anywhere from 14 to 17,000 different codes as opposed to 700
plus, they would bring a great deal more clarity and make the
information that the VA is collecting much more useful in terms
of how to allocate resources, in terms of how to develop
programs, and provide the sort of the services that the entire
Nation wishes our veterans to have.
Mr. Hall. Thank you.
And my 7 minutes have just gone flying by.
Congressman Rodriguez.
Mr. Bilirakis. I have one question.
Mr. Hall. Mr. Bilirakis.
Mr. Bilirakis. One question. Thank you.
Dr. McMahon, how might the VA adjust the rating schedule so
that it more accurately reflects the consequences of PTSD?
Ms. McMahon. Well, I am not a clinical expert. We approach
this at CNA from a point of analysis of what the rating
schedule showed. I would say that the information with regard
to individual unemployability suggested that there was an
inability to rate the person in terms of the fullness of the
disability. In other words, many people were unable to work and
were granted individual unemployability who did have PTSD.
One way to address that would be to rate them at a higher
rating for PTSD instead of at their current rating level. So
part of it may be a systematic rating that does not properly
assess the degree of disability associated with PTSD. But that
gets into some more clinical issues which I do not really feel
I should address. The IOM is more appropriate for that.
We certainly could see, however, that, overall, the
earnings capability of those people who had a primary
disability of mental disability or PTSD was much lower than for
someone who had a physical disability. There was a sharp
discrepancy between physical disability and mental disability
in terms of how people fared.
This was true with regard to earnings and it was also true
with quality of life. Those with mental primary disabilities
tended to earn less than people with a physical disability at
the same rating level, and they tended to have a lower quality
of life when you compared both their mental and physical
quality of life in the scales that we calculated.
The story becomes consistent that they do not earn as much
and they have a lower quality of life. I think that could be
reflected in terms of how the schedules are applied. But the
actual clinical way in which that could be done, I am not
prepared to answer.
Mr. Bilirakis. Thank you.
Mr. Hall. Mr. Rodriguez.
Mr. Rodriguez. Yes. Thank you very much.
Dr. Kilpatrick or maybe anyone else that might know, what
are your thoughts on the possibility of delayed onset of PTSD
and how would the Department of Veteran Affairs detect where we
have missed that.
I am referring to as they arrive, the importance of picking
up on them as quickly as possible, but then--and this is an
additional question, how do we distinguish between those
veterans that have been out there maybe from Vietnam and the
duration of PTSD and the onset? Have we been able to come to
grips with that?
Mr. Kilpatrick. Yes. In fact, our Committee report
addresses that at some length. And a CliffsNotes version of
what we found was that basically there is ample evidence that
you can get delayed responses of PTSD.
And that can occur for a number of reasons, one of which is
it may be that people are symptomatic and they have been
symptomatic for a long period of time and all of a sudden, it
gets to a threshold where they recognize that there is a
problem or more commonly a family member or a co-worker or
somebody like that recognizes that they have a problem, brings
them to the attention of mental health professionals and
whatnot, and then they get diagnosed.
The other aspect of what you are saying is that there is a
strong belief on the part of many servicemembers when they get
out that they will be fine when they go back home. In other
words: ``I have been in a dangerous war zone situation. All I
need is to get back to my family and to my civilian life and I
will be fine.''
In many cases, it turns out that not to be the case, so
that it takes a while for them to understand that this is not
going away. It is here and maybe I need to do something about
it.
For mental health, PTSD specifically, but also with a lot
of mental disorders, there are ample epidemiological data
suggesting that probably the majority of people who have PTSD
or mental health problems do not seek treatment out for some of
these reasons. There is still a lot of stigma.
In fact, you know, my previous testimony about why we did
not want to have a reexam mandated was that if it is just for
PTSD and not for anything else, it is telling people with PTSD
that you have a suspect condition here and we are concerned
that might, in fact, deter people from being willing to come
forward for treatment.
Mr. Rodriguez. Do we know a little bit in terms of the
condition because I know and I have given the example of
schizophrenia where the worse the person acts as the prognosis,
they are better for prognosis because they are reacting to
their illness? Do we have any indication that post traumatic
stress works in the same way, that those where the onset is
very slow, their prognosis may be less? Or are we still
researching that? Where their prognosis is more evident
initially, do we have any information in that?
Mr. Kilpatrick. Well, I think that is a complicated
question and so I will give you a somewhat complicated answer,
not too complicated, I hope.
But the thing is is that some people if they are just
totally unable to function, in other words, if they are, you
know, very, very, very disturbed very soon afterward and it
comes to other people's attention, they are more likely to have
a severe case perhaps.
But the number of people who basically may have
subthreshold PTSD or who may actually meet all the diagnostic
criteria, but they keep it to themselves, I would suggest the
Ken Burns movie that came out on PBS fairly recently in which
one of the most moving things to me was seeing these World War
II veterans, many of whom had functioned incredibly well for 50
or 60 years and who now are tearing up.
And, you know, military people do not tear up very much.
That is not what they are supposed to do. And these people had
functioned very well throughout life, but it had taken a toll
to the point that they still had a great deal of difficulty
talking about things.
So that I think there are two groups that we are talking
about. One group is people that you can see what is going on
and it is obvious that they are very disturbed. There is
another group that may through their force of will and their
character and everything else be striving to work and striving
to have relationships, but who are still, it has taken a toll
on them and, you know, it takes a while for it to become
obvious to everybody else.
Mr. Rodriguez. And I know, if I can followup with another
question, I know psychiatrists that will tell you that there is
a clear distinction. But have we been able to get a clear
distinction between the people that have been diagnosed with
personality disorders versus having post traumatic stress
disorders?
Mr. Kilpatrick. There are people who have PTSD who can have
personality changes, but I would argue that someone who is a
competent mental health professional who knows something about
PTSD would not make the mistake of diagnosing somebody as
having a personality disorder when, in fact, it is an outcome
of PTSD.
For example, one of the symptoms of PTSD is, you know,
maybe angry outbursts and things like that. So if you are still
in the military and you are telling, you know, your superior
officers to do something or you are getting in fights and maybe
you are drinking a lot to try to cope maladaptively with some
of the PTSD symptoms, that may look a little like a personality
disorder. But anybody who knows something about PTSD and knows
how to assess people should not make the mistake of saying this
is primarily a personality disorder versus this is PTSD.
Mr. Rodriguez. Yes. I was bringing that up because I know,
I think it was DoD that had identified some 20,000 soldiers
with personality disorders. And that makes a big difference in
terms of benefits for one when it comes to the VA.
If on the personality disorders, if they are picked up and
allowed to participate in the military with a personality
disorder, you would think that that trait would come up pretty
quickly. At what point do you think that personality disorder
reveals itself as such and not as PTSD?
Mr. Kilpatrick. Well, I would say that most people think
that most personality disorders might, in fact, predate, I mean
just in terms of time of onset, would predate, you know, entry
into service. Now, most of us get worse under stress and so if
you had a personality disorder, maybe that would be get worse
under stress too.
But the key is that if you can look at military trauma,
sexual trauma, other kinds of trauma, you can look at things
that happened during the military and then you look at that to
see how that relates to the specific PTSD symptoms.
Mr. Rodriguez. Okay. I am out of time. Thank you.
Mr. Hall. Thank you.
I would like to ask a couple more questions, if I may.
Dr. Kilpatrick, the rating schedule for mental health is
very much based on the Global Assessment of Functioning or GAF
scale, which a different IOM Committee found to be ineffective
and recommended that it should be replaced.
What do you think that says about the rating schedule
itself and should the same conclusion apply?
Mr. Kilpatrick. Well, I believe our Committee did, in fact,
reach that conclusion. The problem with it is that it was not
designed to capture the specific types of disabilities that go
along with and difficulties in functioning that go along with
PTSD. And so the items and the anchors in it do not really fit
PTSD very well. So there are better measures there.
And if anybody wants chapter and verse on that, there is a
long discussion of it in, you know, our report. But the
Committee really felt like that there were better ways to
capture that than a rating system that is based on the GAF.
Mr. Hall. You mentioned that the current rating schedule
serves as a disincentive for both recovery and work for those
with PTSD who might also be able to work.
Should VA allow veterans with mental disabilities to be
rated 100 percent and for them to be employable just like with
physical disabilities?
Mr. Kilpatrick. Well, I think if you were interested in
parity, that would be something that would appear to be
attractive. Again, this is my personal opinion.
But I think the Committee also felt that encouraging people
to work and not setting up a system that provides a
disincentive to do that is probably not what you would want to
do if you were wanting to encourage people to, you know, get
vocational services and other kinds of things that would enable
them to be productive.
There are clearly people who are 100-percent disabled for a
physical disability, but who if they go to work, they do not
have to give up the disability. And it seems to me that parity
would suggest that, you know, that you try to do the same thing
for people with PTSD specifically, but also for other mental
disorders.
Mr. Hall. Thank you.
Dr. Samet, it sounds like the causal effect level of
evidence that your Committee proposes is very stringent and
would make it even more difficult for veterans to achieve
service connection on a presumptive basis.
Is that really the intention and does that really serve our
veterans best?
Dr. Samet. Several comments. The four-level categorization
of evidence has a point of balance between 50 percent certainty
that there might be a causal association or less. And we
suggest that, in fact, the 50 percent and above level of
certainty be used for compensation.
I do not know that this is necessarily more stringent than
the current approach. We also call for a more holistic approach
to evidence evaluation, making certain that the latest
understanding of how exposures received in the military might
cause disease or incorporate it into the decision making.
We also suggest that when the evidence does not meet that
balance point, action still might be taken. For one, research
might be developed to fill the gaps that are there so that the
level of certainty can be higher.
I think this is a point for an important discussion
because, as I pointed out, our case studies show that, in fact,
sometimes judgments have been made on the standard of
association and sometimes on causation. We think that this
should be uniform. It should be clear. It should be
transparent.
And as the decision is made about what is the right
approach, there should be a weighing of how many potential
presumptions might be made when the evidence is not there yet,
a false positive, and then also how often an association, a
causal association might be missed, a false negative.
We want a system that assures that we do not miss those
conditions that are actually linked to exposures in the
military and at the same time does not let some through where
there is no association. It is a difficult balancing and we
propose a system that we hope will do the right job.
Mr. Hall. Thank you.
The Committee recommended the creation of a VA Presumption
Advisory Committee and a Scientific Review Board to consider
and review scientific evidence. But developing this level of
evidence as described in your report could take years.
What should we do about getting veterans their benefits in
the meantime?
Dr. Samet. You know, I think embedded in your question is
an important point. Scientific evidence will always be
accumulating and first we call for the accumulation of the best
stream of evidence possible on the health of veterans.
I mean, going back to the question about PTSD, if we did
have the right public health surveillance approaches in place,
some of the questions that were posed would be answerable.
So we think that while evidence is accumulating, judgments
have to be made. The evidence needs to be looked at serially.
When there are gaps, they need to be targeted. If there are
questions about delayed onset of PTSD, there should be a
focused investigation. And I think the VA needs the capacity to
do that.
An Advisory Committee would have the role of providing
guidance on what evidence is needed and how it might be
obtained. And, again, if perhaps evidence is unobtainable, then
it is best to know that and to make a decision with
acknowledgment of the uncertainty.
Mr. Hall. Thank you.
Dr. McMahon, the data you have presented is compelling and
it seems that the groups who suffer the most from service
disabling injuries and illnesses are those who are younger,
more severely injured, those with mental health issues, and
those who are unemployable.
If VA were able to augment those whose disabilities were
more impairing with a quality of life loss schedule, do you
think that would improve the financial parity for those
veterans or is there a need to change the rates of compensation
or the levels of severity?
Ms. McMahon. Well, I would think that you would want to
address these issues separately. I would have to say that while
I can identify the quality of life degradation pretty sharply
by some of the criteria that you mentioned, I am not able to
put a dollar figure on exactly how much would be appropriate
for a quality of life adjustment.
We did look in some of our analysis at some of the steps
that other countries took with regard to quality of life
adjustments. Some of those countries dealt with it with a lump
sum payment, for example. I am not suggesting that that is the
way we would want to go.
I do think that these are separable issues. One of them is
a matter of compensation and whether a person is unable to work
in the accustomed area or maybe has not been able to be
retrained into another line of work. That is a matter of
fairness. You have lost something compared to what you started
with. You have not been able to keep up with your peer group.
The issue of a loss of quality of life is something
different and I think that needs to be dealt with separately
rather than merged together in a single payment because that
gives you a cleaner way of dealing with the situation.
Mr. Hall. Thank you.
I want to thank you all for your testimony.
We were talking before about the various resources that are
available that are more up to date than the VA's rating
schedule. This DSM manual from the American Psychiatric
Association, which has a section on post traumatic stress
disorder in it, it is copyrighted in 1994 and updated through
1997 with new codes and so on.
I am hopeful that all of us together with the testimony
that you have provided us and with what the other panels will
be providing us, we can help VA move from the fifties or
sixties or wherever they last were into the present and future
in terms of clarifying this and making this a more logical
system and one that serves our veterans better.
Thank you all so much for you patience and for testifying
before the Subcommittee today, and the first panel is now
excused.
And we will ask our second panel, Mark Hyman, M.D.,
American Academy of Disability Evaluating Physicians (AADEP);
Sidney Weissman, M.D., member of the American Psychiatric
Association; Ronald Abrams, Joint Executive Director of the
National Veterans Legal Services Program (NVLSP), to join us
please.
Thank you also for your patience. As usual, your full
written statement will be entered in the record and you will
each be recognized for 5 minutes. So feel free to summarize or
deviate from it in whichever way you choose.
Dr. Hyman, you are now recognized for 5 minutes.
STATEMENTS OF MARK H. HYMAN, M.D., FAADEP, PRESENTER, AMERICAN
ACADEMY OF DISABILITY EVALUATING PHYSICIANS, AND MARK H. HYMAN,
M.D., INC., F.A.C.P., F.A.A.D.E.P., LOS ANGELES, CA; SIDNEY
WEISSMAN, M.D., MEMBER, COMMITTEE ON MENTAL HEALTHCARE FOR
VETERANS AND MILITARY PERSONNEL AND THEIR FAMILIES, AMERICAN
PSYCHIATRIC ASSOCIATION; AND RONALD B. ABRAMS, JOINT EXECUTIVE
DIRECTOR, NATIONAL VETERANS LEGAL SERVICES PROGRAM
STATEMENT OF MARK H. HYMAN, M.D.
Dr. Hyman. Thank you very much, Mr. Hall, Members, and
staff.
I read the Institute of Medicine report and do wish to
align my recommendations from the private sector experience.
In the community, if we have an injured person, they file a
claim within a recognized jurisdiction, usually at the State
level. This triggers a claims handling by either a private
insurance entity or a State mandated agency. Records are
obtained and the patient is then referred to a physician for
evaluation.
A report is prepared in the format required by the
jurisdiction and the findings of the evaluation are then
translated into an impairment rating which then triggers
subsequent administrative actions.
Implementation of the recommendations in the report would
bring our veterans system in a closer approximation to what I
have just described. In particular, I must strongly underscore
the need for a common language and the process which emanates
from already existing national standards, including the AMA
Guides, the ICD, and the DSM.
These resources are the products of multiple leaders
throughout the world. The AMA Guides began in 1958 in response
to the developing field of disability evaluation. The mission
has always been to bring the soundest possible reasoning to the
impairment process. The Guides have become the community
standard in the majority of the States within our country. In
essence, the Guides are the tools and the rules of the
disability trade.
We have just produced the sixth edition of this seminal
work and there are many companion books that go with this.
These have been provided to your staff and I have copies of
them here. Together these books represent the efforts of
experts around the country who regularly work in the disability
field.
There is also a mechanism of updating this information
through an Advisory Board that we have and we also do major
revisions when it is warranted.
Through this mechanism that is used in the private sector,
we can thoroughly describe and categorize the range of human
injury. We are able to develop a fair, equitable, consistent
rating on an individual's impairment, small or large.
Further, the Guides are aligned with the World Health
Organization's (WHO's) standards of disablement which are
called the International Classification of Functioning,
Disability, and Health.
As with all jurisdictions, once an impairment rating
process has occurred, then, like all other jurisdictions,
specific unique coding or administrative concerns can then be
added to the process.
Indeed, in many jurisdictions, the evaluators may not even
fully know all of the subsequent claims processing that their
impairment rating triggers.
In the current VA example, raters could take this report
from the medical evaluation and cohesively apply a disability
rating with good reproducibility. They can add whatever
modifiers they feel are necessary or unique to the VA system.
The use of these resources will allow for a transition to
an electronic health record which is currently the standard for
the veterans health system on the medical side. Tracking of the
data then becomes much easier.
To accomplish this process, all shareholders from the VA
system must have a seat at round-table discussions and have
input into recommendations from the Advisory Committee. The
Advisory Committee must be charged and funded to meet at least
once yearly with quarterly telephonic meetings in order to
ensure implementation, assess outcomes, and ensure proper
education.
I cannot underscore enough the importance of education as
this field is one that is not covered heavily or extensively in
standard medical training and has many unique aspects.
By using the resources which I have identified as central
to this process, the common language of impairment and
disability will be broadened to all personnel involved in the
process. I personally, as a citizen of this country and our
organization that I am representing today, AADEP, offer
assistance to you in furthering this project.
Finally, based on briefly some comments I heard today, I
want you to know that there is data that works for the vast
majority of people and these resources cover the vast majority
of concerns.
In looking at your reporting from the Institute of
Medicine, the three most common difficulties, orthopedic,
hearing, psychiatric, are all covered in the AMA Guides. The
best way to get this done is through the AMA Guides. The
research already exists. You do not have to reinvent the wheel.
The resources are already regularly examined and updated. These
resources cover matters of concern to you.
There is no perfect book. There will never be a perfect
book to describe the entire human condition. But the AMA Guides
is the closest we have to equanimity and I strongly recommend
it.
Thank you for allowing me to help our country, but, in
particular, for giving me a chance to help those men and women
who have provided for our security that we can meet here today
and try to repay their effort. May God bless you in your
deliberations.
[The prepared statement of Dr. Hyman appears on p. 79.]
Mr. Hall. Thank you, Dr. Hyman.
Dr. Weissman, now you are recognized for 5 minutes.
STATEMENT OF SIDNEY WEISSMAN, M.D.
Dr. Weissman. Thank you, Mr. Chairman.
I am Sidney Weissman and I am here to represent the
American Psychiatric Association which is the publisher of the
DSM which has been spoken about this afternoon.
The American Psychiatric Association published the current
DSM in 1994 and you noted some of the revisions.
As publisher, we have a vital interest in the work of the
Subcommittee and particularly in the interest of expanding the
criteria for psychiatric disability, especially for veterans
suffering from post traumatic stress disorder.
I would like to say I share the Chairman's concern that we
have instruments for assessing the disability of our members
who have served us so well, but I would also, though, disagree
that the GAF as has been reported and commented on by a number
of people does not do that job.
The GAF or the global assessment of functioning of the DSM
is designed to look at all mental health disorders. And what I
think has been confusing to some people is that as it describes
varying levels of functioning, it has references or it will say
EG, for example. What is confusing is that the for examples
frequently refer to schizophrenia or depressive disorders, but
in point of fact, the broad categories themselves can be used
to apply for all mental health disorders and could as readily
be designed to respond to post traumatic stress disorder. We at
the APA or myself would be glad to work on some models of that.
I should also note that I would like to agree with the
Institute of Medicine for the need for the establishment of
broad criteria and the training of Veterans Administration's
physicians and evaluators to a standardization of the criteria
and the terms in which all mental health diagnoses are made.
Four years ago, I had the opportunity as a psychiatrist
working for Veteran Integrated Services Network (VISN) 12 to
review how PTSD was diagnosed and treated in the Veterans
Administration hospitals in the Great Lakes. To my amazement,
there was no universal agreement. The treatment you got or the
diagnosis you received depended totally on which hospital you
attended. There was no comparability. One hospitalized
everybody for a month. One treated everybody in a day treatment
center and one treated everybody as an outpatient. This will
not do.
It's not surprising that categorization of assessment tools
do not work if the people filling them out and completing them
have no standardization.
I should note that all mental disorders ranging from mild
depression to schizophrenia to PTSD vary in the degree of
disability associated with them. The questions of disability
not only affect veterans and active-duty military personnel,
but they affect civilians in Social Security Disability
Insurance (SSDI) and Supplemental Security Income (SSI).
We believe it is important that clinical research,
insurance claims management, and government use of mental
disorders diagnosis all have a common frame of reference and a
common diagnostic set of tools.
The DSM is that common reference point and it is used
throughout the world to accomplish this, not just in the United
States, but in all sectors of the world. It has been used and
worked on by World Health Organization. And on the basis of
that work, for the past 26 years, we have been working then to
reassess and redevise and reexamine and reformulate the DSM.
I should note that the DSM is used by all mental health
practitioners, psychologists, social workers, counselors,
mental health administrators. And the need for a common
language has been noted by some of my colleagues. In the
absence of a common language and standards, epidemiological
surveys and studies of mental health practice patterns cannot
be made. Practice guidelines for clinicians to improve and
standardize patient care could not be made.
Our concern is that we not fragment our system of
assessment by introducing new forms which could be
idiosyncratic, but that we use a standardized form. We can work
to modify the for examples used for the global assessment
functioning be changed to respond to PTSD and refer
specifically to PTSD.
We should also note in closing that all forms of the U.S.
Government from TRICARE to Champus to Medicaid and Social
Security all use the DSM.
In closing, I should also note that we are in the process
of developing a new DSM or DSM-V. The Chair of the work group
to develop the DSM-V apropos of PTSD is Dr. Matthew Freedman.
He is a psychiatrist and Executive Director of the U.S.
Department of Veterans National Center for Post Traumatic
Stress, so he brings a critical perspective to the review of
the DSM. And a particular focus of this DSM-V work group will
be the reevaluation of the relationship between mental disorder
and disability.
And I close as did my colleague of our need to ensure the
adequate and responsible acknowledgment of the needs of the men
and women who have served our country so well.
Thank you.
[The prepared statement of Dr. Weissman appears on p. 83.]
Mr. Hall. Thank you, Doctor.
I should have acknowledged our Ranking Member, Congressman
Lamborn, who obviously you noticed his presence, but I am
acknowledging it officially and thanking him for being here.
And now we will turn to Mr. Abrams who is recognized for 5
minutes.
STATEMENT OF RONALD B. ABRAMS
Mr. Abrams. Thank you, Mr. Chairman and Members. I am
pleased to have the opportunity to submit this testimony on
behalf of NVLSP.
I would like to point out that many parts of the rating
schedule have been updated, amended, and changed. Some have
been helpful. Some of the changes have been helpful. Some have
been harmful. If you want to look at a bad one, go look at the
way they changed the back condition evaluations.
As someone with a severe back condition, I can tell you
that the current rules on evaluating back conditions where you
have to be in bed for so many weeks really hurts people with
those conditions and they ought to do something about that and
fix that.
Of course, NVLSP would want the rating schedule updated,
modernized, and otherwise improved. However, we want to caution
that improving the rating schedule is not a cure all. In our
opinion, there is no amount of money that would adequately
compensate any veteran for the loss or loss of use of a body
part, permanent cognitive impairment, or the loss of a creative
organ. We should be asking not how much is the disability
worth, but how much can this Nation afford to pay.
I want to stress that our priority is the evaluation of
mental conditions and we believe that for a long time, the VA
has tended to under-evaluate mental disabilities. This has
occurred at the same time that our society has evolved from one
dominated by manual labor to a work environment that
emphasizing intellectual endeavors.
We really cannot compare the impact of a mental condition
today to the impact of a mental condition in 1947 where we had
more of a farm economy than we do today.
I also want to stress that veterans with mental conditions
are handicapped. While vets with heart conditions, lung
conditions, and other conditions can get 100-percent schedule
or evaluation, a veteran with a severe mental condition who is
lucky enough to find some kind of minimal work cannot work and
get the 100-percent evaluation. We do not think that is fair.
Also, we would like to stress that we agree with the
current VA rating policy on individual unemployability or IU.
We reject any recommendation that would require the VA to
implement a periodic evaluation or review of veterans in
receipt of IU benefits. They tried this in the eighties. I
worked for the VA at that time. And we ended up being pushed as
employees to cut off as many veterans as we could.
At one time, the rolls went from, I believe, 180,000 vets
getting IU to under 80,000. I do not think you want to go
there. That is not the way to go.
This longstanding policy about paying people unable to
perform substantial gainful employment because of their
service-connected conditions without considering nonservice-
connected conditions, without considering age should not be
changed.
We have already talked about at other hearings our views on
traumatic brain injury, so I will leave that for you to talk
about later.
And we also want to stress that the current association
standard regarding presumptive service-connected conditions
should not be changed. The causal effect would be almost
impossible for vets who come back from Vietnam after being
exposed to Agent Orange to win benefits unless science can
determine what is a causal effect.
Do not go there. This is not working. We are getting
benefits for people when statistically we can see an
association between being in a terrible place in the world
where we send our troops and then later getting hypertension
and other terrible conditions, lung cancers.
Thank you very much.
[The prepared statement of Mr. Abrams appears on p. 85.]
Mr. Hall. Thank you, Mr. Abrams.
It is true I was noticing reading the pages in the part of
the DSM on post traumatic stress and anxiety disorder that a
substantial number of our former panelists said numbers of the
population at large, civilians, exhibit these symptoms
depending on exposure to robberies or muggings or volcanic
events, I am sure there are quite a few residents of the New
Orleans area who were exhibiting symptoms because of Hurricanes
Katrina and Rita and so on.
Now we are hearing from Iraq and Afghanistan that our
Diplomat Corps and their families are reporting symptoms that
would probably qualify as PTSD.
I wanted to ask Dr. Hyman, based on your testimony, it
seems you are advocating for the use of the current WHO
standard as encompassed in the AMA Guides.
Can you give us an example so we can better understand the
difference between disability and impairment?
Dr. Hyman. Yes, Mr. Hall.
Let me give you an example from my own private practice. I
take care of a conductor for the Philharmonic in my city. And
he called me 1 day and said, you know, Mark, there is something
wrong with my ear and I cannot hear very well.
Now, hearing loss, which is one of the three most common
conditions that are in the claims for the veterans, would be
evaluated with specific hearing tests. And one would generate
an impairment rating. In other words, how impaired, how much
loss of use of that hearing has somebody obtained.
But that loss of hearing for my conductor patient could
translate into 100-percent disability because he is not able to
work as a conductor because hearing is so critical to his work,
whereas for another worker where that level of hearing acuity
is not necessary to perform their essential job functions would
have a lower disability.
Another example might be in that same type of field a
concert violinist. If somebody injures their finger and they
happen to be performing janitorial services and it happens to
be their fourth digit and it is a partial amputation, they
could probably fulfill all the job requirements of their
janitorial duties. And in that respect, they would have no
disability from their job. But a concert violinist is now 100-
percent disabled.
They both have the same injury. They both have the same
impairment. They are both evaluated in the same manner and are
given a very fair, appropriate, understandable impairment
rating, which is then translated by the impairment rating
process and the disability process into their ultimate effects.
Mr. Hall. Dr. Weissman, the issues with mental health and
PTSD have been complex. Could we have your opinion on these as
well? For instance, what is your reaction to the IOM study on
PTSD and compensation?
Dr. Weissman. It is interesting because I think they are
not unlike my colleague's comments vis-`-vis what your tasks
are and what your jobs are. I think that we have probably
underestimated for varying reasons the significance of PTSD and
its disabling effect on people.
I think that as is the case in all mental disorders, it can
be so totaling disabling and marginally disabling. I think that
the need for a thorough diagnostic assessment of someone with
PTSD is the aid and the assistance in making that
determination, but I believe that we have probably
underestimated the significance of it because, as you noted, we
frequently think in terms of mental disorders of schizophrenia
and, again, a global notion of it.
So I would agree with the Institute of Medicine report. It
is understated. It is more complex and we need to do a much
better job in assessing veterans who suffer from it.
Mr. Hall. What do you think of the VA's reliance on the GAF
and should that be changed, especially as the basis of the
rating schedule?
Dr. Weissman. If one went to the GAF, I have my DSM also,
and where it says EG, it will say every ten points, there is a
statement and then it is EG. If I started on the top at 90, I
suspect any number of people here are at 100, but we will not
quibble about our scores, not myself, but I believe you could
take the GAF, use as the EGS, which means for example, elements
of the symptomatology and behaviors observed in PTSD and as you
would go down the GAF scores, the EGS, would describe more
intensive intrusion into functioning. One could make the GAF an
extremely effective agent for assessing PTSD as you could for
any number of other mental disorders as it is used, by the way,
around the world.
Mr. Hall. Would this fall into your comment about common
language and standards? Is that specific enough and simple
enough to be part of a rating system which could be automated,
which could be computerized?
Dr. Weissman. I would not want to computerize the
diagnostic assessment of the man or woman who has served our
country.
Mr. Hall. I am not saying computerize the assessment. I am
saying that once a psychiatrist has diagnosed a particular
level on the scale and that it could be entered in assuming--
both the Ranking Member and I have an interest in moving
toward, as much as we can, toward artificial intelligence for
the purpose of rating and processing claims.
Dr. Weissman. Assuming we went through the DSM and the GAF
down the line and used as our example now, for our for example,
PTSD and the varying elements of it, then I believe you could
do just what you said. So, I have seen the patient with an
extensive diagnostic interview and I have given him a rating of
55 and that scale should fit.
But I would also want to make sure that we have then done
what the IOM also reported or asked for, which is a training
schedule so that you certify people and that there is some
inter-rater reliability because if there is no inter-rater
reliability, then the number doesn't mean anything.
Mr. Hall. Mr. Abrams, would you be so kind as to give us in
writing, at your earliest convenience, specifically how we
should change the evaluation for back conditions.
Mr. Abrams. I would be happy to.
Mr. Hall. Thank you. I am personally interested in that as
well.
Mr. Abrams. As someone who suffers from severe spinal
stenosis, I would not get much if I could apply for my back
condition. And I can tell you that I am lucky to have a job
that I can do where I can sit, not stand, where I do not have
to walk. And I truly believe that if I applied for Social
Security, I would get it if I was not working. But in VA, I
might get ten percent.
I do want to add something to what Dr. Weissman said. The
GAF score would be a wonderful tool if the VA followed it and
all they have to do is say--in fact, they are obligated to do
it now. We take many cases to the Court of Appeals for Veterans
Claims where the GAF is not consistent with the symptomatology
and the VA under-evaluates the veteran's mental condition.
We feel that if the VA was encouraged to either accept the
GAF score, I mean, we have seen people with 40 GAF scores get a
30 percent evaluation. That is just nuts. If they do not think
the GAF score is right, the VA should send it back to the
examiner and ask them to explain why such a score was assigned.
And we win those cases on a routine basis at the court.
And so you do have a common language there if you can just
get the VA to buy into that and do it, but we see that as a
consistent error. In fact, if you look at our American Legion
quality checks, you will see that is many of the errors that we
found in the Regional Offices.
Mr. Hall. Thank you.
Mr. Lamborn, you are recognized for 5 minutes.
Mr. Lamborn. Thank you, Mr. Chairman.
Dr. Weissman, will you briefly summarize for us the
findings of the planning conference on PTSD from June of 2005?
For example, what were the specific recommendations for
research and will these be included in the DSM revision due in
2011?
Dr. Weissman. Well, in one of my other roles, I happen to
be a trustee of the American Psychiatric Association. We are in
the very early form of developing a number of task forces to
look at the totality of the psychiatric diagnostic system.
So I cannot tell you explicitly what that conference was
other than to say that that was to form the framework of
beginning to put together people from around the world to
create the new DSM-V, which will not be published until 2011
and 2012. So this is the formative period. It will use all of
this data.
I would hope that as my friend here, I will sound like one
of the candidates, I believe that if we work on the common
language, use it effectively, understand language from as
follows, that will then be able to inform not just for
veterans, men and women who have experienced combat. But, as
Mr. Hall says, PTSD is not simply a disorder of the military.
It is a disorder for all of us. All of us have family members
who have experienced traumatic situations. And I dare say all
of us could find members of our families who have some degree
of PTSD.
But that is the formative period for the task force and the
work groups to establish the DSM-V and one element that one of
the task force works on these issues.
Mr. Lamborn. Thank you.
Mr. Hall. Thank you, Mr. Lamborn. And----
Dr. Hyman. Mr. Chairman.
Mr. Hall. Yes.
Dr. Hyman. One brief comment. In reflecting on some of the
comments here, I do hear an understandable concern as the
mechanisms of bringing the science to the patient. And I think
these resources have that process built into them. And I said,
there will never be a perfect scale for many of these
conditions, but this is the state of where we are at and we
will always get better.
What I think is very important is to have the mechanisms in
place of using these standard references. And as an example, I
want you to know that in California where I am now at, we have
the country's largest workers' compensation system and we
passed a law to put into place the AMA Guides. And that process
took 8 months.
This is not something that, requires a long period of
startup and evaluation in order to accomplish what is doable.
And that could be something for your deliberations as far as
putting something in place that can begin to bear on the
benefits for these veterans that are needed and over time, work
on the associated issues.
Mr. Hall. Thank you.
Dr. Weissman, I wanted to ask you, would you say that if a
veteran is diagnosed with PTSD, it would be safe to assume that
the stressor occurred in a combat zone even if the veteran did
not have a combat action ribbon or some other combat related
award?
Dr. Weissman. One could serve in the military and
experience a traumatic situation, which is not in the combat
zone. A woman, and we know this is the case, could be sexually
abused and assaulted and experience PTSD that is not combat
related. One could be in an accident.
So the existence of PTSD in a veteran or an active-duty
soldier does not in and of itself tell me that that was
obtained in a combat zone.
Mr. Hall. Your comment that each VA hospital that you
studied handled PTSD differently, diagnosed it differently,
treated it differently is disturbing to me and not surprising
based on some of the other testimony that this Subcommittee has
heard.
Other than the common language and common standards, can
you get more specific than that in terms of how you would
suggest that we approach this?
Dr. Weissman. I would take and work using the GAF, for
example, work it through to each of those points where it says
EG, develop a model that fits PTSD. I would then view the cases
or interviews of men and women with PTSD and I would have a
number of people observe those interviews, assess that data so
that I could get a standardization.
And then after I have obtained a standardization and inter-
rater reliability from my people developing the
standardization--we have wonderful ways now of communicating
that instantly around the country. With the web, I would then
develop a training program to be taken by all VA psychiatrists
or mental health workers who would assess someone for a mental
disorder, for PTSD so that there would then be an agreement
that if I was evaluated in Milwaukee or at Hines VA or Jesse
Brown or in Tomah, Wisconsin, these are some of the places we
looked at it, I would have the same rating.
However, I could warn you that when you do this, the inter-
rater reliability fails after a time. The three of us could
take the training and agree and very quickly, he goes to
California and I go to Chicago, my friend, I am not sure where
you are going, you have to make sure that the training is
repeated, that we redo the training. This is a constant
process. The VA is not always effective at constant processes.
It is not one where you get your transfer punched and it is
good for the lifetime. You have to do this repeatedly. And I am
convinced if we did that, we could develop a scale that works
and I could ensure you, Mr. Chairman, and the American people
that a vet evaluated in Milwaukee or Chicago or Los Angeles or
Washington would get a comparable evaluation and be treated
fairly. And he would not or she would not have to go somewhere
else.
Mr. Hall. Thank you, Doctor.
Dr. Weissman, Dr. Hyman, Mr. Abrams, thank you all for your
testimony and you have been very helpful to us. And thank you
again for your patience. This panel is excused. Have a lovely
evening.
Would our third panel please come to the table, Dean
Stoline, the Assistant Director of the National Legislative
Commission, the American Legion; Kerry Baker, Associate
National Legislative Director of Disabled American Veterans
(DAV); and Gerald T. Manar, Deputy Director, National Veterans
Service of the Veterans of Foreign Wars (VFW) of the United
States.
Gentlemen, thank you. Your full written statements have
been entered as is customary into the record, so your oral
testimony may be as brief or lengthy as you would like it to
be. Hopefully not more than 5 minutes.
Mr. Stoline, you are recognized now.
STATEMENTS OF DEAN F. STOLINE, ASSISTANT DIRECTOR, NATIONAL
LEGISLATIVE COMMISSION, AMERICAN LEGION; KERRY BAKER, ASSOCIATE
NATIONAL LEGISLATIVE DIRECTOR, DISABLED AMERICAN VETERANS; AND
GERALD T. MANAR, DEPUTY DIRECTOR, NATIONAL VETERANS SERVICE,
VETERANS OF FOREIGN WARS OF THE UNITED STATES
STATEMENT OF DEAN F. STOLINE
Mr. Stoline. Thank you, Mr. Chairman, Mr. Lamborn, and
Members of the Subcommittee. My name is Dean Stoline. I am
Assistant Director for the National Legislative Commission of
the American Legion.
Thank you for this opportunity to present the American
Legion's views on revising the Department of Veterans Affairs
schedule for rating disabilities.
My statement includes the American Legion's views on this
subject and also our views on recommendations contained in the
Veterans' Disability Benefits Commission.
The VA should update the current rating schedule and begin
with body systems that evaluate post traumatic stress disorder
and other mental disorders such as traumatic brain injury. This
revision process should be completed within 5 years and a
published system of keeping the rating schedule up-to-date
should be devised.
The American Legion cautions that revision of the rating
schedule should be put into its proper perspective as the
Committee conducts its work.
While we agree with the need for a new schedule, the
problem for veterans is getting service connection on their
claims. The rating schedule is a downstream issue a veteran
contends with after the award of service connection.
In addition, the rating schedule is not the major cause of
problems in the VA process. While updating disabilities that
have not been properly reviewed is a good idea, the real
problems veterans face are the inadequate staffing, the
inadequate funding, the ineffective quality assurance, the
premature adjudications, and the inadequate training that
plague the VA, especially in the Regional Offices.
For example, what good is a new rating schedule if the
veteran who files a claim waits for years going through a
series of VA denials, remands, appeals, requests for submission
of new evidence, and hearings before finally receiving the
service connection award?
Only after service connection is the rating schedule
relevant. And in the rating schedule, if the disability is
lower than it should be, the veteran must appeal that decision
through the same process all over again.
What good is a new rating schedule to Reservists and
National Guardsmen who submit claims only to have them denied
because the VA decides the disability did not occur or have its
onset when they were serving on active duty? As with the prior
example, the Reservist must appeal and face many years of
fighting and waiting before a service connection is awarded.
Only then will the rating schedule be relevant.
The Committee should note VA's lack of proper review of
Reserve component servicemembers' claims will become more
exacerbated as this Nation continues with the Global War on
Terrorism.
Recent VA figures indicate that while the conflicts in
Afghanistan and Iraq may be an active-duty war, they are also a
citizen-soldier fight. Only 48 percent of the veterans from
Afghanistan and Iraq have been active-duty servicemembers.
Fifty-2 percent are Reserve and National Guard members.
Clearly VA and DoD must be held accountable to properly
ensure Reserve component servicemembers are getting the proper
documentation while in active service for review of potential
disability claims.And the Committee must ask how a seamless
transition for Reserve component servicemembers from DoD to VA
can ever be made if the citizen-soldiers are not given an end-
of-service medical examination. This DoD examination would be
the one piece of medical evidence Reserve component
servicemembers would need most for a VA claim to succeed.
Clearly these problems will not be resolved by a new rating
schedule. The American Legion emphasizes the solution of those
problems must be a major focus to reform the adjudication
process.
Getting back to improving the schedule, the American Legion
first stresses that we are a Nation at war. Therefore, no
injury or disability to any current servicemember should
receive less compensation because of an update to the rating
schedule.
The American Legion believes evaluations for some
disabilities, for example, amputations, loss of use of limb,
loss of use of creative organ, are under-compensated because
they fail to consider the impact of those disabilities on a
veteran's quality of life and other disabilities such as mental
conditions fail to adjust to changing American work
environments over time. The American Legion welcomes changes to
the rating schedule to take care of these inequities.
I will skip the PTSD and IU subjects because they were
adequately covered in prior testimony by NVLSP.
I will move on to the periodic evaluation of IU eligible
veterans. VA should authorize only a gradual reduction of their
compensation for those returning to substantial gainful
employment rather than abruptly terminating payments to them at
an arbitrary level of earnings.
The American Legion opposes part of the Commission's
recommendation that would be interpreted as requiring
consideration of age in determining eligibility. It is
inherently unfair to punish an older veteran who would not be
able to work at any age because of a service-connected
condition and award the benefit to a similarly disabled younger
veteran.
The schedule is based on the average impairment in earning
capacity. If the veteran cannot work because of service-
connected disabilities, then IU should be awarded.
With regard to TBI, VA proposes a regulation to amend the
current criteria. The American Legion commends the VA for
recognizing the situation and for making an effort to revise
the current criteria.
Last, the proposed regulation does not discuss
consideration of the history of the disability on TBI. TBI
symptoms wax and wane for some veterans. Therefore, some
veterans may be under-evaluated if the history of their
symptomatology is not considered.
With regard to the evaluation of cognitive impairment, we
believe that ``moderately impaired'' and ``severely impaired''
should also be defined in the regulation.
With regard to applicability date, the VA contends the
proposed rule should be applicable to claims received on or
after the effective date. The American Legion disagrees. It
does not make sense to apply the old rating criteria to a claim
that has not been initially adjudicated or is pending
readjudication due to an appeal simply because the claim was
received prior to the effective date of the new rule.
With regard to presumptions, the Commission made
recommendations regarding the replacement of the current
association standard with its causal effect standard in the
presumptive disability, decisionmaking process. The American
Legion does not support those recommendations because the
association standard currently used in the presumption
determination process is consistent with a nonadversarial and
liberal nature of the VA disability process.
For example, for 1991 Gulf War veterans, specific or
reliable exposure data is not available due to improper
recordkeeping. So for Operations Desert Storm and Desert Shield
veterans, there is insufficient information to properly
determine their exposure to the numerous environmental and
other hazards found in that conflict. This lack of data clearly
diminishes the value and reliability of a causation standard.
It should be noted that despite its recommendation, the
Commission did state that it was concerned that causation
rather than association may be too stringent and encourage
further study of the matter.
In closing, I thank you again, Mr. Chairman, for allowing
the American Legion to present its comments on these important
matters. As always, the American Legion welcomes the
opportunity to work closely with you and your colleagues. I
stand ready for any questions you may have of me.
[The prepared statement of Mr. Stoline appears on p. 89.]
Mr. Hall. Thank you, sir, and we appreciate your testimony.
We will have questions in a minute.
But, first, Mr. Baker is recognized.
STATEMENT OF KERRY BAKER
Mr. Baker. Mr. Chairman and Members of the Subcommittee, on
behalf of the DAV, I am pleased to offer my testimony to
address the VA disability rating schedule.
The present rating schedule was developed in 1945. By 1961,
there had been no less than 15 revisions. In fact, since the
beginning 1990, there have been no less than 28 sections of the
rating schedule updated to some degree.
I am providing this information in response to most of the
rhetoric that VA must completely revise its entire compensation
system. The majority of support for such rhetoric stems from
speechless proposals that VA's compensation system is over 60
years. It is not. VA's disability system in 1945 was but a
shell of today's system.
In no previous war was there a need to recreate VA's
disability system nor does such a need currently exist.
However, the DAV agrees that portions of the rating schedule
must be updated such as but not limited to traumatic brain
injury or TBI and residuals and the mental health rating
criteria.
The problem with the mental health criteria is the weak
nexus between severity of symptoms and degree of disability.
Another problem is the proclivity for VA decisionmakers to deny
increased rating claims based on failure to demonstrate
symptoms required for a higher rating and the lack of such
symptoms is not at all associated with a condition. Therefore,
any update to the mental health disorders rating schedule
should be condition specific rather than a one-size-fits-all
criteria.
Essentially the DAV supports the Veterans' Disability
Benefits Commission or VDBC recommendation that VA update the
rating schedule, keep it up-to-date, and establish an Advisory
Committee to assist in the updating process.
With respect to ratings for individual unemployability or
IU, the VDBC asked the CNA Corp. to conduct an analysis of
veterans receiving IU. The central focus of their work was to
determine whether the increase in IU was due to veterans
manipulating the system.
The CNA Corp. discovered that the growth in the IU
population is a function of demographics and that disabilities
are worsening as veterans age. The CNA Corp. concluded that the
increase in IU is not due to veteran manipulation.
We realize the need to help unemployed veterans return to
work when feasible. Most desire to lead productive lives rather
than attempt to survive only on VA compensation. Nonetheless
the slightest misinterpretation by VA employees of a change in
law regarding entitlement to benefits under this program will
result in a large number of veterans receiving an unlawful
denial of benefits or worse a revocation of benefits.
We ask that you realize that no single disability will ever
affect two veterans in the same manner. What may render one
unemployable may simply not the other.
With respect to quality of life, the VDBC recommended that
Congress increase compensation rates up to 25 percent for loss
of quality of life. The DAV fully supports this recommendation.
Through comprehensive research, the Commission determined
that compensation at most helps some groups of disabled
veterans achieve parity with their nondisabled counterparts,
but only with respect to loss of earnings due to disability.
However, other groups were found to be below parity when
compared to nondisabled veterans.
These findings show that VA compensation replaces only the
average in lost earnings for many veterans, but much less for
others. In no event are veterans being overcompensated. The
question then arises of how, not if, VA should develop a way to
compensate for each. I believe that question is simply yet to
be answered.
In conclusion, we know that society has laws that are
evolutionary. The founders took great care in assuring that
change does not come easy, but still provided for its
evolvement. Some ignore this by acting hastily, attempting to
push legislative agendas aimed at more conserving the bottom
line than conserving the benefits that disabled veterans spent
the last 100 years fighting for.
Some of these agendas would pit veterans against veterans
or worse pit veterans against their government. We simply urge
caution. We support a vast majority of the VDBC's
recommendations because they are well-researched, carefully
planned suggestions with the potential of improving what is
already a good system.
Once again, however, we urge Congress to resist hastily
laid plans designed to do more undoing than doing or else the
next battle we will fight will be the one against unintended
consequences.
Mr. Chairman, thank you for inviting the DAV to testify
today. I will be happy to answer any of your questions.
[The prepared statement of Mr. Baker appears on p. 93.]
Mr. Hall. Thank you, Mr. Baker.
Mr. Manar, you are now recognized.
STATEMENT OF GERALD T. MANAR
Mr. Manar. Thank you. Chairman Hall, thank you for this
opportunity to present the views of the 2.3 million veterans
and auxiliaries of the Veterans of Foreign Wars of the United
States on the state of the VA's schedule for rating
disabilities.
Today I am going to talk about the rating schedule,
individual unemployability, and presumptions. We address other
topics in our testimony, and we hope that you have an
opportunity to review it.
We have heard today about the history of the development of
the rating schedule. I think it was you yourself who mentioned
that there was a rating schedule that was created in 1917.
Certainly there was one in 1921, 1925, 1933, and 1945.
The interesting thing about the 1925 rating schedule is
that it attempted to do what one of your earlier witnesses
advocates and that is to tailor individual evaluations based on
the profession or the occupation of the individual veteran.
While it is a laudable goal, it is in our view, unworkable.
Certainly the VA found that it was, in fact, unworkable and
they reverted to an earlier scheme in 1933.
The VA has, as my colleague here from the DAV has said,
continuously updated bits and pieces of the rating schedule
since 1945. They have not ignored it.
The problem is that as time has passed, they have been able
to, in our view, devote fewer and fewer resources to it. And as
a consequence, the changes have flowed less frequently.
And, in fact, as they have made changes, they have
incorporated some problems into the rating schedule that might
have been avoided had they been able to devote more resources
and more experts to the process.
Now, the Institute of Medicine, the Dole-Shalala Commission
and the Veterans' Disability Benefits Commission all found that
the rating schedule is filled with terminology that is archaic,
had criteria for evaluating disabilities that needs to be
refined. Medical knowledge has advanced to the point where much
of the rating schedule needs to be rearranged and reformed.
Everybody has an alternative approach to doing this. Under
Dole-Shalala, they would simply throw it out and start fresh.
In our view, their proposals would have a new rating schedule
in a very short period of time, formulated in a back room of a
bureaucracy, reviewed and modified by the Office of Management
and Budget, and then presented to the world for their
consideration.
If left alone, the VA also will continue reviewing and
fixing bits and pieces of the rating schedule. But they are
doing so with the resources that they have at hand. So we will
get what we have already got in that respect.
The Veterans' Disability Benefits Commission, on the other
hand, has made recommendations that build on those from the
Institute of Medicine. It is the only plan to create a process
for the logical, methodical, measured review in updating of the
rating schedule.
We do not agree with everything the Institute of Medicine
recommended, but we do support their structured approach. They
have presented a blueprint for change. They advocate the
creation of an Advisory Committee, which would be staffed with
experts in medical care, disability evaluation, functional and
vocational assessment and rehabilitation, representatives from
health, health policy, disability law, and from the veterans
community.
Our view of its function is somewhat different from what
the Veterans' Disability Benefits Commission and the Institute
of Medicine have recommended. We think this Committee should
perhaps look at, as an example, the Defense Health Board and
see how that has worked for the Defense Department.
We think that this Advisory Committee needs to be
separately funded and not directly under the Compensation and
Pension Service. We expect that it would meet several times a
year and work in the open. We view this as very important. And
it would provide guidance and direction to the VA. We expect
that it would make changes based on data and research.
In our view, individual unemployability is not broken. You
have heard testimony earlier today from the Center for Naval
Analysis that the increase in the grants of individual
unemployability over the last 10 years is almost certainly
related to defects or problems with the rating schedule rather
than any other single individual cause.
Understanding why there is something like individual
unemployability is very important. The rating schedule is very
mechanical. If you can only raise your arm to your shoulder
level, you get a certain evaluation. If you can only raise it
to your waist level, you get a higher evaluation. It is very
uniform.
The regulations allowing the grant of individual
unemployability allows the VA in this one instance to exercise
flexibility to address the inequities in the rating schedule
and differences among individuals. It allows the rating
specialists to look at education, vocational skills, job
history, and experiences of the individual.
If the VA grants individual unemployability for certain
conditions more than others, it may be an indication that the
rating criteria is not appropriate and should be changed.
[The prepared statement of Mr. Manar appears on p. 100.]
Mr. Hall. Thank you, Mr. Manar.
Mr. Manar. Thank you.
Mr. Hall. Thank you all.
Mr. Stoline, your comment that 48 percent of Operation
Iraqi Freedom/Operation Enduring Freedom soldiers are active
duty and the remainder Guard and Reserve is a striking one.
One of our earlier hearings, we had a witness testify that
we should approach this--well, he was specifically talking
about educational benefits, but I believe he would say the same
for disabilities or for medical benefits. Same service, same
battlefield, same benefits.
And in this case, it is just a reminder to me that we are
using our Guard and Reserve today in a way that perhaps they
have historically not been used.
And also your comment about, I was not sure if you said it
was turning into a system soldier fight or if we want----
Mr. Stoline. Citizen soldiers fight because the Reserve----
Mr. Hall. Citizen. Excuse me. I heard you wrong. Citizen
soldiers fight, right.
Mr. Stoline. I think the Nation looks upon what they see on
the news as the active duty of the President's force. But when
you look at the statistics, which are VA statistics, not
American Legion, you rapidly see it is the folks who are the
part-time soldiers who are paying the price and not the price
just on the battlefield but the price after the war because
when they get back to the VA, the VA is not able to understand.
Even though the health problems are the same, they do not think
because it is a Reservist they suffered it under active-duty
conditions and it is just a real struggle.
And that is why in my testimony I said it is a DoD as well
as a VA problem. They have to have the proper documentation,
especially that end-of-service documentation. Otherwise,
citizen-soldiers just lose out with the VA. And a rating
schedule, no matter how good, will not change that.
Mr. Hall. Okay. All right. Thank you for clearing that up
for me.
Timeliness issues seem to be a priority concern with the
veterans I have spoken with, especially older veterans who have
waited years for decisions and younger veterans who are just
now leaving the military and do not have months of financial
reserves to fall back on while waiting for VA to rate a claim.
Would it not be better to get these veterans paid in 45
days as opposed to months or years later?
Mr. Stoline. Is that to me?
Mr. Hall. Yes.
Mr. Stoline. Yes. I would think it would be. We understand
the nature that VA has to protect the public, but the law is
quite clear that it is to be liberally applied and the veteran
should get the benefit of the doubt.
And I think there is ample opportunity for the VA to relook
back at the record after they have made a decision because it
is in the law that they can rectify a decision that was erred
too much to the side of the veteran. But as you see, most of
the time, it errs too much to the side of the government.
Mr. Hall. As CNA studied and found, but most of us believe
to be true, that the veterans are not massively trying to rip
off the government. And I think that most people would expect
that to be the case.
What I hear from my constituents and people I meet around
the country and especially in these hearing rooms is that we
should be presuming more on the side of the veteran and not
asking them to clear a high bar or jump through hoops.
You have expressed concern in your testimony over the
presumption standard proposed by the IOM and the VDBC. After
hearing your testimony today that explains the need to create a
model to develop better scientific and medical data, do you not
think it would be in the best interest of veterans to know more
about the environmental and occupational hazards that they are
exposed to during military service and could that not also mean
better treatment and recovery? And I would also like to hear
DAV and VFW's thoughts on this subject.
Mr. Stoline. Well, mine, of course, we talked about and
used the Gulf War as an example is that the military does not
keep proper records. How are you ever going to be able to
scientifically study what the exposures were? And I think that
speaks for itself.
Mr. Baker. I can probably add a little bit to what Mr.
Stoline said. I mean, I cannot speak to the military's
recordkeeping process as far as the Gulf War is concerned. I am
sure it could have been better. But they do have records of
what they know was there.
I was there extensively. They know the things in the
atmosphere as far as oils and some of the chemicals and some of
the biological agents. But they still have not been able to
point a finger of any of those things to any particular symptom
from any of the veterans that have been sick after they
returned from the Gulf War.
And that is why I think if you try to structure the
presumptions around some of the ways that the IOM suggested,
you are never going to get to that answer. The same thing
applies to Vietnam veterans with dioxin exposure. A statistical
relationship is all that has ever been shown.
I believe one of the gentlemen mentioned you would give the
presumption at least when it is 50 percent or more that a
specific condition is related to a specific exposure, whatever
it may be. But if you cannot prove one way or the other, I do
not see how you get past that 50 percent. If it is inconclusive
results, it is inconclusive results.
But if you know that 80 percent of the veteran population
that were exposed as opposed to 80 percent that were unexposed
are getting sick, well, then I think you have to rely on that
statistical information if you have no other route to go down.
Mr. Hall. Mr. Manar.
Mr. Manar. Both my colleagues have pointed out first the
real difficulty is in gathering data on a battlefield or in
every-day occupations. You can imagine somebody at an airfield
being exposed to gasoline fumes, toxic chemicals of all kinds
and perhaps not even know it.
It would probably be an overwhelming task for the military
to accumulate data on every possible exposure. So knowing that
it is impossible, I think the law has to take into account that
we have to know that there are some things we are not going to
know fully or we might not know for many years to come.
So that is why, of course, there are presumptions and that
is why we oppose any proposal that would raise the bar, whether
it is legal or scientific, to ensure that veterans receive
healthcare and compensation.
We believe that the current standard of association is
appropriately high enough and to make veterans wait years,
perhaps even die while they are waiting for science to catch up
with and make a decision as to whether there is a causation
between something that occurred in service and a current
disability is too high.
Mr. Hall. Thank you.
Mr. Manar, in your testimony, you stated that Compensation
and Pension Service has fewer than 140 people. However, VA
reports that its C&P direct labor full-time equivalent (FTE)
for 2008 is about 10,304.
Are you suggesting that more of the FTE be directed to the
Central Office rather than in the field?
Mr. Manar. You direct more people in the Central Office,
fewer claims get rated or processed. But at the same time, this
is a $30 billion plus program or set of programs and VA needs
to dedicate adequate resources to administer it.
As I mentioned earlier, the rating schedule has slowly
eroded or fallen into disrepair because not enough resources
were allocated to keeping it up to date and keeping it current.
Had the VA done so, many of the problems that veterans face
today would not exist.
So I think that, yes, there should be more people in
Central Office. As difficult as it is to recruit and find
qualified people to come to Washington, a high-cost area, they
need to make the effort because this is too important to let go
on as it has in the past.
Mr. Hall. Thank you.
And just one more question to Mr. Baker. I understand that
DAV is cautious in changing the way VA does business since
there are components of the process that do work. I thank you
for your extensive review of rating schedule revisions.
But as staunch veterans' advocates, you must see that the
system the way it is needs serious repair and cannot continue
to rely on antiquated medical concepts, outdated tools, and
ineffective business practices.
Has the DAV explored how to improve the system beyond
resources and training which we have heard? What else would you
suggest to make this a better rating system for disabled
veterans?
Mr. Baker. We only give the impression that we are against
updating the rating schedule. We are certainly not. Anything
that is outdated, we support 100-percent updating that.
What we are opposed to is recreating the system. The system
that VA works within is very good. And over the years, if you
look at the 1945 schedule and the 1945 system and compared it
to today, you would find a lot of holes that veterans can fall
through in the 1945 system that have been accounted for now.
And if you recreate that, you are going to recreate those holes
and I think you are going to recreate some problems.
We all in DAV have some ideas about some large policy
changes, maybe some small policy changes that we think could
make some very good improvements in the system. I would suggest
looking at all aspects from the top down or bottom up, however
you wanted to start, looking at practices of the Court of
Appeals for Veterans Claims. There are issues there that could
be very cost effective, that could be changed, that would
support the court more, the veteran more, and help the VA more.
The same thing with the Board of Veterans Appeals. Same
thing with developmental procedures at the Regional Offices.
Everybody is looking at IT technology. I think it is
important to focus that IT technology in the right place. What
is taking the longest in developing these claims? Well, the
development is. It is not the rating decision. So focus the IT
technology to the development process. That is currently taking
the longest time. It is about 90 percent of the whole timeframe
to decide a case.
Once a case is ready to rate, it is not taking that long.
You can develop an automated system for rating once you focus
on the larger problem.
There are other smaller things, changes in small
regulations or maybe statutes that, you know, I would be happy
to submit for the record in writing so I can give you a little
bit more detailed answer without getting into the weeds too
much here.
But we are certainly not opposed, you know, to updating
anything. We want to see the updates. We just do not want to
recreate the system that has served veterans pretty good for a
very long time.
Mr. Hall. Thank you very much, sir.
Thank you all for your service to our country and to our
veterans. Thank you for your patience. Thank you for your
testimony this afternoon, and you are now excused.
And changing of the guard, we will ask our fourth panel to
join us, Brad Mayes, the Director for Compensation and Pension
Service of the Veterans Benefits Administration, U.S.
Department of Veterans Affairs; accompanied by Tom Pamprin,
Deputy Director for Policy, Compensation and Pension Service,
Veterans Benefits Administration; Steven H. Brown, M.D., M.S.,
Director for Compensation and Pension Exam Program, the
Veterans Health Administration; Patrick Joyce, M.D., Chief
Occupational Health Clinic, Veterans Health Administration;
Richard Hipolit, Assistant General Counsel for Department of
Veterans Affairs; Joseph Kelley, M.D., Deputy Assistant
Secretary of Defense for Clinical and Program Policy, U.S.
Department of Defense; and Horace Carson, M.D., Senior Medical
Advisor, Air Force Review Boards Agency, Department of Defense.
Thank you all for being with us. Thank you for your patience
also. This has been a long afternoon. Somehow it always turns
out that way.
And, Director Mayes, your statement is in the record, as
you submitted it, and you are given 5 minutes to address us
however you choose.
STATEMENTS BRADLEY G. MAYES, DIRECTOR, COMPENSATION AND PENSION
SERVICE, VETERANS BENEFITS ADMINISTRATION, U.S. DEPARTMENT OF
VETERANS AFFAIRS; ACCOMPANIED BY TOM PAMPRIN, DEPUTY DIRECTOR
FOR POLICY, COMPENSATION AND PENSION SERVICE, VETERANS BENEFITS
ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; STEVEN H.
BROWN, M.D., M.S., DIRECTOR, COMPENSATION AND PENSION
EXAMINATION PROGRAM, VETERANS HEALTH ADMINISTRATION, U.S.
DEPARTMENT OF VETERANS AFFAIRS; PATRICK JOYCE, M.D., CHIEF,
OCCUPATIONAL HEALTH CLINIC, AND CHIEF PHYSICIAN, COMPENSATION
AND PENSION PROGRAM, WASHINGTON, DC, VETERANS AFFAIRS MEDICAL
CENTER, VETERANS HEALTH ADMINISTRATION U.S. DEPARTMENT OF
VETERANS AFFAIRS; RICHARD HIPOLIT, ASSISTANT GENERAL COUNSEL,
OFFICE OF GENERAL COUNSEL, U.S. DEPARTMENT OF VETERANS AFFAIRS;
AND MAJOR GENERAL JOSEPH E. KELLEY, M.D., USAF (RET.), DEPUTY
ASSISTANT SECRETARY OF DEFENSE FOR CLINICAL AND PROGRAM POLICY
(HEALTH AFFAIRS), U.S. DEPARTMENT OF DEFENSE; ACCOMPANIED BY
HORACE CARSON, M.D., SENIOR MEDICAL ADVISOR, AIR FORCE REVIEW
BOARDS AGENCY, U.S. DEPARTMENT OF DEFENSE
STATEMENT OF BRADLEY G. MAYES
Mr. Mayes. Thank you. Mr. Chairman, Mr. Rodriguez, I am
pleased to appear before you today to speak on the subject of
revising the Department of Veterans Affairs VA schedule for
rating disabilities.
As you noted, I am accompanied by Dr. Patrick Joyce, Chief
of the Occupational Health Clinic and Chief Physician,
Compensation and Pension Program at the Washington, DC, VA
Medical Center; Dr. Steven Brown, Director of the Compensation
and Pension Examination Program Office, Veterans Health
Administration; Mr. Tom Pamperin, Deputy Director for Policy,
Compensation and Pension Service; and Mr. Richard Hipoli, VA
Office of General Counsel.
I would like to briefly highlight some points made in my
written statement, which was submitted for the record. Before I
begin, however, Mr. Chairman, I want to apologize for getting
the statement to the Committee so late.
We spent a great deal of time preparing for this hearing,
to include my statement, because we know this subject is of
such great importance. I regret, however, that you may not have
had sufficient time to review what was submitted for the record
and I hope that you have an opportunity to do so. I described,
in some detail, the history of VA's rating schedule and how we
got where we are today, much of which we have heard from the
previous panels.
With that, let me say that the VA rating schedule has truly
evolved over time and continues to evolve. It has served
literally millions of veterans throughout much of this Nation's
great history.
There are some fundamental underpinnings to VA's disability
compensation program that bear mentioning. First, it is a
system designed to compensate disabled veterans for lost
earnings capacity.
The system is modeled after workmen's compensation programs
developed at the turn of the 20th century and still in use by
society today.
The system is based on the ``average man'' concept so that
individuals are not penalized because they may be able to
overcome their disability.
And, finally, the system generally relies on degree of
anatomic loss and functional loss to approximate those lost
earnings, with the exception of mental disorders where there is
consideration of social and economic impacts.
Fundamentally, I believe we need to ask two questions. Does
the VA rating schedule meet Congress' mandate to compensate
veterans for reductions in earning capacity from specific
injuries or combinations of injuries and should that mandate be
expanded to include compensation for loss in quality of life
due to injury or disease in service?
The second part of the question is a broader public policy
question that requires study and that is exactly what this
administration initiated in recent proposed legislation sent to
Congress this past October.
Title 2 of the President's draft bill, ``America's Wounded
Warriors Act,'' would require VA to complete a study regarding
creation of a schedule for rating disabilities based upon
current concepts of medicine and disability, taking into
account loss of quality of life and loss of earnings resulting
from specific injuries.
VA entered into a contract on January 25th of this year for
a study to analyze the nature of specific injuries and diseases
for which disability compensation is payable under various
disability programs of Federal and State Governments, including
VA's own program, and those of other countries.
The study will examine specific approaches and the
usefulness of currently available instruments for measuring
disabilities' effects on an individual's psychological state,
loss of physical integrity, and social inadaptability to
include the impact on quality of life. We expect that study
will be completed by August of 2008.
Finally, in my written statement, I outline a five-point
plan to update the schedule and address various suggestions
made by recent commissions and studies. The elements of the
plan include the above-mentioned contract for a study,
aggressive staff development and possible utilization of
further contractor support, continued revisions to the schedule
that are already underway, (we recently published a new
regulation for evaluation of traumatic brain injury and we are
reviewing the mental disorders portion of the rating schedule
currently) development of a periodic review process to
ascertain the effectiveness of the schedule, and, finally,
evaluation of a possible quality of life component to VA's
disability compensation scheme.
Mr. Chairman, this concludes my prepared remarks. I and
others on the panel would be pleased to answer any questions
you and Members of the Subcommittee might have.
[The prepared statement of Mr. Mayes appears on p. 104.]
Mr. Hall. Thank you.
Dr. Kelley, you are recognized for 5 minutes.
STATEMENT OF MAJOR GENERAL JOSEPH E. KELLEY, M.D., USAF (RET.)
Dr. Kelley. Thank you, Mr. Chairman.
Due to the time constraints, I have submitted a statement
and I will summarize the major points of that. And hopefully we
will have more time for questions then.
The Administration has made significant efforts to improve
the treatment of active-duty servicemembers and veterans. And
they have commissioned independent review groups, task forces,
Presidential Commissions, and this has culminated in the
formation of a Senior Oversight Committee (SOC) chaired by the
Deputy Secretary of Defense and the Deputy Secretary of the
Department of Veterans Affairs. This has resulted in
significant progress in DoD and VA cooperation.
When DoD looks at the issues for the goals for a disability
system, they would like to have a fair, consistent, timely, and
accurate adjudication of the disabilities which maximizes or
incentivizes rehabilitation.
And the components of those that I think we have heard
discussed is that it be scientifically based or evidence based,
up to date and rapidly modifiable to meet new developments, new
types of injuries, illnesses, medical treatments, consistent
nomenclature, and that the DoD would have the ability to input
when changes are needed in that system.
Recently, there has been great success in that as we have
looked at the newly formed and revised standards for traumatic
brain injury and burns, which were published in the Federal
Register in January of this year. We would like to see that
process formalized or institutionalized so that DoD would be
involved in the revision of any of those standards as they went
forward.
And I would like to also mention the pilot program in the
National Capital region where there is an effort to have a
single discharge disability evaluation where the DoD is
concentrating on determining fitness for duty and all
disability ratings are being done by the VA so there is not an
inconsistency between the departments.
And that so far has gone well, but we do not have any
conclusions from that study which is in progress right now. And
we look forward to that and potentially promulgating that
throughout the entire system.
Sir, thank you for the opportunity to make a statement and
appreciate your comments.
[The prepared statement of Dr. Kelley appears on p. 108.]
Mr. Hall. Thank you, Dr. Kelley.
This is a little bit off topic, but since I have both Dr.
Kelley and Mr. Mayes here, I wanted to ask you if you are
consistent with nomenclature and the electronic transition or
transfer of records that we all want to see happen.
I heard in Landstuhl from the Commander of the hospital
there in October that he thought it was going to start
happening in December, where the onion, as he described it of
electronic information coming back with each wounded service
man or woman from the field of battle, which would have added
to it a layer in Balad, and again in the plane on the way to
Germany, and again in Germany and the Landstuhl Medical Center,
and then, every step of the way, there would be the medication,
the treatment, the surgeries, whatever, starting with the
diagnosis and any continued additions or changes in the
diagnosis or diagnoses and then again on the plane back to the
States to Walter Reed or Bethesda or whichever DoD facility
they were in and the entire onion would then be able to be
handed off to the VA.
And when Deputy Under Secretary Walcoff was with us last
week, I asked him if he knew how close we were to that
happening and he was not able to say, but I wondered if you
could give us any update, based on your knowledge as to how
close we are. We are not talking about a rating schedule here
as much as we are IT, but the compatibility of technology
between the two departments. How close are we?
Dr. Kelley. Sir, if I could make a comment, I would like to
take that and give you a more detailed answer later.
But just a summary statement is that we do have what we
call the Joint Patient Tracking Application which goes through
the system. It captures that data that you were talking about
from the far forward front, bringing it back in the system. And
it is not visible at all VA facilities at this time, but it is
visible at the VA facilities where there are major treatment
centers. And we plan to expand that broader to encompass the
entire system so that those who have the need to know have
that.
So it is partially in place, what you describe, but it is
not completely available. And that goes along with increasing
cooperation. We are developing a common methodology for our
next generation of electronic medical records.
Mr. Hall. Just do not call it Next Gen, okay? We will get
confused.
Dr. Kelley. And so we are making progress and it is going
on and it is becoming present at more and more facilities as we
go on.
Mr. Hall. That is good to hear. Thank you.
And please update us as it progresses because it is
something the Subcommittee and the full Committee are very
interested in, and concerned with.
Director Mayes, you said that the revision of the rating
schedule has actually been underway since the nineties, which
seems like a long time to get this done. Realizing, of course,
that as the battle changes and the weapons change and the
circumstances change that, maybe it will never be done, but it
seems you are still working on recommendations, some
recommendations anyway, from 1956 and ones that never
materialized in 1971.
Have you been doing one code at a time or why does it
appear this way? Would it not be better accomplished by an
established editorial panel that constantly updates the Codes?
Mr. Mayes. Mr. Chairman, I think you are right on point. We
agree with the Institute of Medicine and with the Disability
Benefits Commission, there has to be an ongoing systematic
approach to revising the schedule. You really are never going
to finish because medical science advances.
We have gone through 12 of the 15 body systems. We take it
a body system at a time. That has been our approach. We begin
looking at that body system which will have multiple diagnostic
codes and we begin reviewing the criteria looking for obsolete
codes or obsolete evaluation criteria, engaging our partners in
the Veterans Health Administration, and then we propose changes
similar to what we did recently with the traumatic brain injury
revisions to the schedule. They are published for notice and
comment so that our stakeholders have an opportunity to weigh
in. And we got lots of comments on the proposed TBI regs and we
are in the process of assimilating those comments.
So, I agree. One of the elements of my five-point plan is
to put in place this regular schedule so that it is continuous.
And we are building the capacity to be able to do that.
Mr. Hall. That is very encouraging and I commend you for
that.
It seems that the private sector relies on some codes and
guides that work well for them that are simpler than the VA's
rating schedule. I am just curious if you had the observation
and if you considered adopting what is already in existence in
terms of disability ratings in the private schedule as opposed
to going through this process of what some would call
reinventing the wheel.
Would it take a shorter time to revise the rating schedule
if we did that?
Mr. Mayes. A couple of comments on that. I guess one could
argue the VA has been revising that schedule since 1917, you
know, in reality. I would say that we are interested in hearing
what the American Medical Association has to say, as well as
the World Health Organization.
As a matter of fact, next week, we are meeting with Dr.
Rondinelli to discuss their compensation scheme. We are open to
considering other alternatives.
I would say, though, I was struck by Dr. Bristow's comment
regarding the International Classification of Disease system. I
think he mentioned 14,000 to 17,000 codes. The VA rating
schedule right now has in excess of 700 codes.
Mr. Hall. They should adopt your schedule then.
Mr. Mayes. Yes, sir. I do not know that we want to get more
complex. What we want to do is make sure that we have a system
that accurately compensates veterans for earnings loss and
quality of life if that becomes the mandate.
And I believe that there is the possibility to cross walk
that system with the International Classification of Disease
system which, as I understand it, was primarily set up for
identifying diseases and for billing purposes.
We are trying to come up with a system and particular codes
that will provide for evaluation criteria to compensate
veterans. I think that makes it a little bit different than the
ICD scheme.
Mr. Hall. Right. I would also assume that the World Health
Organization and other organizations have to consider some
genetic syndromes and diseases that, may not be something that
would be service related. They could be if you happened to be
serving in an area where a rare pathogen was at work, but that
some of them could be ruled out.
I wanted to ask you, does VHA already evaluate veterans for
their quality of life? Is that not what the SF36 scale is
designed to indicate?
Mr. Mayes. I am aware of that standard form and I do
believe that they administer that, but I personally am not
familiar with how frequently or who they administer that
instrument to.
Mr. Hall. Can you explain why according to the VDBC report
so many veterans with PTSD are rated with IU instead of a 100-
percent schedule rating?
Mr. Mayes. I cannot unequivocally explain that, although I
would take the opportunity to echo what some of the previous
panel members from the Veteran Service Organizations said.
The IU benefit was created in 1934, and it was set up to
provide VA with the ability to compensate a veteran for an
unusual disability picture that the schedule may not have been
able to deal with when that disability precluded employment.
And that was the purpose of the IU benefit.
I would agree with some of the previous panel members. It
may be that we have a higher percentage of PTSD recipients who
are having difficulty securing and maintaining gainful
employment. Therefore, we have exercised that discretion and
granted the IU benefit. And that is precisely why we are
beginning to tackle the mental disabilities portion of the
rating schedule.
Mr. Hall. In 2006, VA agreed with the GAO recommendation to
establish procedures for rating specialists to request
Vocational Rehabilitation and Employment to conduct vocational
assessments of IU claimants ``as appropriate.'' But VA has
never acted on its concurrence.
Why is this?
Mr. Mayes. The purposes of the vocational rehabilitation
program is to assimilate veterans back into the work force. The
vocational rehabilitation assessment was designed to assist our
voc rehab employees with developing a rehabilitation plan. And
the whole construct for that program was to evaluate and to try
to transition those servicemembers or veterans back into the
workforce.
I do not have a short answer for you. I think that we
talked about it. I do not believe we were resourced. I do not
want to say that we were not resourced. But our distribution of
resources would have been challenging because we had never done
that for IU. The decision was made to continue on that path.
Tom, do you want to add to that? I know you were here
during those discussions.
Mr. Pamperin. Yes, sir. We looked at it extensively. And I
think there is value in looking at the potential for
rehabilitation when considering individual unemployability.
There are, however, a couple of immediate barriers that
have to be confronted. This would require a vocational
assessment for everyone who claimed individual unemployability
or whose disability picture was such that it reasonably raised
IU as an issue.
And when we were looking at the numbers, this is in excess
of 80,000 people a year who would have to be assessed through
vocational rehabilitation. And whether or not we are positioned
to deal with that level of workload and still deliver
rehabilitation services to people who want them is a real
challenge.
There is also the question as to whether or not legally
that could be done without legislation.
Mr. Hall. Thank you.
Mr. Mayes, you were asked to discuss presumption in your
testimony today, but you only mentioned it as it was applied in
1921 for tuberculosis.
Is there a further VA response to the recent IOM report on
presumptive disability decisionmaking?
Mr. Mayes. We are still evaluating the IOM study. I do not
have a formal position regarding their recommendations at this
point, although I would say that it seems that the causation
standard would be a high standard.
Mr. Hall. Maybe you could send us a message when you come
to a further conclusion.
I keep hearing that there are three simple things needed to
establish service connection, the diagnosis, eligible military
service, and a nexus between the two.
Can you explain the overwhelming need for evidence? How
much evidence is enough and why does VA require so much
documentation from a veteran?
Mr. Mayes. Ultimately I believe that we want to make sure
that we collect all of the evidence that is available so that
we render an accurate decision and a decision that favors the
veteran to the extent possible.
Further, we do have certain statutory requirements, a duty
to assist, a duty to notify. Those requirements are very
specific that we must attempt to obtain any and all evidence
that is referenced by the claimant.
Those records that are in our constructive custody, we must
obtain those unless the custodian of those records tell us that
they do not exist. That truly is a statutory requirement, and
we want to help the veteran.
Mr. Hall. Thank you.
Dr. Kelley, you mentioned that since National Defense
Authorization Act of 2008 (NDAA) and the creation of the Senior
Oversight Committee (SOC), many of the issues between the two
departments on the application and revisions of the VASRD are
now being worked in a collaborative and productive manner,
unquote.
Can you tell me what those applications and revisions are
and how did you communicate your input on the VASRD prior to
the SOC?
Dr. Kelley. Let me let Dr. Carson answer that first.
Mr. Hall. Sure.
Dr. Carson. Mr. Chairman, thank you for the opportunity.
My current role as an appellate review physician at our Air
Force Review Boards Agency, I am prefacing my remarks with this
statement so that you will understand a bit about how we
communicate with our sister services and the VA.
We have established communication that is via the
Disability Advisory Council, which is a Department of Defense
Committee, where there is cross talk, communication, discussion
on issues. It is also attended by a Department of Veterans
Affairs representative. So that forum has been and will be a
principal entity for the type of communication that you are
referring to.
I will say that as recent as this past Friday, the
Department of Veterans Affairs and the Air Force Personnel
Center at Randolph Air Force Base initiated an initial
conference call to discuss variances in methodologies in
ratings.
Also, the Department of Veterans Affairs has offered
training as soon as March of this year and April of this year
designed to train our adjudicators on VA methodologies.
Additionally, the NDAA 2008 has been reviewed top to bottom
and all disability-related matters have been looked at
carefully. And we are in the process as of the execution date
of that Act in looking at applications and our current policy
under Department of Defense instruction 1332.39, which is our
principal document that we use along with the VASRD in rating
disabilities.
And we are identifying those areas that we are now
prohibited from utilizing in rating disabilities that may
result in a reduction or a deduction or a rating less than the
VA absent the existence of this policy.
This is ongoing. And as of even yesterday, we received at
our agency an initial inventory of records that have recently
been adjudicated so that immediate disability rating
corrections, or adjustments, may be made as necessary, in the
context of current law; specifically, the NDAA that become
effective on January 28, 2008.
[The following information was subsequently received:]
The specific implementation methods for services to review ALL
cases previously rated at ``less than 30 percent dating to ``9/
11,'' is still in the planning phase. This item will be
followed-up to assure it is addressed at the next Disability
Advisory Council meeting.
Dr. Carson. I will pause at this point and allow Dr. Kelley
to speak.
Dr. Kelley. Yes, sir. So I think Dr. Carson mentioned that
we are having the combined training. Each of the services will
have their senior physician that does the disability processes
going to that training in April. And there are some on the
personnel side that are also going to that training in April.
Dr. Carson mentioned the Disability Advisory Council. There
is also a review in the H-E-C, which we call the HEC, which is
the Health Executive Council. That is chaired by the Assistant
Secretaries for Health on both sides, as well as the JEC, which
is the Joint Executive Council, which reviews both the health
and the personnel issues. And that is at the Under Secretary
that is chaired.
And then the example that I cited in my summary where we
have had a working group that worked extensively with the VA on
the TBI and the burn revisions that were just published. And so
that is moving forward.
Mr. Hall. Well, that is encouraging. If you guys keep
working together like that, we might not have anything to do.
Mr. Pamperin. Sir, could I add something?
Mr. Hall. Yes.
Mr. Pamperin. Because I, like Dr. Carson, am on the
Disability Advisory Council. Based upon the conversations we
had at the last session, DoD did submit to us concerns or
issues or recommendations on about four items in the rating
schedule that we took under advisement and provided them with a
response to. I believe it was last week.
Mr. Hall. Thank you.
And if you could keep the Committee in the loop or the
Subcommittee because you are a little bit of a moving target.
We are trying to figure out what to do or what we might need to
do or what would be helpful for us to do legislatively.
And I am happy to hear that these working groups and
conversations and cross talk is going on because we all think
that it is essential certainly to the accuracy and the
timeliness of the ratings and the provision of benefits to the
veterans who deserve them.
And, Dr. Kelley, the Veterans' Disability Benefits
Commission found in their study that there were variances in
the way DoD rates disabilities and compares them to the way VA
does them. As you probably know, VA has also had its own issues
with variances between raters and Regional Offices.
What steps beside the training that you mentioned would you
recommend to gain more consistency in rating disabled veterans
regardless of where or who did the rating?
Dr. Kelley. Well, I think that the training is important as
a first step. I think that there needs to be a greater
understanding of the exact nature of why those differences
occur which we need to discuss and adjust so that we understand
so that there are some--we have heard several other panel
members talk about how a specific illness or injury could
affect different people depending on their occupation
differently.
And the DoD when they do a fitness for duty, they determine
a fitness to work in the particular job. It is not a general
fitness for duty. And so because of that and the VA is doing a
general and total evaluation, there are some differences.
I think that we need to have the common nomenclature so
that we are all talking the same way, and that, again, has been
mentioned earlier, so that we can interpret the rating systems
in the same way on both sides.
Mr. Hall. You mentioned that in your oral testimony,
``consistent nomenclature.'' I think that would be a helpful
step among other things in terms of getting closer to a system
that could do a substantial number of ratings electronically
with artificial intelligence.
You mentioned the Disability Advisory Committee. When did
that group start interacting with the VA and do they or are you
discussing the rating schedule as part of those discussions?
What would make the rating schedule a better tool from DoD's
standpoint besides consistent nomenclature?
Dr. Kelley. I will get back to you on when the VA actually
started working in the Disability Advisory Committee.
Mr. Hall. Dr. Carson.
Dr. Carson. I can assure you that since my entry into the
system in 1998, I know you have a decade of it at least, and I
am sure it is many, many years before that.
Mr. Hall. Good.
From your statement, Dr. Kelley, it sounds as if DoD is
already preparing to implement the findings of the disability
evaluation system pilot that is ongoing with VA.
What steps are being taken to prepare for this transition
to a single system for evaluating disabilities?
Dr. Kelley. We are looking forward to doing that and we are
not prepared to do that right now. So we do not have a complete
strategic plan of how we will do that because we are waiting
for some of the results or the results of the lessons learned
from that pilot.
We are working with the VA. We have issues to work out on
the resources that are going to be required, who is going to do
the exams. There are certain locations. For example, having the
VA do the exams would work, but there are no VA facilities
overseas.
And so we have to work out those details of the specific
cases. Some places we have bases and there is only clinics that
do not have the VA capability of providing many services. Other
places the VA has much better facilities than the military
does.
And so we think that it is probably going to require a
mapping process for each specific site and then when we bring
in the Reserves and the Guards, that is going to make that a
much more difficult conclusion or solution for that. And so we
have to work those out, but are looking for the lessons learned
as we go along so that we can apply that.
Mr. Hall. Difficulty aside or taken into account, do you
have a time frame in mind that you think this can be done in?
Dr. Kelley. I do not, sir. I will get back to you if we
have one.
Mr. Hall. Somewhere between 2 and 10 years?
Dr. Kelley. Sir, we are looking in terms of short term
rather than long term.
[Followup information from Dr. Kelly was supplied in the
post-hearing questions and responses for the record, which
appear on p. 138.]
Mr. Hall. We will all be grateful for that.
Last, I have a question from Ranking Member Lamborn to Mr.
Mayes. Your testimony suggests that the revision of the rating
schedule has been underway since the nineties.
I recently became aware of a case of a veteran who is
completely deaf in one ear, yet he only receives the minimum
level of compensation. I was unable to explain to him why the
rates for hearing loss are at such a seemingly paltry level.
I understand that The Independent Budget has a longstanding
resolution calling for a compensable rating for anyone with a
hearing aid. It seems reasonable to me that the required use of
a prosthetic device would easily warrant compensation,
especially when one considers the high noise environment
inherent to military service.
Has any consideration been given to revising the rates for
hearing loss?
Mr. Mayes. Specifically, consideration has been given to
compensation for veterans who are in need of a hearing aid. We
have had those discussions in our policy shop and have
contemplated moving forward with that.
As far as changing the diagnostic criteria for hearing
loss, there is nothing currently in the works to change that
diagnostic criteria.
Mr. Hall. What about for other prosthetic devices?Mr.
MAYES. For other prosthetic devices?
Mr. Hall. Right. The question was specifically about
hearing aids, but I would also ask the question about----
Mr. Mayes. Typically a veteran in need of prosthetic
devices is going to have an amputation. There is already a
compensation scheme in place for amputation. It is very
detailed and lays out the criteria, whether it be, for example,
a below-knee amputation, above-knee amputation, below the
elbow, above the elbow, etc.
I am not sure that there is the difficulty or maybe the
perception that I am hearing about the hearing loss----
Mr. Hall. It is more concrete and easily identified than
hearing loss?
Mr. Mayes. Exactly. We hear this because veterans are
service-connected because there is some impairment, but it is
not at a level sufficient for us to pay disability compensation
based on the evaluation criteria. VHA will issue them a hearing
aid. We understand that and we have had discussions regarding
that.
Mr. Hall. Thank you.
I want to thank you all very much for your testimony, for
your dedication to our Nation's veterans, for your patience
this afternoon waiting to be the fourth but greatest panel.
And we thank everyone for their interesting and informative
statements this afternoon. We look forward to working with you
on this very important topic and improving the VA claims
process system.
This hearing now stands adjourned.
[Whereupon, at 6:20 p.m., the Subcommittee was adjourned.]
A P P E N D I X
----------
Prepared Statement of the Honorable John J. Hall
Chairman, Subcommittee on Disability Assistance and Memorial Affairs
This is the third hearing this Subcommittee has held regarding VA's
claims processing system. As we have discussed before, this system has
not lived up to expectations and has left many disabled veterans
without proper and timely compensation and other benefits.
At the heart of this system is the VA Schedule for Rating
Disabilities (or VASRD). The Rating Schedule, as we know it today is
divided into 14 body systems, which incorporate approximately 700 codes
that describe illness or injury symptoms and levels of severity.
Ratings range from 0 to 100 percent and are in increments of 10. This
schedule was uniquely developed for use by VA, but the Defense
Department has also mandated its use when the service branches conduct
evaluation boards on servicemembers who are unfit for duty. Otherwise,
it is not used by any other governmental agencies or private sector
disability plans.
In its study, the Veterans' Disability Benefits Commission (VDBC)
concluded that the VA Rating Schedule has not been comprehensively
updated since 1945. Although sections of it have been modified, no
overall review has been satisfactorily conducted leaving some parts of
the schedule out of date, relying on arcane medical practices, and not
in sync with modern disability concepts. The notion of a Rating
Schedule was first crafted in 1917, so that returning World War I
veterans could be cared for when they could no longer function in their
pre-war occupations. At the time, the American economy was primarily
agricultural based and labor intensive. Today's economy is different
and the effects of disability are understood to be greater than the
average loss of earning capacity. Many disability specialists agree
that quality of life, functionality, and social adaptation are just as
important. Our Nation's disabled veterans deserve to have a system that
is based on the most available and relevant medical knowledge.
There are several issues pertaining to the Rating Schedule I hope
to have us discuss today:
First would be the need to remove out-of-date and archaic criteria
that is still part of the schedule for some conditions and replace them
with current medical and psychiatric evaluation instruments for
determining and understanding disabilities. The medical community
relies on codes from the International Classification of Diseases and
the Diagnostic and Statistical Manual of Mental Disorders. Should the
VBA be relying on these and other AMA guides as well?
Individual Unemployability (IU) as a rating gives VA an alternative
means by which to compensate veterans who cannot sustain gainful
occupation, but might not otherwise be rated 100 percent. The
Government Accountability Office found that the use of IU was
ineffective and inefficient since it relies on old data, outdated
criteria, and lacks guidance. The VDBC, IOM, and CNA also studied IU
and expressed their concerns over how it is utilized instead of
scheduled ratings. I look forward to hearing more from them today.
The criteria for psychiatric disabilities, especially for Post
Traumatic Stress Disorder (PTSD) are in dire need of expansion. The
current Rating Schedule has only one schedule for all of mental health,
which is based on the Global Assessment of Functioning Scale (GAF). The
IOM noted that one of the many problems with GAF is that it was
developed for Schizophrenia, therefore not as accurate for other
disorders and recommended that VA replace it as a diagnostic tool. I am
especially concerned about this issue and how it pertains to PTSD and
other mental disorders.
The VDBC also recommended that traumatic brain injury (TBI) be a
priority area of concentration, and for VA to improve the neurological
criteria for TBI, which has become one of the signature injuries of
this war.
I know there has been much discussion on how to compensate veterans
for their quality of life losses. Both the VDBC and the Dole/Shalala
Reports recommended that this be a new category added to the Rating
Schedule in some fashion. But, they did not necessarily agree or
provide clear guidance on how to do this or whether the current system
does so implicitly. So, next steps are still needed.
Presumptions have had a major impact on VA compensation over the
last few decades for conditions related to Ionizing Radiation, Agent
Orange and the Gulf War. The IOM therefore engaged in a lengthy study
for the VDBC on presumptions and recommended that there be evidence-
based criteria, which could impact the Rating Schedule. I commend
Secretary Peake for changing the regulation on PTSD, but we also might
want to add a presumption that combat zone service is a stressor when
evaluating PTSD.
I look forward to the testimony today on these complex Rating
Schedule issues. I know there is a lot to be done to improve the VA
claims processing system, but with the Rating Schedule at the core of
the process, it seems that the centerpiece is in need of immediate
comprehensive repair, which I intend to advocate.
I look forward to working with Ranking Member Lamborn and the
Members of this Subcommittee in providing oversight for the VA Schedule
for Rating Disabilities. VA needs the right tools to do the right
thing, so our Nation's disabled veterans get the right assistance.
Prepared Statement of Hon. Doug Lamborn
Ranking Republican Member
Thank you Mr. Chairman for yielding.
I look forward to hearing our witnesses' testimony and I am pleased
to have this opportunity for a collective discussion on the Department
of Veterans Affairs', Schedule for Rating Disabilities.
The VA Rating Schedule provides the basis for determining the level
of compensation that is appropriate for veterans' disabilities.
It is a complex schedule that is unparalleled by any other
disability benefits system.
The schedule is complex, because the human body is complex.
It may seem a paradox that the complexity of the rating schedule
favors veterans, but this is due to the fact that each rating is as
specific to individual injuries as possible.
The result is more than 700 diagnostic codes that pertain to each
body system.
While the VA has made adjustments over the course of many decades,
it is still obviously important that this Committee confer with VA and
its stakeholders to ensure that the rating schedule is as accurate and
up-to-date as possible.
Veterans must be assured that the compensation they receive for
disabilities is based on information that is both credible and fair.
Recent Congressional and Administrative Commissions have questioned
the validity of the rating schedule in as much as it is unclear how
well quality-of-life and loss-of-earnings are taken into consideration.
Perhaps further study is needed to analyze these points, and also
to look at the rating schedule from a contemporary perspective with
regard to today's job market.
I want to make clear; the purpose in doing such a study is to
ensure veterans are justly compensated for their sacrifices.
I have read the statements that have been submitted, and I
understand veterans' service organizations have rightly expressed
concern that the schedule should not be subject to arbitrary tampering.
I commend VSOs for their protective posture regarding veterans'
disability compensation, and want to emphasize that their stance is
precisely why we need them to be active participants in any effort to
examine and update the schedule.
Mr. Chairman, I thank you for yielding, and I look forward to
working with you on this issue in the favorable, bipartisan manner we
have established on this Subcommittee.
I yield back.
Statement of Vice Admiral Dennis Vincent McGinn, USN (Ret.)
Member, Veterans' Disability Benefits Commission on behalf of
Lieutenant General James Terry Scott, USA (Ret.), Chairman
Chairman Hall, Ranking Member Lamborn, Members of the Committee, I
am pleased to appear before you today on behalf of the Chairman of the
Veterans' Disability Benefits, General Terry Scott, to discuss the
findings, conclusions, and recommendations of the Commission related to
revising the VA Rating Schedule.
The Commission was created by Public Law 108-136 and Commissioners
were appointed by the President and the four leaders of Congress to
study the benefits and services that are provided to compensate and
assist veterans and their survivors for disabilities and deaths
attributable to military service. Specifically, the Commission was
tasked to examine and make recommendations concerning:
The appropriateness of such benefits;
The appropriateness of the level of such benefits; and
The appropriate standards for determining whether a
disability or death of a veteran should be compensated.
The Commission completed its work and submitted its report on
October 3, 2007.
My statements today are my own and do not necessarily represent the
views of the Commission.
For almost 2\1/2\ years, the Commission conducted an extensive and
comprehensive examination of issues relating to veterans' disability
benefits. This was the first time that the subject has been studied in
depth by an independent body since the Bradley Commission in 1956. We
identified 31 key issues for study. We made every effort to ensure that
our analysis was evidence based and data driven, and we engaged two
well-known organizations to provide medical expertise and analysis:
the Institute of Medicine (IOM) of the National
Academies, and
the CNA Corp. (CNAC).
Both of those organizations are represented today at this hearing.
Of the many issues the Commission examined, one of the most
important was determining the effectiveness of the VA Rating Schedule.
You will be hearing from four panels today including Drs. Bristow,
Kilpatrick, and Samet representing their IOM Committees, Dr. McMahon
from CNAC, independent experts, veteran service organizations, and
Admiral Cooper and Mr. Mayes representing the Department of Veterans
Affairs. I will keep my remarks brief and focus on the conclusions and
recommendations of our Commission relative to the Rating Schedule.
Our Commission is most appreciative of the outstanding work of the
IOM Committees and CNAC. Our intent was to complete a data-driven and
evidenced-based analysis of disability benefits and IOM and CNAC
enabled us to do exactly that. We believe that their efforts were
exceptionally complimentary of each other and that their results were
remarkably consistent with each other. The Commission's report
summarizes the analysis and recommendations of CNAC and the IOM
Committees in some detail, however, the reports to the Commission are
rich in detail, with extensive analysis, and each should be carefully
reviewed.
I would like to highlight a few of their key findings that the
Commission found especially helpful. For example, Dr Bristow's
Committee emphasized that the Rating Schedule should achieve horizontal
and vertical equity. Vertical equity means that VA ratings of severity
of disability, assigned in 10 percent increments from 0 to 100 percent,
should be accurately assigned so that those assigned more severe
ratings should be those veterans whose disabilities impact their
earnings more than those assigned less severe ratings. CNAC's
comparison of the earnings of veterans who are not service disabled
with service disabled veterans demonstrated that disability causes
lower earnings and employment at all levels of severity and types of
disabilities and that the earnings loss of the disabled increases as
the percent rating increases. Thus VA ratings, using the Rating
Schedule, are generally achieving vertical equity. Horizontal equity
means that assigned ratings of severity should reflect average loss of
earnings among the nearly 800 diagnostic codes and across the 16 body
systems. CNAC's analysis generally confirmed horizontal equity as well.
Overall, CNAC's analysis confirmed that the VA Rating Schedule, and
VA's assignment of ratings using the Rating Schedule, results in
compensation paid to veterans that is generally adequate to offset
average impairment of earnings. Taken as a whole, the Rating Schedule
is doing its job reasonably well. The detailed and comprehensive
analysis demonstrated that even veterans with less severe ratings do,
in fact, have loss of earnings.
However, the key word here is generally. CNAC's analysis also
identified very pronounced disparities for some veteran cohorts in
which vertical and horizontal equity are not being achieved. The amount
of compensation is not sufficient to offset loss of earnings for three
groups of veterans:
those whose primary disability is post traumatic stress
disorder (PTSD) or other mental disorders,
those who are severely disabled at a young age, and
those who are granted maximum benefits because their
disabilities make them unemployable.
For these veterans, horizontal and vertical equity is not being
achieved.
Those severely disabled at a young age have greater loss of
earnings, especially over their remaining lives, since they did not
have established civilian careers or transferable job skills and have
more of their normal working years ahead of them. The analysis also
clearly demonstrates that veterans with PTSD and other mental disorders
experience much greater loss of employment and earnings than those with
physical disabilities, particularly those more severely disabled. These
disparities should be addressed by a careful but prompt revision to the
Rating Schedule, leading to a more equitable level payment to disabled
veterans in this severely disabled category.
Concerning PTSD and mental disorders, the reasons for insufficient
compensation may lie partly in the criteria in the Rating Schedule
itself, and partly in how the VA raters interpret or apply the
criteria. The Rating Schedule was revised a few years ago to eliminate
separate criteria for diagnoses such as PTSD and in order to have a
single set of criteria for all 67 diagnoses contained in the body
system known as mental disorders. The Commission asked the IOM to
provide advice as to whether a single set of criteria is effective. IOM
recommended that separate criteria should be established for PTSD and
CNAC's survey of VA raters and VSO service officers found agreement
with that advice.
Concerning the interpretation of the criteria by raters, the
Commission learned that almost one half of 223,000 veterans granted
Individual Unemployability (IU) as being unable to work due to their
service-connected disabilities had primary diagnoses of PTSD (31
percent) or other mental disorders (16 percent.) To be granted IU, the
veteran must be rated 60 to 90 percent disabled and also be found
unable to work due to the service-connected disability. The criteria
for all mental disorders require that the veteran be unable to work due
to the disorder in order to be rated 100 percent. Yet, these veterans
are not rated 100 percent. They are rated 70 percent and assigned IU
status and paid at the 100-percent rate. The Commission did not
understand why these veterans were not rated 100 percent according to
the Rating Schedule. Our Commission recommended that as the Rating
Schedule is revised, every effort should be made to reduce the need to
rely on the IU category. That said, we agreed that in some cases, there
will continue to be some need for the IU category.
The IOM reports on PTSD Diagnosis, PTSD Compensation, and PTSD
Treatment together provide a solid analysis of this disability and the
problems associated with diagnosis, examination, treatment, and
compensation. The report on PTSD Treatment was completed after our
report and, therefore, could not be reflected in our report. Our
Commission considered the diagnosis and compensation Committee reports
and they weighed heavily in our deliberations. Ultimately, we
recommended a course of action for PTSD somewhat different from the
IOM: a holistic approach that couples treatment, compensation, and
vocational assessment along with reevaluation every 2-3 years to gauge
treatment effectiveness and encourage wellness. We felt that veterans
with PTSD would not be well served by simply providing compensation
without continuing follow up and incentives to seek treatment.
Our Commission concluded that there has been an implied but
unstated Congressional intent to compensate disabled veterans for
impairment to quality of life due to their service-connected
disabilities. Our conclusion was reflected in our consideration of
question 2 of our 31 research questions. The Commission addressed this
quality of life question in two ways. First, we asked the IOM to
suggest specific measures for assessing the impact of disability on
quality of life. Second, we requested that CNAC conduct an extensive
survey of a representative sample of disabled veterans to ascertain the
extent of the impact. IOM concluded that limiting veterans'
compensation to only address work disability or earnings loss would be
too restrictive and inconsistent with current models of disability. IOM
recommended compensating veterans for the loss of some ability to
engage in usual life activities, other than work, and for loss in
overall quality of life. The results of the extensive CNAC survey of
disabled veterans and their families demonstrated that disabilities
diminish quality of life at all levels of ratings and, further, that
the impact is greater for those with mental rather than physical
disabilities. Together, the IOM and CNAC findings provide a sound
philosophical and research based justification for compensating
veterans for the impact of their service-connected disabilities on
quality of life. That is what the Commission's considerable
deliberations about loss of quality of life reflect.
In addition, CNAC's survey analysis demonstrated that current
compensation payments do not provide payment above that required to
offset earnings loss. Therefore, there is currently no compensation for
the impact of disability on quality of life for most veterans. As a
result, our Commission recommended that current compensation payments
should be increased up to 25 percent, with priority to the more
seriously disabled, while permanent quality of life measures are
developed and implemented. We understand that VA has contracted for an
additional study to address how to properly compensate for the impact
of disability on quality of life.
Regarding the current determination of presumptive conditions, when
there is considerable evidence that a condition is experienced by a
sufficient cohort of veterans, a ``presumption'' is established that
the condition is the likely result of military service. This has been
done for radiation exposure, Agent Orange defoliant in Vietnam, and
other conditions. The Commission asked the IOM to review the existing
process for making these decisions and IOM recommended a detailed,
comprehensive, and transparent framework based on better and consistent
use of scientific principles. Dr. Samet will address this subject in
greater depth. Our Commission believes that his presumption
determination framework will significantly improve the process and
result in better outcomes for both the veterans and the VA. Moving
forward, there is some concern over the ``causal effect'' standard that
Dr. Samet's IOM Committee recommended be implemented. The Committee
proposed that this standard be used instead of the existing standard
based on ``association''. In our report, the Committee cautions that
Congress should weigh this aspect of the IOM recommendations carefully.
Despite the evidence that the Rating Schedule generally results in
veterans being compensated adequately for average loss of earnings
except for PTSD and other mental disorders, those severely disabled at
younger ages, and those currently compensated as IU, there are
significant problems with the Rating Schedule that need to be addressed
in an urgent manner. Dr. Bristow and Dr. Kilpatrick will address these
problems in much greater detail but let me summarize the Commission's
thoughts.
The Commission concluded that the current VA Rating Schedule has
not been adequately revised. IOM found that 47 percent of the 798
disability codes organized in 16 body systems have been revised since
1990, but 35 percent have not been revised since 1945 and only 18
percent were revised between 1945 and 1989. We recommended that the
Rating Schedule be updated as soon as possible but certainly within the
next 5 years. We disagreed somewhat with IOM's recommendation in that
we felt that priority should be placed on specific criteria for the
evaluation and rating of traumatic brain injury (TBI) and all mental
disorders, especially PTSD. IOM recommended beginning with those
diagnostic codes that have been the longest without update. We both
agree that the revision should be accomplished as quickly as possible.
By any reasonable standard, VA has not paid sufficient attention to
keeping the Rating Schedule up to date. Dr. Bristow will, I'm sure,
address the medical aspects of the criteria. I noted that his Committee
compared the VA resources and staffing levels to those that the Social
Security Administration has devoted to keeping their equivalent of the
rating schedule current. VA's staffing does not compare well. It is
very clear that VA must devote increased staff to this important task.
As Dr. Bristow's Committee recommended, VA should create an ongoing
process for keeping the Rating Schedule up to date, including
publishing a timetable, and creating an advisory Committee for revising
the medical criteria for each body system.
As I understand the current status of revisions, VA published a
notice revising the Rating Schedule criteria for TBI and the comment
period ended February 4, 2008. I further understand that a draft
revision for PTSD rating criteria is nearing completion. While these
actions are welcome, I would point out that Dr. Bristow's Committee
report was released in June of 2007. Revisions to 2 of 798 diagnostic
codes in 8 months is not a satisfactory pace for review. This may
indicate that VA still needs a stronger sense of urgency and the
application of adequate resources to conduct the Rating Schedule
revision at a faster pace.
In summary, the Veterans' Disability Benefits Commission found that
although the Rating Schedule generally enables service-disabled
veterans to receive adequate compensation for average loss of earnings
capacity, the Schedule falls short for those with PTSD and other mental
disorders, those severely disabled at younger ages, and those needing
IU. It does not provide any compensation for loss of quality of life.
It is somewhat ironic and certainly relevant to today's
deliberations, that the Bradley Commission in 1956, only 11 years after
the major revision of the Rating Schedule in 1945, found that the
schedule had not been updated sufficiently. Now, 50 years later, our
Commission and the IOM arrived at the same conclusion. This situation
needs to be corrected expeditiously.
The Bradley report also recommended extensive analysis on an
ongoing basis to assess the adequacy of payments and the effectiveness
of the Rating Schedule. Until our Commission was constituted in 2004,
only one attempt to review the Rating Schedule was made in the
seventies and the results of that analysis were discarded. Our
Commission recommended that Congress should grant statutory authority
to VA and DoD to obtain and analyze data from the Social Security
Administration in order to periodically assess program outcomes at the
diagnostic code level and adjust compensation levels accordingly.
As I have reflected in the foregoing statement, only by keeping the
Rating Schedule current with the best, up-to-date, medical knowledge
and by adjusting the payment levels to offset both loss of earnings and
quality of life can we be assured that disabled veterans and their
families are adequately compensated. These conclusions were the clear
consensus of our Commission. The specific recommendations in our report
should be used to guide needed legislative actions by Congress as well
as the policy and resource allocations by the Departments and Agencies
needed to update and improve disabled veterans' benefits.
Statement of Lonnie Bristow, M.D., Chair
Committee on Medical Evaluation of Veterans for Disability Benefits
Board on Military and Veterans Health, Institute of Medicine
The National Academies
Good afternoon, Chairman Hall, Ranking Member Lamborn, and Members
of the Committee. My name is Lonnie Bristow. I am a physician and a
Navy veteran, and I have served as the president of the American
Medical Association. I'm joined on this panel by Drs. Dean Kilpatrick
and Jonathan Samet, who will introduce themselves shortly. On their
behalf, thank you for the opportunity to testify about the work of our
Institute of Medicine (IOM) Committees. Established in 1970 under the
charter of the National Academy of Sciences, the IOM provides
independent, objective advice to the Nation on improving health.
My task today is to present to you the recommendations of the IOM
Committee I chaired, which was asked to evaluate the VA Schedule for
Rating Disabilities and related matters. Dr. Kilpatrick will follow me
to speak about his Committee's work, which focused on post-traumatic
stress disorder, which is a particular challenge for the VA top
evaluate. Dr. Samet will conclude our panel's presentation by briefing
you on the findings of his Committee, which was asked to offer its
perspective on the scientific considerations underlying the question of
whether a health outcome should be presumed to be connected to military
service.
I had the great pleasure and honor of chairing the IOM Committee on
Medical Evaluation of Veterans for Disability Compensation, which was
established at the request of the Veterans' Disability Benefits
Commission and funded by the Department of Veterans Affairs (VA).
Updating the Basis for Disability Compensation
Our report, A 21st Century System for Evaluating Veterans for
Disability Benefits, which was issued last July, makes a number of
important recommendations regarding the VA Rating Schedule and related
matters. Our first recommendation is to broaden the purpose of the VA
disability compensation program, which currently is to compensate for
average loss of earning capacity, or work disability. We recommend that
VA also compensate for loss of ability to engage in the usual
activities of everyday life other than work and, if possible, for
diminished quality of life. We recognize that legislative action will
be required to change the statutory purpose of the disability
compensation program, but doing so would bring the compensation program
in line with our current understanding that disability has broad
effects (see attached figure 4-1 from the report).
Assessing the Rating Schedule
When the Committee reviewed the Rating Schedule, we found that:
Although it is called the Schedule for Rating
Disabilities, it currently evaluates degree of impairment (i.e., loss
of a body part or function) rather than degree of disability (i.e.,
limits on a person's ability to function at work or in life).
Even in rating degree of impairment, the Schedule is not
as current medically as it could and should be.
The relationship of the rating levels to average loss of
earning capacity is not known.
The Schedule does not evaluate impact on a veteran's
ability to function in everyday life.
The Schedule does not evaluate loss of quality of life.
Accordingly, we made a series of recommendations to update and
revise the Rating Schedule.
Updating the Rating Schedule
First, the Committee recommends that VA should immediately update
the current Rating Schedule, beginning with those body systems that
have gone the longest without a comprehensive update (i.e., the
orthopedic part of the musculoskeletal system, the neurological system,
and the digestive system). Revisions of the remaining systems could be
done on a rolling basis, several a year, after which VA should adopt a
system for keeping the Schedule up to date medically. Also, VA should
establish an external disability advisory Committee to provide advice
during the updating process.
As part of updating the Rating Schedule, VA should move to the
International Classification of Diseases (ICD) and Diagnostic and
Statistical Manual of Mental Disorders (DSM)diagnostic classification
systems that are used in today's healthcare systems, including VA's.
Evaluating Traumatic Brain Injury
We were asked by your staff about improving the criteria for
traumatic brain injury, or TBI. TBI is an excellent example of where
the rating criteria in the Schedule need to be updated in accord with
current medical knowledge and practice.
TBI is rated under diagnostic code 8045, ``Brain disease due to
trauma,'' which was last updated substantively in 1961. Today, we
understand much better how concussions from blast injuries can affect
cognition even though there is no evident physical injury. In Iraq,
many servicemembers have been subjected to multiple improvised
explosive device blasts. The current criteria emphasize physical
manifestations, such as paralysis and seizures. The Rating Schedule
recognizes that symptoms such as headache, dizziness, and insomnia are
common in brain trauma but limits them to a 10 percent rating. It is
time to review how to properly evaluate and rate TBI in light of
current medical knowledge, along with the rest of the neurological
conditions, most of which have not been revised since 1945.
Relating the Rating Schedule to Average Loss of Earnings
In addition to updating the Schedule medically, VA should
investigate the relationship between the ratings and actual earnings to
see the extent to which the Rating Schedule as revised is compensating
for loss of earnings on average. This would build on the analyses done
by the CNA Corp. at the body system level but use samples large enough
to study the most prevalent conditions being rated. Just 38 conditions
account for two-thirds of the compensation rating decisions. If VA
finds disparities in average earnings, for example, that veterans with
a mental disorder rated 70 percent earn substantially less on average
than veterans rated 70 percent for other kinds of disabilities, it
could adjust the rating criteria to narrow the gap.
Compensating for Non-Work-Related Functional Limitations
The Committee recommends that VA compensate for non-work
disability, defined as functional limitations on usual life activities,
to the extent that the Rating Schedule does not. To do this, VA should
develop a set of functional measures--e.g., ADLs (activities of daily
living), IADLs (instrumental activities of daily living)--and specific
performance measures, such as time to ambulate a certain distance, or
ability to do specific work-related tasks in both physical domains
(e.g., climbing stairs or gripping) and cognitive domains (e.g.,
communicating or coordinating with other people). After the measures
are validated in the disability compensation population, VA should
conduct a study of functional capacity among applicants to see how well
the revised Rating Schedule compensates for loss of functional
capacity. There may be a close correlation between the rating levels
based on impairment and degree of functional limitations (i.e., the
higher the rating, the more functional capacity is limited), in which
case the Rating Schedule compensates for both impairment and functional
loss. But if the correlation is not high or does not exist, VA should
develop a mechanism to compensate for loss of function that exceeds
degree of impairment. This could be done by including functional
criteria in the Rating Schedule or by rating function separately, with
compensation based on the higher of the two ratings.
Compensating for Loss of Quality of Life
The Committee also recommends that VA compensate for loss of
quality of life. We realize that quality-of-life assessment is
relatively new and still at a formative stage, which makes this
recommendation conditional on further research and development. VA
should develop a tool for measuring quality of life validly and
reliably in the veteran population, then VA should conduct research to
determine the extent to which the Rating Schedule might already account
for loss in quality of life. We might find that veterans with the
lowest quality of life already have the highest percentage ratings, but
if not, VA should develop a procedure for evaluating and rating loss of
quality of life of veterans with disabilities where it exceeds the
degree of disability based on impairment and functional limitations
determined according to the Rating Schedule.
Evaluating Individual Unemployability
The Committee also reviewed individual unemployability, or IU,
which has been a fast-growing part of the compensation program. Our
main finding concerning IU is that it is not something that can be
determined on medical grounds alone. IU is based on an evaluation of
the individual veteran's capacity to engage in a substantially gainful
occupation, rather than on the Rating Schedule, which is based on the
average impairment of earnings concept. Thus the determination of IU
must consider occupational as well as medical factors. To analyze IU
claims, raters have medical evaluations from medical professionals and
other medical records but usually they do not have comparable
functional capacity or vocational evaluations from vocational experts.
Therefore, the Committee recommends that, in addition to medical
evaluations by medical professionals, VA require vocational assessment
in the determination of eligibility for individual unemployability
benefits. Raters should receive training on how to interpret findings
from vocational assessments for the evaluation of individual
unemployability claims.
Other Recommendations
The Committee made additional recommendations on issues other than
the VA Schedule for Rating Disabilities, which I am not reviewing
today. They can be found in our report and our recommendations for
improving the medical examination and rating processes were presented
to you by our staff director, Michael McGeary, on February 14 (for
example, mandating the use of the online medical examination templates
and having medical consultants to advise the raters on medical
evidence).
This concludes my remarks. Thank you for the opportunity to
testify. I would be happy to address any questions the Subcommittee
might have.
FIGURE 4-1 The consequences of an injury or disease.
[GRAPHIC] [TIFF OMITTED] T1371A.001
From: A 21st Century System for Evaluating Veterans for Disability
Benefits. National Academies Press, 2007.
INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES
REPORT BRIEF NOVEMBER 2007
``A DUTY TO UPHOLD: MODERNIZING THE VETERANS' BENEFIT SYSTEM''
In times of war, the United States puts great demands on the men
and women of our Armed Forces. We ask that they risk life and limb for
our country, and they do so, willingly.
We honor our troops by providing them with the best medical support
possible. Today, thanks to advances in battlefield medicine and
logistics, a wounded soldier can be off the battlefield in minutes, in
surgery within an hour, and recovering in the U.S. within days.
Surviving the initial trauma, however, is only half the battle. The
impact of service-related injuries can last years, and indeed, a
lifetime. And while our on-the-ground medical treatment is a model of
science and efficiency, our system for handling veterans' disabilities
is often mired in outmoded procedures. Worse, it is sometimes mired in
World War II-era medical science.
This does not reflect a lack of will: Our Nation is unwavering in
its commitment to honor those who serve, and to compensate them for the
sacrifices they make. But our benefits system does not currently
measure up to this ideal.
Recognizing these disparities, the Congressionally established
Veterans' Disability Benefits Commission asked the Institute of
Medicine (IOM) to provide guidance in two critical areas:
How veterans are evaluated and compensated for
disability benefits; and
How we determine if a veteran's disability was caused by
their service to our country.
A 21st CENTURY SYSTEM FOR EVALUATING VETERANS FOR DISABILITY BENEFITS
Nearly three million veterans of the U.S. Armed Forces receive
compensation for disabilities incurred as a result of their service.
The financial burden of this compensation is significant: $30 billion
per year, with dependents and survivors receiving an additional $5
billion. The system for managing this compensation is necessarily large
and complex: In 2006, the Veterans Administration (VA) received over
650,000 claims for disability compensation, and made decisions on
nearly 630,000.
The efficiency suggested by those numbers, however, is illusory.
The average time to process a claim is 177 days, and appeals--some
100,000 annually--take almost 2 years. These delays come with
significant costs to deserving veterans, creating frustration and
hardship from those who most deserve our support.
EVALUATING THE CURRENT SYSTEM
The most critical component in deciding whether a veteran is
eligible for benefits is the ``VA Schedule for Rating Disabilities,''
better known as the ``Rating Schedule,'' or simply the ``Schedule.''
The Schedule is a list of more than 700 diagnostic codes, each with
criteria for determining the extent of impairment in a particular limb,
organ, or body system. A soldier who is shot in the arm, for instance,
may see a 10 percent, 50 percent, or other percentage impairment in the
use of that arm.
Clinical professionals medically evaluate claimants and provide
assessments to a group of nonclinical professionals, who then apply the
Schedule to determine a disability rating between a and 100 percent, in
l0-percent increments. Veterans with a service-connected disability
receive monthly payments tied to their ratings, currently ranging from
$115 a month for a 100-percent rating to $2,471 per month for a l00-
percent rating.
In principle, the VA disability benefits program is designed to
compensate individuals for their loss in earning power. It's only fair:
A soldier should not have to ``pay'' for their injuries by having their
income reduced throughout their life. In practice, Congress and the VA
have also recognized and compensated veterans for non-economic losses
since the disability program was put in place at the end of World War
I.
These targets, however, have been approached inconsistently. There
has been no systematic attempt to evaluate the connections between
medical conditions and actual earnings potential since the seventies,
and no effort to move beyond an ad hoc link between quality of life and
benefit ratings. Moreover, the Schedule itself has lagged substantially
behind changes in modem medicine.
In 2004, the Veterans' Disability Benefits Commission, an
independent group created by Congress for the sole purpose of assessing
the veterans' disability program, charged the IOM to study and
recommend improvements in the rating system. The research agenda
featured dozens of areas for investigation, including:
How well does the current system evaluate and compensate
losses of both quality-of-life and earnings capacity?
How well does the system provide additional benefits
(such as adapted housing and rehabilitation) where these benefits would
be beneficial?
Does the existing set of ratings and their application
accurately reflect a veteran's ability to make a living?
The IOM established a Committee to review these and other issues
and has published its findings in A 21st Century System for Evaluating
Veterans for Disability Benefits (2007).
A CALL TO ACTION
The Committee called for immediate action. It found the current
system to be out-of-date and out-of-touch with both modem medicine and
our modem understanding of disability.
The most urgent finding was a call to reassess the fundamental link
between disability and compensation, and to bring our understanding of
the impact of different disabilities into the 21st century.
The Rating Schedule is predicated on compensating veterans for a
loss of income related directly to their injury. And yet, there is no
comprehensive process in place to ensure that the Schedule reflects an
accurate connection between the two. Moreover, there is no system to
systematically update this connection to reflect changes in jobs,
lifestyles, healthcare, or living arrangements.
The Committee noted that the entire Schedule needs an immediate
update, beginning with those sections not systematically updated since
World War II, and that the VA should establish an expert advisory
Committee to manage the change process. The sections that have not been
overhauled since 1945 include the orthopedic (e.g., amputations),
neurological (e.g., traumatic brain injury), and digestive (e.g.,
ulcers) sections. Most of the other sections, such as mental (e.g.,
PTSD) and endocrine (e.g., diabetes), have not been comprehensively
updated for more than 10 years.
The very construction of the Schedule also needs to be re-
evaluated. Currently, the Rating Schedule focuses on discrete body
systems: A veteran may be 50 percent disabled in one leg and 30 percent
disabled in one arm, etc. Today, we understand disability to be driven
by the whole person, and that the interplay of disabilities has an
important impact on a person's level of functioning. Moreover, a
comprehensive system needs to be put in place to account for
additional, non-medical factors like age, experience, education and
location when evaluating individual disabilities. A person may face
different challenges, after all, if they are a 50-year-old teacher
living in New York City than if they are a corn farmer living in Ames,
Iowa.
At a minimum, the Rating Schedule needs to be aligned with the work
done in the International Classification of Diseases (ICD) codes and
the Diagnostic and Statistical Manual of Mental Disorders (DSM). Simply
aligning codes and descriptions will help bridge a substantial gap
between the existing schedule and the current medical understanding of
injuries and diseases and their impacts on a person's ability to
function.
While updating the evaluation process is a start, it is not enough
to bring the VA disability system into the 21st century. In a truly
modem disability program, veterans should be compensated for their
difficulties in pursuing a fulfilling life apart from work; for a loss
in the quality of their lives. While we have done this in practice
historically, the current ad hoc process of accounting for reduced
quality of life should be systematized and driven by research and
science.
A FUNDAMENTAL CHANGE
These changes will not come easily, and the VA needs to make a
commitment to ongoing research. This shift in perspective-from a simple
``the postman cannot walk'' mentality toward a true, holistic model of
the human experience and the effect of disability is fundamental. It
implies, and the Committee recommends, that healthcare professionals be
made accessible throughout the benefits process for consultation and
advice. It also requires constant updating to keep pace with continued
changes in medicine and the workplace.
The motivations of the VA benefits program are noble and no change
in intent or focus could possibly be desired. What is needed is not a
change in motivation, but a commitment to continuous improvement; a
commitment to being veteran-focused; a commitment to refining and
modernizing processes, criteria and tools; and a commitment to
evidence-based decisionmaking.
The Committee's full report outlines myriad ways in which these
commitments can be met. To access a copy, visit www.iom.edu.
IMPROVING THE PRESUMPTIVE DISABILITY DECISION-MAKING PROCESS FOR
VETERANS
When a veteran applies for disability benefits, the VA has to make
several decisions. The first step, outlined above, is to examine the
individual and quantify their level of disability--work-related or
otherwise. But this is only half of the equation. In order to receive
benefits, a veteran's disability must be related to their military
service. While these connections can be obvious (a battlefield wound),
they can also be murky and complex (as with most environmental
exposures).
Since the 1920s, the VA Administrator (now Secretary) and Congress
having had the power to establish ``presumptions'': conditions that, if
present, are ``presumed'' to be the result of military service. These
presumptions are, important because they streamline the process of
providing benefits to veterans in need. When a ``presumption'' is made,
veterans do not have to prove that their particular disability or
illness was caused by their service; if the served in a particular
capacity and developed a particular ailment, they are entitled to
benefits.
The best-known example is Agent Orange. In 1991, Congress passed
law (the 1991 Agent Orange Act) requiring the VA to investigate the
health impacts of Vietnam-era exposure to the herbicide Agent Orange.
The VA asked the IOM to review the evidence, and on the basis of an IOM
recommendation, decided that any soldier setting foot on Vietnamese
soil during the war may have been exposed to Agent Orange. Moreover, a
range of medical problems (including Hodgkin's disease and prostate
cancer) were linked to this exposure. Therefore, any veteran developing
these conditions after serving on Vietnamese soil was entitled to
benefits, as it was ``presumed'' that their service led to these
conditions.
Today, nearly 150 health conditions have been codified, allowing
veterans to receive benefits based on presumptive service connection.
However, the current system for determining presumptions has not been
standardized.
In order to ensure that future decisions are based on sound science
and evidence, the Veterans' Disability Benefits Commission asked the
IOM to examine the current process and propose a framework for
establishing presumptions in the future. The IOM appointed a Committee
experts from fields including epidemiology, toxicology, and industrial
hygiene.
In its report, Improving the Presumptive Disability Decision-Making
Process for Veterans (2007), the Committee finds that the current
process has met most noble goal: the VA has consistently given the
benefit of the doubt to disabled veterans, in an effort to ensure that
no veteran who might have been affected by their service is denied
compensation. But this apparent generosity has come not from policy as
much as from an inadequate process. Congress has been inconsistent in
giving guidance when asking for assessments, and the VA has lacked
clarity in its requests to IOM Committees evaluating individual cases.
There has been an inconsistent burden of proof: in some cases, Congress
has required a causal link between a certain exposure and a cert health
risk; at other times, only an ``association'' was required. In many
cases, the Department of Defense has been unable to provide health and
exposure data to inform the decisionmaking process.
Such a system cannot help but lead to flaws--granting benefits
where disabilities are not service-connected or denying benefits to
those entitled to them. Perhaps more damaging, the ad hoc and ill-
defined process undermines veterans' confidence in the VA system,
fostering discontent and confusion among those who have sacrificed for
their country.
A CALL FOR STRUCTURE
The Committee's findings are clear: What the system needs is
structure. This structure must ensure that presumptive decisions are
based on evidence, not emotion, and that decisions are made quickly,
transparently, and consistently. Such a system must have the
flexibility to grow and change as science advances, and cannot be a
top-down government program: It needs the input and cooperation of all
potential stakeholders to function well.
Toward this end, the Committee took the unusual step of making
broad recommendations to Congress, the Department of Veterans Affairs,
and the Department of Defense, both individually and collectively. It
is rare to make recommendations to multiple organizations, but in this
case, cooperation and coordination are critical.
The Committee laid out the structure in careful detail. It
envisions a new system, created by Congress, consisting of two parts:
an Advisory Committee and a Science Review Board. The Advisory
Committee would be made up of stakeholders from government, the
scientific community, veterans groups, and others. Its task would be to
consider potential exposures, illnesses and circumstances that might
require the establishment of presumptions. Based on this Advisory
Committee's recommendations, the VA Secretary would then charge the
Science Review Board--a completely independent group-to examine the
evidence and provide recommendations.
The Science Review Board is the linchpin of this new system.
Relying on evidence-based decisionmaking, the Board will consider how
strong the link is between a given exposure and a particular medical
ailment, classifying that connection into four categories:
1. Sufficient: A causal relationship exists.
2. Equipoise and Above: A causal relationship is at least as likely as
not.
3. Below Equipoise: Either a causal relationship is unlikely, or there
is insufficient information to make a scientifically informed judgment.
4. Against: The evidence suggests the lack of a causal relationship.
When the evidence permits, the Board would estimate how many
veterans were exposed, to what extent, and what fraction of their
medical condition was due to this exposure. These findings would then
be delivered to the VA, which would determine if a presumptive ruling
is merited.
This kind of structure will not be put into place overnight, and
substantial work remains to be done. For instance, the VA needs to
develop and publish a formal process for how these presumptions will be
made. This must be consistently applied, and needs to be transparent
from start to finish, documenting all evidence collected and the
reasoning behind each decision--pro or con. But most importantly, the
DoD and the VA need to make a commitment to work together. For example,
evaluating causality is only possible for the VA if the DoD has
accurate medical records, reports on pre-existing conditions, and
information on what time individual veterans spent operating in
different military theaters. The Committee's report provides many
recommendations, from strategic planning to computer data interfaces,
where a commitment to joint research, knowledge-sharing, and resource
allocation will be required. Without this cooperation, no new structure
will succeed.
A COMMITMENT RENEWED
America remains steadfast in its commitment to the men and women of
our Armed Forces, whether they still wear the uniform or have re-
entered private life. The Department of Veterans Affairs, in
recognizing the need for research and change, has shown its commitment
to extending this commitment for as long as is necessary to support
those harmed in the line of duty.
The way in which we compensate our disabled veterans is far from
broken--millions of veterans rely on it and more are granted benefits
every day. But it can and should be as effective as possible. Our
veterans deserve nothing less.
FOR MORE INFORMATION . . .
Copies of A 21st Century System for Evaluating Veterans for
Disability Benefits and Improving the Presumptive Disability Decision-
Making Process for Veterans are available from the National Academies
Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800)
624-6242 or (202) 334-3313 (in the Washington metropolitan area);
Internet, www.nap.edu. The full text of this report is available at
www.nap.edu.
These studies were supported by funds from the Veterans' Disability
Benefits Commission.
Any opinions, findings, conclusions, or recommendations expressed
in the publications are those of the author(s) and do not necessarily
reflect the views of the organization that provided support for the
project.
The Institute of Medicine serves as adviser to the Nation to
improve health. Established in 1970 under the charter of the National
Academy of Sciences, the Institute of Medicine provides independent,
objective, evidence-based advice to policymakers, health professionals,
the private sector, and the public. For more information about the
Institute of Medicine, visit the IOM Web site at www.iom.edu.
Permission is granted to reproduce this document in its entirety,
with no additions or alterations. Copyright 2007 by the National
Academy of Sciences. All rights reserved.
COMMITTEE ON MEDICAL EVALUATION OF VETERANS FOR DISABILITY COMPENSATION
LONNIE R. BRISTOW, M.D., M.A.C.P. (Chair), Former President,
American Medical Association, Walnut Creek, CA; GUNNAR B. J. ANDERSSON,
M.D., Ph.D., Professor and Chair, Department of Orthopedic Surgery,
Rush University Medical Center; JOHN E BURTON, JR., Ph.D., LL.B.,
Professor Emeritus, School of Management & Labor Relations, Rutgers
University; LYNN H. GERBER, M.D., Director, Center for Chronic Illness
and Disability, College of Nursing and Health Science, George Mason
University; SID GILMAN, M.D., F.R.C.P., William J. Herdman
Distinguished University Professor of Neurology, Director, Michigan
Alzheimer's Disease Research Center, University of Michigan; HOWARD H.
GOLDMAN, M.D., M.P.H., Ph.D., Professor of Psychiatry, University of
Maryland at Baltimore, School of Medicine; SANDRA GORDONSALANT, Ph.D.,
Professor, Department of Hearing and Speech Sciences, University of
Maryland; JAY HIMMELSTEIN, M.D., M.P.H., Assistant Chancellor for
Health Policy, Director, UMass Center for Health Policy and Research,
University of Massachusetts Medical School; ANA E. NUNEZ, M.D.,
Associate Professor, Drexel University College of Medicine, Institute
for Women's Health and Leadership; JAMES W. REED, M.D., M.A.C.P., Chief
of Endocrinology, Grady Memorial Hospital, Professor of Medicine and
Associate Chair of Medicine for Clinical Research, Morehouse School of
Medicine; DENISE G. TATE, Ph.D., ABPP, FACRM, Professor, Director of
Research, Division of Rehabilitation Psychology and Neuropsychology,
Department of Physical Medicine and Rehabilitation, University of
Michigan; BRIAN M. THACKER, Regional Director, Congressional Medal of
Honor Society, Wheaton, MD; DENNIS TURK, Ph.D., John and Emma Bonica
Professor of Anesthesiology & Pain Research, Department of
Anesthesiology, University of Washington School of Medicine; RAYMOND
JOHN VOGEL, M.S., President, RJ VOGEL and Associates, Mt. Pleasant, SC;
REBECCA A. WASSEM, D.N.S., Professor of Nursing, University of Utah
College of Nursing; ED H. YELIN, Ph.D., Professor of Medicine and
Health Policy, Institute for Health Policy Studies, University of
California at San Francisco.
STUDY STAFF
RICK ERDTMANN, M.D., M.P.H., Division Director; MORGAN A. FORD,
Program Officer; REINE HOMAWOO, Sr. Program Assistant; SUSAN McCUTCHEN,
Research Associate; MICHAEL McGEARY, Study Director; PAMELA RAMEY-
MCCRAY, Administrative Assistant.
COMMITTEE ON EVALUATION OF THE PRESUMPTIVE DISABILITY DECISION-MAKING
PROCESS FOR VETERANS
JONATHAN M. SAMET, M.D., M.S. (Chair), Professor and Chair,
Department of Epidemiology, The Johns Hopkins University; MARGARET A.
BERGER, J.D., Suzanne J. and Norman Miles Professor of Law, Brooklyn
Law School; KIRSTEN BIBBINS-DOMINGO, Ph.D., M.D., Assistant Professor
and Attending Physician, Departments of Medicine and Epidemiology and
Biostatistics, University of California-- San Francisco, San Francisco
General Hospital; ERIC G. BING, M.D., Ph.D., M.P.H., Assistant
Professor and Director, Department of Psychiatry, The Collaborative
Public Health AIDS Research Center, Charles R. Drew University of
Medicine and Science; BERNARD D. GOLDSTEIN, M.D., Professor and Dean
(Emeritus), Graduate School of Public Health, University of Pittsburgh;
GUY H. McMICHAEL III, J.D., President, GHM Consulting; JOHN R.
MULHAUSEN, Ph.D., C.I.H., Manager, Corporate Industrial Hygiene, 3M
Co.; RICHARD P. SCHEINES, Ph.D., Professor and Head, Department of
Philosophy, Carnegie Mellon University; KENNETH R. STILL, Ph.D., M.S.,
M.B.A., C.I.H., U.S. Navy Captain (Retired), President and Scientific
Director, Occupational Toxicology Associates; DUNCAN C. THOMAS, Ph.D.,
Professor and Director, Biostatistics Division, Department of
Preventive Medicine, University of southern California; SVERRE VEDAL,
M.D., M.Sc., Professor, Department of Environmental and Occupational
Health Sciences and Occupational Medicine Program, University of
Washington; ALLEN J. WILCOX, M.D., Ph.D., M.P.H., Senior Investigator,
Epidemiology Branch, National Institute of Environmental Health
Sciences; SCOTT L. ZEGER, Ph.D., Hurley-Dorrier Professor of
Biostatistics and Chair, Department of Biostatistics, The Johns Hopkins
University; LAUREN ZEISE, Ph.D., S.M., Chief, Reproductive and Cancer
Hazard Assessment Branch, California Environmental Protection Agency.
VOLUNTEER SCIENTIFIC CONSULTANT:
MELISSA McDIARMID, M.D., M.P.H., D.A.B.T., Professor of Medicine,
University of Maryland, IPA to VA, Director, Depleted Uranium Program.
STUDY STAFF
RICK ERDTMANN, M.D., M.P.H., Board Director; CATHERINE BODUROW,
M.S.P.H., Study Director; ANISHA DHARSHI, B.A., Research Associate;
CARA JAMES, M.S., Research Associate; PAMELA RAMEY-MCCRAY, B.A.,
Administrative Assistant; JON SANDERS, B.A., Senior Program Assistant.
Statement of Dean G. Kilpatrick, Ph.D.
Member, Committee on Veterans' Compensation for Posttraumatic
Stress Disorder, Institute of Medicine, The National Academies, and
Distinguished University Professor and Director
National Crime Victims Research and Treatment Center
Medical University of South Carolina, Charleston, SC
Good afternoon, Mr. Chairman and Members of the Committee. My name
is Dean Kilpatrick and I am Distinguished University Professor in the
Department of Psychiatry and Behavioral Sciences and Director of the
National Crime Victims Research and Treatment Center at the Medical
University of South Carolina. Thank you for the opportunity to testify
on behalf of the Members of the Committee on Veterans' Compensation for
Post Traumatic Stress Disorder. This Committee was convened under the
auspices of the National Research Council and the Institute of
Medicine. Our Committee's work was requested by the Department of
Veterans Affairs, which provided funding for the effort. Its work was
also presented to and used by the congressionally constituted Veterans
Disability Benefits Commission.
Last June, our Committee completed its report--entitled PTSD
Compensation and Military Service--which addresses potential revisions
to the Schedule for Rating Disabilities in the context of a larger
review of how VA administers its PTSD compensation program. I am
pleased to be here today to share with you the content of that report,
the knowledge I've gained as a clinical psychologist and researcher on
traumatic stress, and my experience as someone who previously served as
a clinician at the VA.
I will begin with some background information on post traumatic
stress disorder. Briefly described, PTSD is a psychiatric disorder that
can develop in a person after a traumatic experience. Someone is
diagnosed with PTSD if, in response to that traumatic experience, he or
she develops a cluster of symptoms that include:
reexperiencing the traumatic event as reflected by
distressing recollections, memories, nightmares, or flashbacks;
avoidance of anything that reminds them of the traumatic
event;
emotional numbing or feeling detached from other people;
hyperarousal as reflected by trouble sleeping, trouble
concentrating, outbursts of anger, and having to always be vigilant for
potential threats in the environment; and
impairment in social or occupational functioning, or
clinically significant distress.
PTSD is one of an interrelated and overlapping set of possible
mental health responses to combat exposures and other traumas
encountered in military service. It has been described as one of the
signature wounds of the most recent Iraq conflicts. Although PTSD has
only been an official diagnosis since the 1980's, the symptoms
associated with it have been reported for centuries. In the U.S.,
expressions including shell shock, combat fatigue, and gross stress
reaction have been used to label what is now called PTSD.
Our Committee's review of the scientific literature regarding PTSD
led it to draw some conclusions that are relevant to this hearing. It
found abundant evidence indicating that PTSD can develop at any time
after exposure to a traumatic stressor, including cases where there is
a long time interval between the stressor and the recognition of
symptoms. Some of these cases may involve the initial onset of symptoms
after many years of symptom-free life, while others may involve the
manifestation of explicit symptoms in persons with previously
undiagnosed PTSD. The determinants of delayed-onset PTSD are not well
understood. The scientific literature does not identify any differences
material to the consideration of compensation between these delayed-
onset or delayed-identification cases and those chronic PTSD cases
where there is a shorter time interval between the stressor and the
recognition of symptoms.
Our review also identified several areas where changes to VA's
current practices might result in more consistent and accurate ratings
for disability associated with PTSD.
There are two primary steps in the disability compensation process
for veterans. The first of these is a compensation and pension, or C&P,
examination. These examinations are conducted by VA mental health
professionals or outside professionals who meet certain education and
licensing requirements. Testimony presented to our Committee indicated
that clinicians often feel pressured to severely constrain the time
that they devote to conducting a PTSD C&P examination--sometimes to as
little as 20 minutes--even though the protocol suggested in a best
practice manual developed by the VA National Center for PTSD can take 3
hours or more to properly complete. The Committee believes that the key
to proper administration of VA's PTSD compensation program is a
thorough C&P clinical examination conducted by an experienced mental
health professional. Many of the problems and issues with the current
process can be addressed by consistently allocating and applying the
time and resources needed for a thorough examination. The Committee
also recommended that a system-wide training program be implemented for
the clinicians who conduct these exams in order to promote uniform and
consistent evaluations.
The second primary step in the compensation process for veterans is
a rating of the level of disability associated with service-connected
disorders identified in the clinical examination. This rating is
performed by a VA employee using the information gathered in the C&P
exam and criteria set forward in the Schedule for Rating Disabilities.
Currently, the same set of criteria are used for rating all mental
disorders. They focus on symptoms from schizophrenia, mood, and anxiety
disorders. The Committee found that the criteria are at best a crude
and overly general instrument for the assessment of PTSD disability. We
recommended that new criteria be developed and applied that
specifically address PTSD symptoms and that are firmly grounded in the
standards set out in the Diagnostic and Statistical Manual of Mental
Disorders used by mental health professionals.
Our Committee also suggested that VA take a broader and more
comprehensive view of what constitutes PTSD disability. In the current
scheme, occupational impairment drives the determination of the rating
level. Under the Committee's recommended framework, the psychosocial
and occupational aspects of functional impairment would be separately
evaluated, and the claimant would be rated on the dimension on which he
or she is more affected. We believe that the special emphasis on
occupational impairment in the current criteria unduly penalizes
veterans who may be capable of working, but significantly symptomatic
or impaired in other dimensions, and thus it may serve as a
disincentive to both work and recovery. This recommendation is
consistent with the Dole-Shalala Commission's suggestion to add quality
of life payments to compensation.
Research reviewed by the Committee indicates that disability
compensation does not in general serve as a disincentive to seeking
treatment. While some beneficiaries will undoubtedly understate their
improvement in the course of pursuing compensation, the scientific
literature suggests that such patients are in the minority, and there
is some evidence that disability payments may actually contribute to
better treatment outcomes in some programs. The literature on recovery
indicates that it is influenced by several factors, and the independent
effect of compensation on recovery is difficult to disentangle from
these.
Determining ratings for mental disabilities in general and for PTSD
specifically is more difficult than for many other disorders because of
the inherently subjective nature of symptom reporting. In order to
promote more accurate, consistent, and uniform PTSD disability ratings,
the Committee recommended that VA establish a specific certification
program for raters who deal with PTSD claims, with the training to
support it, as well as periodic recertification. Rater certification
should foster greater confidence in ratings decisions and in the
decisionmaking process.
At VA's request, the Committee addressed whether it would be
advisable to establish a set schedule for re-examining veterans
receiving compensation for PTSD. We concluded that it is not
appropriate to require across-the-board periodic reexaminations for
veterans with PTSD service-connected disability. The Committee instead
recommended that reexamination be done only on a case-by-case basis
when there are sound reasons to expect that major changes in disability
status might occur. These conclusions were based on two considerations.
First, there are finite resources--both funds and personnel--to conduct
C&P examinations and determine disability ratings. The Committee
believes that resources should be focused on the performance of
uniformly high-quality C&P clinical examinations. It believes that
allocating resources to such examinations--in particular, to initial
C&P evaluations--is a better use of resources than periodic, across-
the-board reexaminations. Second, as the Committee understands it,
across-the-board periodic reexaminations are not required for other
mental disorders or medical conditions. The Committee's review of the
literature on misreporting or exaggeration of symptoms by PTSD
claimants yielded no justification for singling out PTSD disability for
special action and thereby potentially stigmatizing veterans with the
disability by implying that their condition requires extra scrutiny.
I understand that the Veterans Disability Benefits Commission
subsequently recommended that VA should conduct PTSD reevaluations
every 2-3 years to gauge treatment effectiveness and encourage
wellness. Since the Commission report was released after the end of our
work, my Committee did not address the disparity in our
recommendations. I know that our Committee and the Commission both want
veterans to receive fair treatment and the finest care, and I consider
this to be an honest difference of opinion on how to best achieve those
goals. There are advantages and disadvantages to the approaches that
our two groups put forward, and the important thing is for VA to give
these careful consideration when they formulate their policy. I believe
that--if periodic reexaminations are implemented--this should not be
done until there are sufficient resources to insure that every veteran
gets a first-rate initial C&P exam in a timely fashion.
To summarize, the Committee identified three major changes that are
needed to improve the compensation evaluation process for veterans with
PTSD:
First, the C&P exam should be done by mental health
professionals who are adequately trained in PTSD and who are allotted
adequate time to conduct the exams.
Second, the current VA disability rating system should
be substantially changed to focus on a more comprehensive measure of
the degree of impairment, disability, and clinically significant
distress caused by PTSD. The current focus on occupational impairment
serves as a disincentive for both work and recovery.
Third, the VA should establish a certification program
for raters who deal with PTSD clams.
Our Committee also reached a series of other recommendations
regarding the conduct of VA's compensation and pension system for PTSD
that are detailed in the body of our report. I have provided copies of
this report as part of my submitted testimony.
Thank you for your attention. I will be happy to answer your
questions.
INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES
REPORT BRIEF JULY 2007
``PTSD COMPENSATION AND MILITARY SERVICE''
The scars of war take many forms: the limb lost, the illness
brought on by a battlefield exposure, and, for some, the psychological
toll of encountering an extreme traumatic event. The mission of the
Department of Veterans Affairs (VA) ``to care for him who shall have
borne the battle'' is met through a series of benefits programs for
veterans and their dependents. One of these programs-compensation to
veterans whose disability is deemed to be service-connected-has risen
in the public eye over the past few years. While several factors have
contributed to this development, three that are particularly prominent
are the increase in the number of veterans seeking and receiving
benefits, the corresponding increase in benefits expenditures, and the
prospect of a large number of veterans of Operation Iraqi Freedom and
Operation Enduring Freedom entering the system.
Compensation claims for post traumatic stress disorder (PTSD) have
attracted special attention. PTSD is a psychiatric disorder that can
develop in a person who experiences, witnesses, or is confronted with a
traumatic event, often one that is life-threatening. PTSD is
characterized by a cluster of symptoms that include:
reexperiencing--intrusive recollections of a traumatic
event, often through flashbacks or nightmares;
avoidance or numbing-efforts to avoid anything
associated with the trauma and numbing of emotions; and
hyperarousal--often manifested by difficulty in sleeping
and concentrating and by irritability.
PTSD is one of an interrelated and overlapping set of possible
mental health responses to combat exposures and other traumas
encountered in military service. While the term ``post traumatic stress
disorder'' has only been part of the lexicon since the 1980's, the
symptoms associated with it have been reported for centuries. In the
U.S., expressions including shell shock, combat fatigue, and gross
stress reaction have been used to label what is now called PTSD.
Against this backdrop, VA's Veterans Benefits Administration (VBA)
asked the National Academies to convene a Committee of experts to
address several issues surrounding its administration of veterans'
compensation for PTSD. The resulting report, PTSD Compensation and
Military Service, identifies several areas where changes might result
in more consistent and accurate ratings for disability associated with
PTSD.
THE PTSD COMPENSATION AND PENSION EXAMINATION
There are two major steps in the disability compensation process
for veterans. The first is a compensation and pension (C&P)
examination. These are conducted by VA clinicians or outside
professionals who meet certain education and licensing requirements.
Clinicians often feel pressured to severely limit the time that they
devote to conducting a PTSD C&P examination-to as little as 20 minutes-
even though the protocol suggested in a best practice manual developed
by the VA National Center for PTSD can take 3 hours or more to properly
complete. The Committee believes that the key to proper administration
of VA's PTSD compensation program is a thorough C&P clinical
examination conducted by an experienced mental health professional.
Many of the problems and issues with the current process can be
addressed by consistently allocating and applying the time and
resources needed for a thorough examination. The Committee also
recommends the implementation of a system-wide training program for the
clinicians who conduct these exams in order to promote uniform and
consistent evaluations.
THE EVALUATION OF PTSD DISABILITY CLAIMS
The second major step in the compensation process is a rating of
the level of disability associated with service-connected disorders.
This rating is performed by a VA employee using the information
gathered in the C&P exam. The Committee found that the criteria used to
evaluate the level of disability resulting from service-connected PTSD
were, at best, crude and overly general. It recommends that new
criteria be developed and applied that specifically address PTSD
symptoms and that are firmly grounded in the standards set out in the
Diagnostic and Statistical Manual of Mental Disorders used by mental
health professionals. As part of this effort, the committee suggested
that VA take a broader and more comprehensive view of what constitutes
PTSD disability. In the current scheme, occupational impairment drives
the determination of the rating level. However, the Committee believes
that this unduly penalizes veterans who may be capable of working but
are impaired in other capacities, and might thus be a disincentive to
both work and recovery. Under the committee's recommended framework,
the applicant's rating would be based on evaluations of both the
psychosocial and occupational aspects of functional impairment.
Determining ratings for mental disabilities in general and for PTSD
specifically is more difficult than for many other disorders because of
the inherently subjective nature of symptom reporting. In order to
promote more accurate, consistent, and uniform PTSD disability ratings,
the Committee recommends that VA establish a specific certification
program for raters who deal with PTSD claims, with the training to
support it, as well as periodic recertification. Rater certification
should foster greater confidence in ratings decisions and in the
decisionmaking process.
SPECIAL ISSUES FOR WOMEN VETERANS
Female veterans are less likely to receive service connection for
PTSD, which could be because of the difficulty of validating exposure
to non-combat traumatic stress-notably, military sexual assault (MSA).
The Committee believes that it is important to gain a better
understanding of the sources of this disparity and to better facilitate
the validation of MSA-related traumas in both women and men. It
therefore recommends that VBA gather more detailed data on the
determinants of service connection and ratings level for MSA-related
PTSD claims, including the gender-specific coding of MSA-related
traumas for analysis purposes; and develop and disseminate reference
materials for raters that more thoroughly address the management of MSA
related claims. Training and testing on MSA-related claims should be a
part of the certification program the Committee recommends for raters
who deal with PTSD claims.
FINAL OBSERVATIONS
The Committee is acutely aware that resource constraints-on both
funds and staff-limit the ability of VA to deliver services and force
difficult decisions on allocations among vital efforts. It believes
that increases in the number of veterans seeking and receiving
disability benefits for PTSD, the prospect of a large number of
veterans of Operation Iraqi Freedom and Operation Enduring Freedom
entering the system, and the profound impact of the disorder on the
Nation's veterans make changes in PTSD C&P policy a priority deserving
of special attention and action by VA and the Congress.
FOR MORE INFORMATION . . .
Copies of PTSD Compensation and Military Service are available from
the National Academies Press, 500 Fifth Street, N.W., Lockbox 285,
Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the
Washington metropolitan area); Internet, http://www.nap.edu. The full
text of this report is available at http://www.nap.edu.
This study was supported by funds from the United States Department
of Veterans Affairs. Any opinions, findings, conclusions, or
recommendations expressed in this publication are those of the
author(s) and do not necessarily reflect the view of the organizations
or agencies that provided support for this project.
The Institute of Medicine serves as adviser to the Nation to
improve health. Established in 1970 under the charter of the National
Academy of Sciences, the Institute of Medicine provides independent,
unbiased, evidence based advice to policymakers, health professionals,
industry, and the public. For more information about the Institute of
Medicine, visit the 10M home page at www.iom.edu.
Permission is granted to reproduce this document in its entirety,
with no additions or alterations.
Copyright 2007 by the National Academy of Sciences. All rights
reserved.
COMMITTEE ON VETERANS' COMPENSATION FOR POST TRAUMATIC STRESS DISORDER
NANCY C. ANDREASEN, M.D., Ph.D. (Chair), University of Iowa Carver
College of Medicine, Iowa City, IA
JACQUELYN C. CAMPBELL, Ph.D., R.N., EA.A.N., The Johns Hopkins School
of Nursing, Baltimore, MD
JUDITH A. COOK, Ph.D., University of Illinois, Chicago
JOHN A. FAIRBANK, Ph.D., Duke University Medical Center, Durham, NC
BONNIE 1. GREEN, Ph.D., Georgetown University Medical School,
Washington, DC
DEAN G. KILPATRICK, Ph.D., Medical University of South Carolina,
Charleston
KURT KROENKE, M.D., Indiana University, Indianapolis
RICHARD A. KULKA, Ph.D., Abt Associates Inc., Durham, NC
PATRICIA M. OWENS, M.P.A., Independent Consultant, Minisink Hills, PA
ROBERT T. REVILLE, Ph.D., RAND Institute of Civil Justice, Santa
Monica, CA
DAVID S. SALKEVER, Ph.D., University of Maryland-Baltimore County,
Baltimore, MD
ROBERT J. URSANO, M.D., Uniformed Services University of the Health
Sciences, Bethesda, MD
GULF WAR AND HEALTH COMMITTEE LIAISON
JANICE L. KRUPNICK, Ph.D. Georgetown University, Washington, DC
CONSULTANTS
ROBERT J. EPLEY, Independent Consultant, Waxhaw, NC
CAROL S. NORTH, M.D., M.P.E., University of Texas Southwestern Medical
Center, Dallas COL. ALFRED V. RASCON, U.S. Army Medical Service Corps,
Laurel, MD
STUDY STAFF
DAVID A. BUTLER, Ph.D., Senior Program Officer; Study Director AMY R.
O'CONNOR, M.P.H., Research Associate
JON Q. SANDERS, B.A., Program Associate
EILEEN SANTA, M.A., Research Associate
FREDERICK (RICK) ERDTMANN, M.D., M.P.H., Director, Board on Military
and Veterans Health and Medical followup Agency
CHRISTINE HARTEL, Ph.D., Director, Board on Behavioral, Cognitive, and
Sensory Sciences
Statement of Jonathan M. Samet, M.D., M.S.
Chairman, Committee on Evaluation of the Presumptive Disability
Decision-Making Process for Veterans, Board on Military and Veterans
Affairs, Institute of Medicine, The National Academies, and
Professor and Chairman, Department of Epidemiology, Johns Hopkins
Bloomberg School of Public Health, Johns Hopkins University
Baltimore, MD
Good afternoon Congressman Hall and Members of the Subcommittee on
Disability Assistance and Memorial Affairs of the House Committee on
Veterans' Affairs. I am pleased to speak with you today about the
Institute of Medicine report, Improving the Presumptive Disability
Decisionmaking Process for Veterans. I am Jonathan Samet, the Chair of
the Committee. I represent my colleagues on the Committee, a
multidisciplinary group of 16 people that covered the broad range of
expertise needed to take on this important, but very challenging topic.
The Subcommittee has access to the report and a copy of the Executive
Summary is attached to my testimony.
Our Committee was charged with describing the current process for
how presumptive decisions are made for veterans who have health
conditions arising from military service and with proposing a
scientific framework for making such presumptive decisions in the
future. Presumptions are made in order to reach decisions in the face
of unavailable or incomplete information. They address the gaps in
evidence that introduce uncertainty in decisionmaking. Presumptions
have been made with regard to exposure and causation. In trying to
assess whether a particular health problem in veterans can be linked to
their exposures in the military, a presumption might be needed because
of missing information on exposures of the veterans to the agent of
concern or because of uncertainty as to whether the exposure increases
risk for the health condition. A presumption might also be made with
regard to the link between an exposure and risk for a disease, while
the evidence is still uncertain or accumulating as to whether the
exposure causes the disease.
Presumptions have long been made; in fact, the first were
established in 1921. More recently, a number of presumptions have been
made with regard to the consequences of Agent Orange exposure during
service in Vietnam and most recently they have been made around the
health risks sustained by military personnel in the Persian Gulf War.
To address its charge, the Committee met with the full range of
involved stakeholders: past and present staffers from Congress, the
Veterans Administration (VA), the Institute of Medicine, veteran's
service organizations, and individual veterans. The Department of
Defense (DoD) gave the Committee information about its current
activities and its plans to track exposures and health conditions of
personnel. The Committee attempted to formally capture how the current
approach works and completed a series of case studies to identify
``lessons learned'' that would be useful in proposing a new approach.
The Committee also considered how information is obtained on the health
of veterans and how exposures during military service can be linked to
any health consequences via scientific investigation. It gave
substantial attention to how information can best be synthesized to
determine if an exposure is associated with a risk to health and
whether the association is causal.
The present approach to presumptive disability decisionmaking
largely flows from the Agent Orange Act 1991, which started a model for
decisionmaking that is still in place. In that law, Congress asked the
VA to contract with an independent organization, --the Institute of
Medicine--to review the scientific evidence for Agent Orange.
Subsequently, the Institute of Medicine has produced reports on Agent
Orange, evaluating whether there is evidence that Agent Orange is
associated with various health outcomes. The Institute of Medicine
provides its reports to the VA, which then acts through its own
internal decisionmaking process to determine if a presumption is to be
made.
The case studies conducted by the Committee probed deeply into this
process. The case studies pointed to a number of difficulties that need
to be addressed in any future approach:
Lack of information on exposures received by military
personnel and inadequate surveillance of veterans for service-related
illnesses.
Gaps in information because of secrecy.
Varying approaches to synthesizing evidence on the
health consequences of military service.
In the instance of Agent Orange, classification of
evidence for association but not for causation.
A failure to quantify the effect of the exposure during
military service, particularly for diseases with other risk factors and
causes.
A general lack of transparency of the presumptive
disability decisionmaking process.
The Committee discussed in great depth the optimum approach to
establishing a scientific foundation for presumptive disability
decisionmaking, including the methods used to determine if exposure to
some factor increases risk for disease. This assessment and the
findings of the case studies led to recommendations to improve the
process:
As the case studies demonstrated, Congress could provide
a clearer and more consistent charge on how much evidence is needed to
make a presumption. There should be clarity as to whether the finding
of an association in one or more studies is sufficient or the evidence
should support causation.
Due to lack of clarity and consistency in congressional
language and VA's charges to the Committees, IOM Committees have taken
somewhat varying approaches since 1991 in reviewing the scientific
evidence, and in forming their opinions on the possibility that
exposures during military service contributed to causing a health
condition. Future Committees could improve their review and
classification of scientific evidence if they were given clear and
consistent charges and followed uniform evaluation procedures.
The internal processes by which the VA makes it
presumptive decisions following receipt of an IOM report have been
unclear. VA should adopt transparent and consistent approaches for
making these decisions.
Adequate exposure data and health condition information
for military personnel (both individuals and groups) usually have not
been available from DoD in the past. Such information is one of the
most critical pieces of evidence for improving the determination of
links between exposures and health conditions. Approaches are needed to
assure that such information is systematically collected in an ongoing
fashion.
All of these improvements are feasible over the longer term and are
needed to ensure that the presumptive disability decisionmaking process
for veterans is based on the best possible scientific evidence.
Decisions about disability compensation and related benefits (e.g.,
medical care) for veterans should be based on the best possible
documentation and evidence of their military exposures as well as on
the best possible information. A fresh approach could do much to
improve the current process. The Committee's recommended approach (see
Figure GS-1 attached) has several parts:
an open process for nominating exposures and health
conditions for review; involving all stakeholders in this process is
critical;
a revised process for evaluating scientific information
on whether a given exposure causes a health condition in veterans; this
includes a new set of categories to assess the strength of the evidence
for causation, and an estimate of the numbers of exposed veterans whose
health condition can be attributed to their military exposure;
a consistent and transparent decisionmaking process by
VA;
a system for tracking the exposures of military
personnel (including chemical, biological, infectious, physical and
psychological stressors), and for monitoring the health conditions of
all military personnel while in service and after separation; and
an organizational structure to support this process.
To support the Committee's recommendations, we suggest the creation
of two panels. One is an Advisory Committee (advisory to VA), that
would assemble, consider and give priority to the exposures and health
conditions proposed for possible presumptive evaluation. Nominations
for presumptions could come from veterans and other stakeholders as
well as from health tracking, surveillance and research. The second
panel would be a Science Review Board, an independent body, which would
evaluate the strength of the evidence (based on causation) which links
a health condition to a military exposure and then estimates the
fraction of exposed veterans whose health condition could be attributed
to their military exposure. The Science Review Board's report and
recommendations would go to the VA for its consideration. The VA would
use explicit criteria to render a decision by the VA Secretary with
regard to whether a presumption would be established. In addition, the
Science Review Board would monitor information on the health of
veterans as it accumulates over time in the DoD and VA tracking
systems, and nominate new exposures or health conditions for evaluation
as appropriate.
This Committee recommends that the following principles be adopted
in establishing this new approach:
1. Stakeholder inclusiveness
2. Evidence-based decisions
3. Transparent process
4. Flexibility
5. Consistency
6. Causation, not just association, as the target for
decisionmaking.
The last principle needs further discussion, as it departs from the
current approach. In proposing causation as the target, the Committee
had concern that the approach of relying on association, particularly
if based on findings of one study, could lead to ``false-positive''
presumptions. The Committee calls for a broad interpretation of
evidence to judge whether a factor causes a disease in order to assure
that relevant findings from laboratory studies are adequately
considered. The Committee also recommends that benefits be considered
when there is at least a 50 percent likelihood of a causal
relationship, and does not call for full certainty on the part of the
Science Review Board.
The Committee suggests that its framework be considered as the
model to guide the evolution of the current approach. While some
aspects of the approach may appear challenging or infeasible at
present, feasibility would be improved by the provision of appropriate
resources to all of the participants in the presumptive disability
decisionmaking process for veterans and future methodological
developments. Veterans deserve to have these improvements accomplished
as soon as possible.
The Committee recognized that action by Congress will be needed to
implement its proposed approach. Legislation to create the two panels
is needed and Congress should also act to assure that needed resources
are available to create and sustain exposure and health trackingfor
service personnel and veterans. Many of the changes proposed by the
Committee could be implemented now, even as steps are taken to move the
DoD and VA toward implementing the model recommended. Veterans deserve
to have an improved system as soon as possible.
Thank you for the opportunity to testify. I would be happy to
address any questions the Subcommittee might have.
[GRAPHIC] [TIFF OMITTED] T1371A.002
FIGURE GS-1 (IOM 2007) Proposed Framework for Future Presumptive
Disability Decision-Making Process for Veterans.
a Includes research for classified or secret
activities, exposures, etc.
b Includes veterans, Veterans Service Organizations,
Federal agencies, scientists, general public, etc.
c This Committee screens stakeholders' proposals and
research in support of evaluating evidence for presumptions and makes
recommendations to the VA Secretary when full evidence review or
additional research is appropriate.
d The board conducts a two-step evidence review process
(see report text for further further detail).
e Final presumptive disability compensation decisions
are made by the Secretary, Department of Veterans Affairs, unless
legislated by Congress.
Statement of Joyce McMahon, Ph.D.
Managing Director, Center for Health Research and Policy
Center for Naval Analyses (CNA) Corp., Alexandria, VA
Chairman Hall, Representative Lamborn, distinguished Members, I
appreciate the opportunity to testify before the House Subcommittee on
Disability Assistance and Memorial Affairs of the House Committee on
Veterans' Affairs today on the subject of Revising the VA Schedule for
Rating Disabilities. This testimony is based on the findings reported
in Final Report for the Veterans' Disability Benefits Commission:
Compensation, Survey Results, and Selected Topics, by Eric Christensen,
Joyce McMahon, Elizabeth Schaefer, Ted Jaditz, and Dan Harris, of the
CNA Corp. (CNA). Details on the specific findings discussed here can be
found in the report, which is available at http://www.cna.org/domestic/
healthcare/. The report also includes reference sources.
The Veterans' Disability Benefits Commission (the Commission) asked
CNA to help assess the appropriateness of the benefits that the
Department of Veterans Affairs (VA) provides to veterans and their
survivors for disabilities and deaths attributable to military service.
Specifically, the Commission was charged with examining the standards
for determining whether a disability or death of a veteran should be
compensated and the appropriateness of benefit levels. The overall
focus of our effort was to provide analyses to the Commission regarding
the appropriateness of the current benefits program for compensating
for loss of average earnings and degradation of quality of life
resulting from service-connected disabilities for veterans.
Pertinent to today's topic of Revising the VA Schedule
for Rating Disabilities is that we were asked to:
Examine the evidence regarding the individual
unemployability (IU) rating.
Evaluate Quality of Life findings for disabled veterans.
Conduct surveys of raters and Veterans Service Officers (VSOs) with
regard to how they perceive the processes of rating claims and
assisting applicants.
The evaluation of IU was, to some extent, embedded in our
evaluation of earnings parity and quality of life assessments from the
disabled veterans' survey.
Earnings comparisons for service-disabled veterans
Our primary task was to answer the question of how well the VA
compensation benefits serve to replace the average loss in earnings
capacity for service-disabled veterans. Our approach identified target
populations of service-disabled veterans and peer or comparison groups
(non-service-disabled veterans) and obtained data to measure earned
income for each group. We also investigated how various factors such as
disability rating, type of disability, and age impact earned income.
Finally, we compared lifetime earned income losses for service-disabled
veterans to their lifetime VA compensation, adjusting for expected
mortality and discounting to present value terms, to see how well VA
compensation replaces lost earning capacity.
Congressional language indicates that the intent of VA compensation
is to provide a replacement for the average impairment in earning
capacity. The VA compensation program is not an individual means tested
program, although there are minor exceptions to this. Therefore, we
focused on average losses, first for all service-disabled veterans and
then for subgroups. We defined the subgroups of disabled veterans,
through consultation with the Commission, on the body system of the
primary disability (16 in all) and on the total combined disability
rating (10 percent, 20-40 percent, 50-90 percent, and 100 percent
disabled).
In addition, we further stratified the 50-90-percent disabled group
into those with and without individual unemployability (IU) status. To
receive IU status, a veteran must have at least one disability that is
rated 60 percent or more or one disability rated at least 40 percent
and a combined disability rating of 70 percent or more. In addition,
the veteran must be unable to engage in substantial gainful employment
as a result of service-connected disabilities. Those with IU status
receive VA compensation as if they were 100-percent disabled, which
results in a substantial increase in VA compensation.
To make earnings comparisons over a lifetime, it is necessary to
have a starting point. In other words, a young service-disabled veteran
will have a long period of lost earnings capacity during prime wage-
earning years, while a veteran who enters into the VA disability
compensation system at an older age will face reduced earnings capacity
for a smaller number of years. If a veteran first becomes eligible for
VA compensation at age 65 or older, the average expectation of lost
earnings is very low, because a large share of individuals are retired
or planning to retire soon by this age. The data show that the average
age of entry into the VA compensation system is about 55 years,
although many enter at a younger or older age. Also, the average age of
entry varies somewhat across the body systems of the primary disability
and combined degree of disability.
Looking at average VA compensation for all male service-disabled
veterans, we find that they are about at parity with respect to lost
earnings capacity at the average age of entry. To calculate expected
earnings parity, we take the ratio of service-disabled earned income
plus VA compensation divided by the present value of total expected
earnings for the peer group. This figure is 0.97, which is very close
to parity. A ratio of exactly 1 would be perfect parity, indicating
that the earnings of disabled veterans, plus their VA compensation,
gives them the same lifetime earnings as their peers. A ratio less than
one would mean that the service-disabled veterans receive less than
their peers on average, while a ratio greater than one would mean that
they receive more than their peers.
We also evaluated the parity of earned income and VA compensation
for service-disabled veterans compared to the peer group by disability
rating group and age at first entry into the VA compensation system.
Our findings indicate that it is important to distinguish whether the
primary disability is a physical or a mental condition. We found that
there is not much difference in the results among physical body systems
(e.g., musculoskeletal, cardiovascular), and for mental disabilities,
it does not matter much whether the disability is for PTSD or some
other mental disability.
If we only look at those with a physical primary disability, our
findings indicate that service-disabled veterans are generally at
parity at the average age of first entry into VA compensation system
(50 to 55 years of age). This is true for each of the rating groups.
However, we observed earnings ratios substantially below parity for
service-disabled veterans who were IU, and slightly below parity for
those who were 100-percent disabled, who entered at a young age (age 45
or less).
For those with a mental primary disability, our findings indicate
that their earnings ratios are generally below parity at the average
age of entry, except for the severely disabled (IU and 100-percent
disabled).
We find that the severely disabled who enter at a young age are
substantially below parity.
To summarize the earnings ratio findings for male veterans, there
is general parity overall. However, when we explored various subgroups,
we found that some were above parity, while others were below parity.
The most important distinguishing characteristic is whether the primary
disability is physical or mental. In general, those with a primary
mental disability have lower earnings ratios than those with a primary
physical disability, and many of the rating subgroups for those with a
primary mental disability had earnings rates below parity. In addition,
entry at a young age is associated with below parity earnings ratios,
especially for severely disabled subgroups.
Veterans' quality-of-life survey results
The second principal tasking from the Commission was to assess
whether the current benefits program compensates not just for loss of
average earnings, but also for veterans' quality-of-life degradation
resulting from service-connected disability. Addressing this issue
required collecting data from a representative sample of service-
disabled veterans, which would allow us to estimate their average
quality of life. To do this, we constructed, in consultation with the
Commission, a survey to evaluate the self-reported physical and mental
health of veterans and other related issues. CNAC's subcontractor, ORC
Macro, conducted the survey and collected the data. As with the earned
income analysis, we designed the survey to collect data by the major
subgroup. We defined subgroups by the body system of the primary
disability and combined disability rating. We also characterized the
survey results by IU status within the 50- to 90-percent disabled
subgroup.
The survey utilized 20 health-related questions taken from a
standardized bank of questions that are widely used to examine heath
status in the overall population. The questions allowed us to calculate
a physical health summary score (physical component summary, or PCS)
and a mental health summary score (mental component summary, or MCS).
As this approach is widely used to measure health status, it allowed us
to compare the results for the service-disabled veterans to widely
published population norms.
For evaluating the survey, we analyzed the results by subgroup
similar to the strategy we used for comparing earnings ratios. We
looked at those with a primary physical disability and those with a
primary mental disability separately. We also examined the PCS and MCS
scores for additional subgroups within those categories. For the
population norms, the PCS and MSC averages are set at 50 points.
For service-disabled veterans with a primary physical disability,
we found that their PCS measures were below population norms for all
disability levels, and that the scores were in general lower as the
disability level increased. In addition, having a primary physical
disability was not generally associated with reduced mental health as
measured by MCS. Mental health scores for those with a primary physical
disability were close to population norms, although those who were
severely disabled had slightly lower mental scores.
For service-disabled veterans with a primary mental disability, we
found that both the physical and mental component summary scores were
well below population norms. This was true for each of the rating
groups. This was a distinction from those with a primary physical
condition, who (except for the severely disabled) did not have MCS
scores below population norms.
To summarize our overall findings, as the degree of disability
increased, generally overall health declined. There were differences
between those with physical and mental primary disabilities in terms of
physical and mental health. Physical disability did not lead to lowered
mental health in general. However, mental disability did appear to lead
to lowered physical health in general. For those with a primary mental
disability, physical scores were well below the population norms for
all rating groups, and those with PTSD had the lowest PCS values.
Combining earnings and quality-of-life findings for service-disabled
veterans
The quality-of-life measures allow us to examine earnings ratio
parity measures in the context of quality-of-life issues. In essence,
the earnings parity measures allow an estimate of whether the VA
compensation benefits provide an implicit quality-of-life payment. If a
subgroup of service-disabled veterans has an earnings ratio above
parity, they are receiving an implicit quality-of-life payment. At
parity, there is no quality-of-life payment, and those with a ratio
less than parity are effectively receiving a negative quality-of-life
payment. We turned next to considering the implicit quality-of-life
payment in the context of the veterans' self-reported health status.
With regard to self-reported quality of life, we had multiple
measures to consider, such as the PCS and MCS measures, and a survey
question on overall life satisfaction. In addition, there is no
intrinsic valuation of a PCS score of 42 compared to a score of 45. We
know that a score of 45 reflects a higher degree of health than a score
of 42 does, but we have no precise way to categorize the magnitude of
the difference. To simplify the analysis, we combined the information
from the PCS and MCS into an overall health score, with a population
norm of 100 points (each scale had a norm of 50 points separately).
Then we calculated the population percentile that would be attributed
to the combined score. For example, for a score of 77 points, we know
that 94 percent of individuals in the age range 45 to 54 would score
above 77. This gave us a way to calibrate our results, in terms of how
the overall physical and mental health of the service-disabled veterans
compared to population norms. By construction, the 50th percentile is
the population norm of this overall measure.
The results of this analysis confirmed our earlier finding that
there are more significant health deficits for those with a primary
mental disability than a primary physical disability. We found that
overall health for those with a mental primary disability is generally
below the 5th percentile in the typical working years for those who are
20 percent or more disabled (this would represent a combined score of
77). Even for the 10-percent group, the overall health score is
generally below the 20th percentile (a combined score of 83).
This approach lets us compare the implicit quality-of-life payment,
based on the parity of the earnings ratio, to the overall health
percentile and the overall life satisfaction measure (the percentage of
respondents who say that they are generally satisfied with their
overall life). We investigated this by rating group and average age at
first entry, separately for those with a physical primary disability
compared to a mental primary disability.
For those with a physical primary disability, the average age at
first entry varies from 45 to 55, rising with the combined degree of
disability. For 10-percent and 20- to 40-percent disability, there is a
negative quality-of-life payment, although their overall health
percentile ranges from 28 to 15 percent. For these groups, the overall
life satisfaction ranges from 78 to 73 percent. For higher disability
groups, there is a modest positive quality-of-life payment, ranging as
high as $2,921 annually for the 100-percent disabled group. For the
100-percent disabled group, the overall health percentile is 4, meaning
that 96 percent of the population would have a higher health score than
the average score for this subgroup, and the overall life satisfaction
is only 60 percent.
In evaluating the service-disabled veterans with a mental primary
disability, we found that there was an implicit negative quality-of-
life payment for veterans of all disability levels except for those
receiving IU. Also, for these subgroups, the overall health percentile
was at the 13th percentile for 10-percent disabled and at the 6th
percentile for 20- to 40-percent disabled. In fact, for the higher
disability groups, the overall health score was at or below 1 percent,
meaning that 99 percent of the population would have a higher overall
health score. Overall life satisfaction, even for the 10-percent
disability level, was only 61 percent. For disability levels 50- to 90-
percent, IU, and 100-percent disabled, the overall life satisfaction
measure hovered around 30 percent.
With regard to the existence of implicit quality-of-life payments,
we found positive quality-of-life payments for those with a physical
primary disability at a combined rating of 50 to 90 percent or higher
(except for IU). For those with a mental primary disability, we found
that there is a positive quality-of-life payment only for the IU
subgroup. In comparing overall health percentiles and life
satisfaction, however, we found that for all rating groups, those with
a mental primary disability have lower overall health percentiles, and
substantially lower overall life satisfaction, than those with a
physical primary disability. Those with a mental primary disability
have lower health and life satisfaction compared to those with a
physical primary disability, but receive less in implicit quality-of-
life payments.
To summarize, we found that VA compensation is about right overall
relative to earnings losses based on comparison groups for those at the
average age at first entry. But the earnings ratios are below parity
for severely disabled veterans who enter the system at a young age and
more generally below parity among subgroups for those with a mental
primary disability. Earnings ratios tend to be above parity for those
who enter the VA system at age 65 or older. On average, VA compensation
does not provide a positive implicit quality-of-life payment. Finally,
the loss of quality of life appears to be greatest for those with a
mental primary disability.
Raters and VSOs survey: pertinent results
With regard to the benefits determination process, the Commission
asked us to gather information by conducting surveys of VBA rating
officials and accredited veterans service officers (VSOs) of National
Veterans Service Organizations (NVSOs). The intent was to gather
insights from those who work most closely with the benefits
determination and claims rating process. Through consultation with the
Commission, we constructed separate (but largely parallel) surveys for
raters and VSOs. The surveys focused on the challenges in implementing
the laws and regulations related to the benefits determination and
claims rating process and perspectives on how the process performs.
The content of the surveys looked at issues involving training,
proficiency on the job, and resource availability and usage.
Respondents were asked about what they considered to be their top three
job challenges. They were also asked about how they decided or
established specific criteria related to a claim, how smoothly the
rating process went, and the perceived capabilities of the various
participants in the process.
The overall assessment indicated that the benefits determination
process is difficult to use by some categories of raters. Many VSOs
find it difficult to assist in the benefits determination process. In
addition, VSOs reported that most veterans and survivors found it
difficult to understand the determination process and difficult to
navigate through the required steps and provide the required evidence.
Most raters and VSOs agreed that veterans had unrealistic expectations
of the claims process and benefits.
Raters and VSOs noted that additional clinical input would be
useful, especially from physicians and mental health professionals.
Raters felt that the complexity of claims is rising over time, and that
additional resources and time to process claims would help. Some raters
felt that they were not adequately trained or that they lacked enough
experience. They viewed rating mental disorder claims as more
problematic than processing physical condition claims. They viewed
mental claims, especially PTSD, as requiring more judgment and
subjectivity and as being more difficult and time-consuming compared to
physical claims.
Specific to the topics of this hearing, many raters indicated that
the criteria for IU are too broad and that more specific decision
criteria or evidence regarding IU would help in deciding IU claims. In
addition, we asked raters and VSOs whether they thought it would be
helpful or appropriate to separately rate the impact of a disability on
quality of life and lost earnings capacity for disabled veterans
applying for benefits. Separating the rating of quality of life from
the earnings impact was not supported by a majority of either raters or
VSOs. Raters did indicate that more specific criteria for rating and
deciding mental health issues - especially PTSD - would be useful.
IU issues and mortality
The Commission asked us to conduct an analysis of those receiving
the individually unemployable (IU) designation. This designation is for
those who do not have a 100-percent combined rating but whom VA
determines to be unemployable. The designation enables them to receive
disability compensation at the 100-percent level.
Overall 8 percent of those receiving VA disability compensation
have IU, but 31 percent of those with PTSD as their primary diagnosis
have IU status. Ideally, if the rating schedule works well, the need
for something like IU will be minimal because those who need 100-
percent disability compensation will get it from the ratings schedule.
The fact that 31 percent of those with PTSD as their primary condition
have IU is an indication that the ratings schedule does not work well
for PTSD.
Another issue is the rapid growth in the number of disabled
veterans categorized as IU--from 117,000 in 2000 to 223,000 in 2005.
This represents a 90-percent increase, an increase that occurred while
the number of disabled veterans increased 15 percent and the total
number of veterans declined by 8 percent. The specific issue is whether
disabled veterans were taking advantage of the system to get IU status
to increase their disability compensation.
The data suggest that this is not the case. While there has been
some increase in the prevalence of getting IU status for certain
rating-and-age combinations, the vast majority of the increase in the
IU population is explained by demographic changes (specifically the
aging of the Vietnam cohort) in the veteran population.
There have also been concerns that individual veterans may be
taking advantage of the system to inappropriately gain IU benefits. We
can use mortality rates to shed light on this issue. The question is
whether those with IU have higher mortality rates than those without
IU. If so, this would seem to provide evidence that there is a clinical
difference between those with and without IU. We found that there are
differences. Those with IU status have higher mortality rates than
those rated 50-90 percent without IU, but the IU mortality rates are
less than for the 100-percent disabled.
Rating system implications for IU
Many individuals receive the IU designation because they are
unemployable. If the purpose of this designation truly relates to
employment, there could be a maximum eligibility age reflecting typical
retirement patterns. If the purpose is to correct for rating schedule
deficiencies, an option is to correct the ratings schedule so that
fewer need to be artificially rated 100-percent through IU. This would
reduce the administrative burden of individual means testing associated
with IU.
In addition, as noted above, almost a third of those with PTSD as
their primary disability condition have IU status. This may be an
indication that the ratings schedule does not work well for PTSD.
It is unlikely that changes to the rating schedule would be able to
completely alleviate the need for the IU designation. There will always
be instances in which a disabled veteran will be rated at less than 100
percent, but will be unable to continue working at the job customarily
performed. However, rating schedule changes might lead to reductions in
the number of veterans that apply for IU. In addition, the VA may want
to consider whether putting more emphasis on retraining programs might
prove useful to veterans designated as IU.
Statement of Mark H. Hyman, M.D., FAADEP
Presenter, American Academy of Disability Evaluating Physicians, and
Mark H. Hyman M.D., Inc., F.A.C.P., F.A.A.D.E.P., Los Angeles, CA
On behalf of the American Academy of Disability Evaluating
Physicians, (AADEP), a duly constituted AMA delegated non-profit
specialty society, I have prepared the following remarks. Having
reviewed the document, A 21st Century System for Evaluating Veterans
for Disability Benefits, I wish to stress the following points in
support of changes to the Veterans Disability System:
1. I am a strong advocate for the adoption of national standards
that are currently in use for the majority of jurisdictions in our
country, including the AMA Guides to the Evaluation of Permanent
Impairment, ICD and DSM codes. Importantly, the legislation should
clearly provide for automatically incorporating updates for these
resource standards when new editions are published.
2. Additional resources that will directly aid in this process
include the AMA books-A Physician's Guide to Return to Work, Guides to
the Evaluation of Disease and Injury Causation, as well as other
resources soon to be released.
3. A secondary benefit of promulgating these same current national
standards and medical textbooks is that all evaluating parties will be
speaking a common medical language. This also aids in teaching, as well
as recruitment of personnel who are involved in the evaluation process.
4. Any unique aspects of the Veteran's claims experience can then
be applied to the impairment rating process so that any perceived area
of inadequacy is addressed.
5. I advocate the formation of the recommended advisory Committee
to be constituted by representatives of both private and governmental
sectors to monitor implementation, assess changes and provide direction
to incorporate evolving concepts. The advisory Committee must have at
minimum, once yearly face-to-face meetings to carry out their duties.
The Advisory Committee must have recognized Subcommittees that review
education and training of personnel and another to review
administrative claims handling including outcomes research. Important
decisions regarding how the Veteran's system chooses to define
disability will need to be explored.
6. All claims and evaluations must be migrated to an electronic
health record.
7. Consideration will need to be given to presumptive conditions
which may streamline some of the claims processing.
8. A roundtable discussion is necessary in the upcoming months to
further crystallize specific recommendations by all shareholders in the
process, with continued outside input from private sector entities
being essential.
9. AADEP stands ready to provide educational support and
intellectual resources to guide any transition process.
10. AADEP is prepared to offer special accommodations for any
active duty military personnel, reserve personnel, Veteran Affairs
Staff, as well as governmental workers to our educational programs and
academy.
----------
I have read the Institute of Medicine report, and do wish to
outline my recommendations from a private sector experience. In the
community, an injured person files a claim within a recognized
jurisdiction-usually at a state level. This triggers a claims handling
by either a private insurance entity or a state mandated agency.
Records are obtained and the patient is then referred to a physician
for evaluation. A report is prepared in the format required by that
jurisdiction. The findings on evaluation are then translated into an
impairment rating, with subsequent administrative actions pursued.
Implementation of the recommendations of the report would bring our
veterans system in a closer approximation to what I have just
described. In particular, I must strongly underscore the need for a
common language in this process which emanates from using already
existing national standards including the AMA Guides, ICD and DSM
coding. These resources are the product of multiple leaders throughout
the world. The AMA Guides began in 1958 in response to the developing
field of disability evaluation. The mission has always been to bring
the soundest possible reasoning to the impairment process. The Guides
have become the community standard in the majority of states within our
country. In essence, the Guides are the tools and rules of the
disability trade. We have just produced the 6th edition of this seminal
work and there are many companion books that go with this resource.
Together, these books represent the efforts of experts around the
country who regularly work in the disability field. There is also a
mechanism of updating this information through a newsletter until there
is the need for a more major revision. Through this mechanism that is
used in the private sector, we can thoroughly describe and categorize
the range of human injury. We are able to develop a fair, equitable,
consistent rating on an individual's impairment, small or large.
Further, the Guides are aligned with the World Health Organization
model of disablement termed the International Classification of
Functioning, Disability and Health.
As with all jurisdictions, once an impairment rating process has
occurred, then, like all jurisdictions, any specific, unique, coding or
administrative concerns can then be added to the process. Indeed, in
many jurisdictions, the evaluators may not even fully know all the
subsequent claims processing above their impairment rating. In the
current VA example, raters could take this report from the medical
evaluation, and cohesively apply the disability rating with good
reproducibility.
The use of these resources will allow for transition to an
electronic health record system, which is currently the standard for
the Veterans health system on the medical side. Tracking of data then
becomes much easier.
To accomplish this process, all shareholders form the VA system
must have a seat at preliminary roundtable discussions and have input
into the recommendations from the advisory Committee. The advisory
Committee must be charged and funded to meet at least once yearly, with
quarterly telephonic meetings, in order to ensure implementation,
assess outcomes and ensure proper education. I can not underscore
enough the importance of education as this field is one that is not
covered well or extensively in standard medical training and has many
unique aspects which must be understood. By using the resources which I
have identified as central to this process, the common language of
impairment and disability will be broadened to all personnel involved
in the process. I personally, as a citizen of this great country, and
our organization AADEP that I am representing today, offer assistance
to you in furthering this project.
Thank you for allowing me to help our country, but in particular,
for giving me a chance to help those men and women who have provided
for our security, that we can meet here today and try to repay their
effort in some way. May God bless you in your deliberations.
----------
2007 Annual Report
AADEP: Doctors Teaching What They Do Best
21 Years
AADEP Fact Sheet
HISTORY
The Chicago-based American Academy of Disability Evaluating
Physicians (AADEP) is a multi-disciplinary, collegial organization,
which transcends the many specialties of its Fellows and Members.
Founded by Orthopaedic Surgeons in 1987, the Academy celebrated its
20th Anniversary in 2006 in St. Petersburg, Florida. Just 75 physicians
met at the First Annual Scientific Session in Detroit to hear 8 hours
of continuing medical education. The 2008 meeting will offer more than
25 CME hours to 300 physicians. Nearly 2000 physicians have achieved
Fellow status, the only enhanced credential for those physicians who
evaluate disabilities or rate impairments. Nearly 300 have achieved a
CEDIR (Certification in Evaluation of Disability and Impairment
Rating). The Academy's mission is quality CME and its vision is to be
the pre-eminent authority in disability evaluation. That mission
stretched to Dublin and Amsterdam with EUMASS (European Union of
Medical Assurance in Social Security) in June 2006, and to Majorca in
2007.
MEMBERSHIP
Membership has more than doubled since inception, AADEP now stands
at 1050, 90 percent are Fellows and 37 percent are AMA Members. Members
represent 23 ABMS specialties, predominantly:
26 percent Orthopaedic Surgery
14 percent PM&R
13 percent Family/General Practice
10 percent Occupational Medicine
and are from all 50 states, Puerto Rico and 6 countries.
ASSOCIATE MEMBERSHIP
Fellows approved Associate Membership for all others on the
evaluation team in 2003--a major step toward an inclusion perspective.
Associate Members make up 3 percent of the total.
CONTINUING MEDICAL EDUCATION
AADEP has trained nearly 20,000 physicians since its founding. The
Academy now provides advanced educational offerings to at least 2000
physicians annually. AADEP maintains its integrity and credibility as
an educator with 45 volunteer faculty teaching more than 300 segments
with average ratings of 4.5 on a 5.0 scale. AADEP is also an approved
provider for mandated courses in Texas, Ohio and Pennsylvania. With
publication of the AMA Guides to Evaluation of Permanent Impairment,
5Mh Edition, the need for impairment rating courses will grow. The real
growth will be the disability focus, using Evidence Based Medicine
skills and tools. Web based guidelines require additional education.
ACADEMY HALLMARKS
Single Source of Focused Disability Evaluation Education
High Energy Network of Experts
Access to Physician Resources on Complex Issues
Disability Medicine Standard Bearers
Unique Certification (CEDIR)
Clearinghouse of Best Available Evidence and EBM tools
Practice Improvement with Evidence-Based Medicine
----------
AMERICAN ACADEMY OF DISABILITY EVALUATING PHYSICIANS
223 West Jackson Boulevard
Suite 1104
Chicago, IL 60606-6900
Telephone: 1/800-456-6095
AADEP PROVIDES EXPERTS
To Develop Resources
To Create/Edit New Publications
To Testify for Fairer Adjudication
To Teach Best Practices
To Fulfill Individual Physician Needs
To Improve Injured Worker Outcomes
To Consult with Physician Learners
AADEP PROVIDES PRE-EMINENT CME
Outstanding Annual Scientific Session with
internationally recognized faculty
Customized Impairment Rating Courses
Texas (5-7 annually)
Ohio (one annually)
Pennsylvania (as mandated)
Washington (as requested)
Other States
AADEP PROVIDES ADDITIONAL CME
2-4 AMA Guides Impairment Rating Courses
5-6 MDA*/ODG** Courses
Customized ODG Courses (as requested)
Functional Capacity Exam Courses
Customized Courses for Medical Associations/Healthcare
Institutions
At least 15-18 Live CME Activities Annually
* Medical Disability Advisor (MDA)
** Official Disability Guidelines (ODG)
AADEP DESIGNATES FELLOWS
Recruits Members
Provides Annual Comprehensive Education Course (Austin,
TX 2008)
Peer Reviews Reports
Evaluates Credentials
Has Designated Nearly 2000 Nationally and
Internationally
AADEP CERTIFIES EXPERTS
Provides Specific Certification Exams (states, editions
of Guides) - since 2002
Certifies at Least 75 Annually as CEDIR (Certification
in Evaluation of Disability and Impairment Rating (CEDIR)
Approved Certification Provider in Texas
Offers Exam at All Live CME Activities
AADEP EDUCATES
Physicians
Attorneys
Psychologists
Insurance Co. Representatives
Industrial Health Services Groups
Occupational Health Nurses
Certified Claims Managers
Certified Vo-Rehab Consultants
All Members of the Disability Arena
AADEP TESTIFIES
For Institute of Medicine Committee on Social Security
Before House Subcommittee on Veterans' Affairs
AMA Committees
Before State Boards of Inquiry
As Expert or Peer Review Witnesses in Courts of Highest
Jurisdiction on Legal Issues of Disability
AADEP VOLUNTEERS
As Resource Authors
As Contributing Authors
As Reference Work Editors
As Board Members
As Researchers
As Faculty for AADEP and Other Aligned Organizations
AADEP COLLABORATES
With AMA as Member of House of Delegates
With governmental Bureaus/Agencies
With Allied Product Developers
With AMA Press
With Affiliated Specialty Societies
With Universities
With Medical Practices
AADEP HEADQUARTERS IN CHICAGO
Organized as Illinois not-for-profit in 1989
Accredited CME Provider since 1991
Provided Hundreds of CME Activities--Both Live and
Distance Learning
1050 MD/DO Members
950 Fellows
50 Associate Members
AADEP INFORMS
Reach by e-mail [email protected]
Check website www.aadep.org
Call 1/800/456-6095
Inquire of Headquarters for ``hot line'' to AADEP
Fellows
Talk to the Executive Director at Ext. 21
Statement of Sidney Weissman, M.D.
Member, Committee on Mental Healthcare for Veterans and Military
Personnel and Their Families, American Psychiatric Association
Good afternoon. I am Sid Weissman M.D., and am pleased to have this
opportunity meet with you representing the American Psychiatric
Association, the medical specialty organization which represents over
37,000 psychiatrists, their patients and families. My professional
experience includes serving as a psychiatric physician for the United
States Air Force and 6 years with the Department of Veterans Affairs.
The American Psychiatric Association (APA) is responsible for the
preparation, publication, and maintenance of the Diagnostic and
Statistical Manual of Mental Disorders, which is now in its fourth
edition (DSM-IV). Thus, we have a vital interest in the work of this
Subcommittee, and particularly the interest in ``expanding the criteria
for psychiatric disabilities, especially for Post Traumatic Stress
Disorder (PTSD).''
As you have heard from many experts, there is a long history of
examining responses to stress, beginning early in this century, with
the notion of ``shell shock'' in World War I and the analytic concept
of ``traumatic neurosis.'' During WW II Roy Grinker and John Spiegel
published War Neurosis in North Africa and Men under Stress addressing
the stresses experienced by Army Aviators. Their work ushered in the
era of scientific study of stress which extends to the present. This
work has expanded to address all severe psychologically traumatizing
life events in addition to those experienced in wartime in combat. The
extensive scientifically informed work over the past 50-plus years has
resulted in a professional consensus, based increasingly on a rigorous
scientific base, of the explicit clinical characteristics of PTSD, its
prevalence, and its responsiveness to appropriate treatment.
We understand that the Committee has an interest in the utilization
of the diagnosis of PTSD in active duty and discharged military
personnel and the impact of this diagnosis on the determination of
health benefits and compensation for service-induced disability.
Need for a Definition Reference Point
All mental disorders - ranging from mild depression to
schizophrenia to PTSD - vary in the disability associated with each
particular diagnosis. Hence, questions of disability and severity are
at the heart of compensation assessments for SSDI and SSI in the
civilian governmental sector. Because of the broad use of diagnostic
criteria, it is important for all clinical, research, insurance claims
management, and governmental use of mental disorder diagnoses to have a
common frame of reference for diagnostic assessments. Without such a
common reference point, the potential for the development of
idiosyncratic diagnostic systems may lead to a dysfunctional and non-
cumulative research base and to misuse of diagnostic approaches for
financial or political purposes.
I hope it will be helpful to the Committee to have some additional
background information about the development of diagnosis criteria and
reporting of mental disorders in the U.S. and internationally. After
the development of the United Nations in the late 1940's, each
signatory to the UN Charter agreed to use the World Health Organization
(WHO) International Classification of Diseases (ICD) for all morbidity
and mortality recording--to assure comparable international health
statistics. Within the U.S., there has been a Clinical Modification
(CM) of the ICD codes since about 1977 when the ninth revision (ICD-9)
was issued by the WHO. Although there was a list of mental disorder
definitions included in the ICD-9-CM, the NIMH supported research
community began using a much more detailed set of explicit Research
Diagnostic Criteria (RDC) to obtain greater homogeneity of research
subjects. In 1980, the APA proposed a third edition of the Diagnostic
and Statistical Manual (DSM-III) that was based heavily on the RDC
prototype of explicit diagnostic criteria, that could be seen as
testable hypotheses for their validity in predicting clinical course,
treatment response, and eventual etiological information such as
genetics or environmental exposure.
This diagnostic prototype was almost immediately adopted by the
international psychiatric community, convened by the WHO Division of
Mental Health in a historic 1982 Copenhagen conference. The WHO then
worked jointly with the APA and NIMH over the next decade, using the
DSM-III as a common reference point, to develop almost identical
diagnostic criteria for ICD-10 and subsequently DSM-IV. Unfortunately,
the U.S. has not yet adopted the ICD-10-CM and continues to use ICD-9-
CM diagnostic codes for required Medicare claims submissions by the
Centers for Medicare & Medicaid services (CMS) (and by private
insurance carriers as well). However, for the past 26 years, mental
health and other healthcare practitioners have been using an
alternative set of ``descriptors'' for ICD-9-CM codes, provided in
successive editions of the DSM by the American Psychiatric Association
(APA).
This alternative classification system for mental disorders is the
Diagnostic and Statistical Manual of Mental Disorders, now in its 4th
edition (called DSM-IV). Even though the American Psychiatric
Association publishes the DSM-IV, psychologists, social workers,
counselors, mental health administrators, and policy planners use it
routinely for clinical management, recordkeeping and communication.
Epidemiological surveys and studies of mental health practice patterns
use DSM-IV definitions for ascertainment of appropriate case inclusion.
Practice guidelines for clinicians to improve and standardize patient
care are keyed to the DSM definitions. Virtually all research studies
on mental disorders define study populations in terms of the DSM
categories. Students of medicine, law, psychiatry, psychology, social
work, and all other mental health professions rely on textbooks that
describe mental disorders based on the DSM definitions.
Furthermore, DSM-IV is the de facto official code set for various
Federal agencies and for virtually all states. Indeed, there are over
650 Federal and state statutes and regulations that rely on or directly
incorporate DSM's diagnostic criteria. For example, the Department of
Veterans Affairs disability program uses the diagnostic criteria in
DSM-IV to assess whether an applicant qualifies for disability on the
basis of a mental disorder [38 CFR 4.125]. In addition, CHAMPUS
required that the ``mental disorder must be one of those conditions
listed in the DSM-III'' [32 CFR 199.2]; and Medicaid beneficiaries
who apply for admission to nursing facilities because of a mental
disorder must meet diagnostic criteria set out in DSM [42 CFR
483.102]. In California, Medicaid reimbursement to hospitals is keyed
to the DSM-IV [9 CCR 1820.205(a)(1)(B) and 1830.205(b)(1)(B)], while
in Tennessee, the mental health qualifications to serve as a police
officer incorporate by statute DSM [Tenn. Code Ann. 38-8-106], as do
the driver's license provisions of Pennsylvania law [67 Pa. Code
83.5].
APA is in the process of assessing the evidence base for PTSD and
all other mental disorders in anticipation of a revision of the DSM
scheduled for publication in 2011. In June 2005, APA, with the
collaboration of the World Health Organization and grant support from
the National Institutes of Health, convened an international research
planning conference on stress-induced and fear circuitry disorders, a
diagnostic grouping that subsumes PTSD.
A key product of the APA/WHO/NIH conference was the compilation of
specific recommendations for research, based on a critical assessment
of the existing science base and our identification of near-,
intermediate-, and longer term opportunities for diverse studies and
analyses. In early March of last year, the APA appointed an official
DSM-V Revision Task Force which includes a workgroup on stress-related
disorders, including PTSD, which will recommend any modifications to
the diagnostic criteria that are supported by the science base. The
chair of the workgroup is Dr. Matthew Friedman. He is a psychiatrist
and Executive Director of the U. S. Department of Veterans Affairs
National Center for Post Traumatic Stress Disorder (PTSD) so he brings
a critical perspective to the review of the DSM. A particular focus of
this DSM-V workgroup is the reevaluation of the relationship between
mental disorders and disability. Research exploring disability and
impairment may benefit from the diagnosis of mental disorders being
uncoupled from a requirement for impairment or disability in order to
foster a more vigorous research agenda on the etiologies, courses, and
treatment of mental disorders as well as disabilities and to avert
unintended consequences of delayed diagnosis and treatment.
The APA welcomed the IOM's intensive review of the VA disability
ratings process and how it related to the DSM. Any additional
information that is specific to the Veteran's population from emerging
from your review will certainly be most welcome by the DSM-V task force
Committee.
In closing, we hope that knowledge gained from working with our
Veterans population will be incorporated into the U.S. and
international diagnostic conventions for mental disorders rather than
be used to develop into an idiosyncratic diagnostic system unique to
the VA or to the Department of Defense. Likewise, we would hope that
there will be a similar interaction with experts convening to study
mental health disorder disability assessment, treatment, management and
compensation programs which are supported by the Social Security
Administration. One instructive source for these and other expert
groups may be found in the work and decisions of the United Nations
Compensation Commission, a subsidiary of the U.N. Security Council. The
Commission was established in 1991 to process claims and pay
compensation - including compensation to claimants who suffered
personal injury and mental pain and anguish - resulting from Iraq's
invasion and occupation of Kuwait. A common goal for both civilian and
military populations is to structure the most effective strategies for
maximizing treatment response and functional capacity in those impacted
by disability associated with a mental disorder.
Thank you very much.
Statement of Ronald B. Abrams
Joint Executive Director, National Veterans Legal Services Program
Mr. Chairman and Members of the Subcommittee:
I am pleased to have the opportunity to submit this testimony on
behalf of the National Veterans Legal Services Program (NVLSP). NVLSP
is a nonprofit veterans service organization founded in 1980 that has
been assisting veterans and their advocates for 28 years. We publish
numerous advocacy materials that thousands of advocates for veterans
regularly use as practice tools to assist them in their representation
of VA claimants. NVLSP also recruits and trains volunteer attorneys,
trains service officers from such veterans service organizations as The
American Legion and Military Order of the Purple Heart in veterans
benefits law, and conducts quality reviews of the decisionmaking of the
VA regional offices on claims for VA benefits on behalf of The American
Legion.
In addition, NVLSP represents veterans and their families on claims
for veterans benefits before VA, the U.S. Court of Appeals for Veterans
Claims (CAVC), and other Federal courts. Since its founding, NVLSP has
represented over 1,000 claimants before the Board of Veterans' Appeals
and the Court of Appeals for Veterans Claims (CAVC). NVLSP is one of
the four veterans service organizations that comprise the Veterans
Consortium Pro Bono Program, which recruits and trains volunteer
lawyers to represent veterans who have appealed a Board of Veterans'
Appeals decision to the CAVC without a representative.
In General
Obviously, updating, modernizing, and otherwise improving the
rating schedule would be beneficial to veterans. NVLSP would like to
caution, however, that improving the rating schedule should not be
considered as cure-all. For example, there is no amount of money that
would adequately compensate anyone for the loss of (or loss of use) of
a body part, permanent cognitive impairment, or loss of a creative
organ. Ideally, in dealing with severe service-connected disability, we
should not ask how much is the disability worth, we should ask how much
we can this Nation afford to pay.
NVLSP suggests that the rating schedule be amended so that it would
more accurately reflect both the impact on the average impairment in
earning capacity and the negative impact of the disability on the
veteran's lifestyle. The current special monthly compensation rules
which are intended in some respects to reflect adverse changes in
lifestyle, (see 38 U.S.C. 1114 and 38 C.F.R. 3.350) are complicated,
confusing, and do not accurately reflect the negative impact of mental
disorders on a veteran's industrial capacity and lifestyle.
The fact that some veterans are not adequately compensated for
their service-connected mental disabilities does not mean that the VA
should reduce the evaluation of some physical disabilities. This is not
a zero-sum game. Also, we caution that no change to the rating schedule
should adversely impact any current servicemember.
Evaluation of Mental Conditions
For a long time, the VA has tended to under-evaluate mental
disabilities. This has occurred at the same time that our society has
evolved from one dominated by manual labor to a work environment that
emphasizes intellectual endeavors. Therefore, the adverse impact of a
mental disability on the average worker has increased over time. That
impact should not be constrained to whether the average person
suffering from a mental disability could work on the type of farm that
existed in 1947.
The VA should adopt new criteria for rating the degree of
disability for all mental conditions that reflect the adverse impact
that severe mental disabilities have on an individual in the civilian
world today. In addition, the rating schedule for mental disorders
should be amended to remove the unfavorable disability rating criteria
that apply to veterans suffering from mental disorders when compared to
veterans suffering from physical disorders. The rating schedule permits
veterans with 100 percent scheduler evaluations for all conditions
other than mental conditions to be evaluated as 100 percent disabled
even if they are gainfully employed.
Veterans who suffer from severe mental disabilities and cannot
perform any work can be evaluated as 100 percent disabled. But veterans
suffering from a mental disorder cannot be rated 100 percent disabled
if they are engaged in any employment, despite the severity of their
mental condition. In the experience of NVLSP, some severely mentally
disabled veterans can be lucky enough to find a job where they can be
somewhat productive. They should not be penalized for trying to do some
work while other veterans with physical disabilities are receiving
compensation at the 100 percent disability level and earn a full-time
salary as a productive worker. This does not mean that there should not
be some connection between earned income and the evaluation of mental
conditions. We just suggest that the connection be not so absolute.
Total Disability Based on Individual Unemployability (IU)
NVLSP agrees with the current VA rating policy regarding IU.
Veterans who are so unlucky to suffer from both severe service-
connected disabilities and severe non-service-connected disabilities
should not be punished because they have multiple disabilities. If a
veteran's service-connected conditions would cause him or her to be
unable to perform substantial gainful employment, that veteran should
be awarded total disability based on individual unemployability.
NVLSP rejects any recommendation that would require the VA to
implement a periodic and comprehensive evaluation (or review) of
veterans in receipt of IU benefits. As a VA employee in the eighties, I
had to perform some of these reviews. They tend to become witch hunts.
While NVLSP has no problem with the VA reviewing grants of disability
benefits on a case-by-case basis, we oppose any systematic review of IU
benefits. Also, age should never be any factor in the award or
evaluation of compensation benefits. With Supreme Court justices
regularly working well past age 80, and candidates for President over
age 70, age should not be considered as a positive or negative factor.
38 C.F.R. 3.340 states:
(a) Total disability ratings--(1) General. Total disability
will be considered to exist when there is present any
impairment of mind or body which is sufficient to render it
impossible for the average person to follow a substantially
gainful occupation. Total disability may or may not be
permanent.
The longstanding policy should not be changed. It is fair and
compassionate. See also, 38 C.F.R. 4.16(b).
Improving rating criteria for Traumatic Brain Injury
NVLSP commends the efforts of the Department of Veterans Affairs'
(VA) to revise the current evaluation criteria for TBI. The current
diagnostic code (DC 8045) is very restrictive and promotes inadequate
evaluations. The current DC is unfair because subjective symptoms of
TBI are limited to a 10 percent evaluation without any consideration to
the frequency and severity of these symptoms. (The current DC provides
that ``[P]urely subjective complaints such as headache, dizziness,
insomnia, etc., recognized as symptomatic of brain trauma, will be
rated as 10 percent disabling and no more. . . . [without a diagnosis
of multi-infarct dementia associated with the brain trauma].''
Addressed below are specific comments regarding the following
provisions of the proposed rule:
Evaluation of Symptom Clusters
The VA proposes to replace the subjective guidelines under DC 8045
with new evaluation levels of 20, 30 and 40 percent. The subjective
symptoms are now lumped into a category described by the VA as symptom
clusters.
While the proposed regulation is an improvement, the Legion and
NVLSP believe that veterans who suffer from TBI should not be required
to satisfy the narrow criteria for an extra-schedular evaluation in
order to receive a total disability rating. Veterans who suffer from
frequent and severe ``symptom clusters'' are unlikely to be able to
obtain substantial gainful employment. Those who are unable to obtain
substantial gainful employment due to a service-connected disability
should be entitled to a 100 percent disability rating. But VA's
proposed rule places a significant roadblock to a 100 percent
disability rating for ``symptom clusters.''
Under VA's proposal, a veteran is entitled to no more than a 40
percent schedular disability rating, no matter how frequent or severe
the following ``symptom clusters'' are:
headaches, dizziness, fatigue, malaise, sleep disturbance,
cognitive impairment, difficulty concentrating, delayed reaction time,
behavioral changes, emotional changes, tinnitus or hypersensitivity to
sound or light, blurred vision, double vision, decreased sense of smell
and taste, and difficulty hearing in noisy situations in the absence of
hearing loss,
The general pathway a veteran must travel to obtain a total
disability rating for individual unemployability (``TDIU'') is to
obtain at least a 70 percent schedular rating and satisfy the
requirements for TDIU under 38 C.F.R. 4.16(a). But under VA's
proposal, veterans suffering from ``symptom clusters'' would be unable
to obtain any schedular rating higher than 40 percent, no matter how
frequent or severe the symptom clusters are. This means that the only
pathway to a 100 percent disability rating is if VA grants an extra-
schedular rating under 38 C.F.R. 4.16(b). Because very few extra-
schedular ratings are issued by VA, (especially an extra-schedular
grant of total disability based on individual unemployability) this is
highly unfair.
The VA indicates that the current diagnostic code 8045 is 45 years
old and reflects a view that the various symptoms associated with TBI
could be due to malingering or hysteria. It appears this comment was
inserted to explain the current rating policy.
Under the proposed rule, there must be at least three of the above
listed symptoms present for a compensable evaluation to be assigned.
The disability percentage would be based on a specific number of
symptoms present (40 percent--9 or more symptoms; 30 percent--5-8
symptoms; 20 percent--3 or 4 symptoms). The proposed regulation wrongly
fails to credit the frequency and severity of these symptoms.
NVLSP appreciates that VA now has recognized that these symptoms
could be due to subtle brain pathology. Because, however, the VA
proposes to replace the current 10 percent maximum evaluation with
rating levels of 20, 30, and 40 percent, NVLSP is concerned that this
rating formula would continue to promote unfair adjudications because
just as in the current DC 8045, the frequency and severity of the
symptoms are ignored.
Also, the proposed regulation does not discuss how and when the
longitudinal history of the disability should be considered. For some
veterans the symptoms of TBI may wax and wane. Therefore, some veterans
may be under evaluated if the history of their symptomatology is not
considered.
Evaluation of Cognitive Impairment
While the proposed regulation does attempt to define mild
impairment for the purposes of evaluating cognitive impairment, the
proposed regulation does not define the terms ``moderately impaired''
and ``severely impaired.'' We strongly urge VA to define these terms
with specificity to promote consistency and fairness in adjudication.
The formula used by the proposed regulation to evaluate the 11
common major effects of cognitive impairment would encourage much
unfair adjudication. The proposed regulation is unfair because the
formula does not fairly capture the impact of some of the major effects
of cognitive impairment. For example suppose a veteran has a score of
three because his or her TBI causes the veteran to require assistance
with the activities of daily living some of the time (but less than
half of the time). If the veteran had only zero scores in the other
major effects of cognitive impairment, the veteran would be evaluated
as only 10 percent disabled. This is patently unfair, especially given
the fact that veterans with a mental condition that causes just mild
memory loss could arguably receive a 30 percent evaluation under 38
C.F.R. 4.130 (see the 9400 diagnostic code series).
Applicability Date
VA proposes that the provisions of this proposed rule would be
applicable only to claims for benefits received by VA on or after the
effective date of the rule. Therefore, pending claims would have to be
adjudicated under the current unfavorable rule.
It does not make sense to apply the old rating criteria to a claim
that has not been initially adjudicated, or is pending re-adjudication
due to an appeal, simply because the claim was received prior to the
effective date of the new rule. NVLSP urge you to amend this portion of
the proposed rule to require claims and appeals filed prior to the
effective date of the rule, but pending at the time the rule takes
effect, to be adjudicated under the new rule.
Emotional and Behavioral Dysfunction and Comorbid Mental Disorders
It is clear, as admitted by VA in its comments, that many veterans
who suffer from TBI also suffer from secondary depression (or other
mental illnesses such as PTSD). Therefore, the proposed rule should be
amended to require the VA to consider whether the record reasonably
raises the issue whether service-connection is warranted for mental
disorders (especially mental disorders secondary to the TBI) whenever
service connection is granted for TBI, and, if so, to adjudicate such a
separate claim. This should be done because it is fair and because many
veterans with mental disorders at a disadvantage when it comes to
prosecuting their claims.
Presumptions
The current ``association'' standard should not, as proposed by the
Veterans' Disability Benefits Commission (VDBC), be replaced with a
``causal effect'' standard. Any move away from the ``benefit of the
doubt'' standard would have a negative impact on all veterans. If we
send our troops into dangerous places, and if we put our servicemembers
into dangerous situations, our Nation must make certain to at least
maintain the non adversarial nature of the VA claims process and
protect the ``benefit of the doubt'' standard. The cost of compensating
veterans who suffer from disabilities that are presumptive in nature is
a cost of war.
Thank you for permitting NVLSP to testify on such an important
issue.
Statement of Dean F. Stoline
Assistant Director, National Legislative Commission, American Legion
Mr. Chairman and Members of the Subcommittee:
Thank you for this opportunity to present The American Legion's
views on revising the Department of Veterans Affairs (VA) Schedule for
Rating Disabilities (VASRD). This statement will focus on the issues
outlined in the Subcommittee's hearing invitation letter.
Rating Schedule (General)
The Veterans' Disability Benefits Commission (Commission or VDBC)
specifically recommended the following with respect to the VASRD:
VA should immediately begin to update the current Rating Schedule,
beginning with those body systems addressing the evaluation and rating
of post-traumatic stress disorder and other mental disorders and of
traumatic brain injury. Then proceed through the other body systems
until the Rating Schedule has been comprehensively revised. The
revision process should be completed within 5 years. VA should create a
system for keeping the Rating Schedule up to date, including a
published schedule for revising each system. (Recommendation 4.23;
Chapter 4, section I.5)
While The American Legion does not disagree with the need to ensure
an up-to-date VASRD, by removing out-of-date and archaic criteria and
using current trends in medicine, science, and technology to evaluate
disabilities, the issues with the Rating Schedule should be put in
proper perspective. In fact, most major body systems in the Rating
Schedule have been updated over the last several years.
In the opinion of The American Legion, the Rating Schedule is not
the major cause of problems with the VA disability compensation
process. The American Legion supports the updating of conditions such
as traumatic brain injury (TBI) that have not been recently updated,
but problems such as inadequate staffing, inadequate funding,
ineffective quality assurance, premature adjudications, and inadequate
training that plague the VA regional offices will not be resolved by an
overhaul of the rating schedule and must be the major focus of any
attempts to reform the adjudication process.
The American Legion must stress that we are a Nation at war.
Therefore, no injury or disability to any current servicemember should
receive less compensation because of an update to the Rating Schedule.
Also, The American Legion believes the evaluations for some
disabilities (for example: amputations, loss of use of a limb, loss of
use of a creative organ) are under-compensated because these ratings
fail to consider the impact of the disability on the veteran's quality
of life. Other disabilities, such as mental conditions, are under-
compensated because they fail to adjust to the changing work
environment. The American Legion welcomes positive changes to the
Rating Schedule to cure these inequities.
Evaluation of Post Traumatic Stress Disorder
The VDBC made the following recommendation regarding the evaluation
of post-traumatic stress disorder (PTSD):
VA should develop and implement new criteria specific to post-
traumatic stress disorder in the VARD. VA should base those criteria on
the Diagnostic and Statistical Manual of Mental Disorders and should
consider a multidimensional framework for characterizing disability due
to post-traumatic stress disorder. (Recommendation 5.28; Chapter 5,
section III.3)
The Rating Schedule currently uses one set of rating criteria for
all mental disorders. There are unique aspects of PTSD that are not
properly evaluated by the current rating criteria and The American
Legion supports the development of rating criteria that addresses the
specific symptoms involved with PTSD.
The VDBC further recommended:
VA should establish a holistic approach that couples post-traumatic
stress disorder treatment, compensation and vocational assessment.
Reevaluation should occur every 2-3 years to gauge treatment
effectiveness and encourage wellness. (Recommendation 5.30; Chapter 5,
section III.3)
While The American Legion supports a holistic approach to the
treatment and compensation of PTSD that encourages wellness, we are
concerned that a mandatory reevaluation every 2-3 years could result in
undue stress among PTSD service-connected veterans. These veterans may
be fearful that the sole purpose of such reevaluations would be to
reduce compensation benefits. This perception could undermine the
treatment process. We would, therefore, encourage study and review of
possible unintended consequences regarding this portion of the
Commission's recommendation.
Individual Unemployability
The VDBC made the following recommendations regarding the use and
evaluation of total ratings based on Individual Unemployability (IU):
Eligibility for Individual Unemployability should be consistently
based on the impact of an individual's service-connected disabilities,
in combination with education, employment history, and medical effects
of an individual's age or potential employability. VA should implement
a periodic and comprehensive evaluation of Individual Unemployability-
eligible veterans. Authorize a gradual reduction in compensation for
Individual Unemployability recipients who are eligible to return to
substantially gainful employment rather than abruptly terminating
disability payments at an arbitrary level of earning. (Recommendation
7.4; Chapter 7, section II.3)
Recognizing that Individual Unemployability is an attempt to
accommodate individuals with multiple lesser ratings, but who remain
unable to work, the Commission recommends that as the VASRD is revised,
every effort should be made to accommodate such individuals fairly
within the basic rating system without the need for an Individual
Unemployability rating. (Recommendation 7.5; Chapter 7, section II.3)
Although The American Legion supports the provision calling for the
gradual reduction in compensation benefits for IU recipients who are
able to return to substantially gainful employment, we strongly oppose
the portion of the recommendation that could be interpreted as
requiring the consideration of age in determining eligibility to IU. It
is inherently unfair to punish an older veteran, who would not be able
to work at any age because of a service-connected condition, while
awarding the benefit to a similarly disabled younger veteran. The
current rule states (in essence) that the impact of a service-connected
condition on a veteran cannot be evaluated to a higher degree because
the veteran is old (38 C.F.R. 3.341(a)). The schedule is based on the
average impairment in earning capacity. If the veteran cannot work
because of service-connected disability(ies), then IU should be
awarded.
Additionally, The American Legionis extremely leery of any
recommendation that would encourage the elimination of a specific
benefit program on the anticipation of a revised Rating Schedule that
would supposedly eliminate the need for that benefit. The current
policy as enunciated by 38 C.F.R. 3.340 states, ``[T]otal disability
will be considered to exist when there is present any impairment of
mind or body which is sufficient to render it impossible for the
average person to follow a substantially gainful occupation.'' This
policy is fair and consistent with the non-adversarial nature of the VA
claims process. Therefore, this policy should not be altered. Veterans
should not be punished because they are so unfortunate to suffer from
both service-connected and nonservice-connected disabilities, either of
which could cause unemployability.
38 C.F.R. 4.16(b) states: It is the established policy of the
Department of Veterans Affairs that all veterans who are unable to
secure and follow a substantially gainful occupation by reason of
service-connected disabilities shall be rated totally disabled.
The bottom line is that veterans who are unable to work due to
service-connected disability should be compensated at the 100 percent
level, whether it be based on a scheduler evaluation (either single
service-connected disability or a combined scheduler evaluation) or
based on Individual Unemployability. This has been a longstanding VA
policy and we see no need to change it. See 38 C.F.R. 3.340.
Improving rating criteria for Traumatic Brain Injury
On January 3, 2008, VA published in the Federal Register a proposed
regulation to amend the current criteria for the evaluation of
Traumatic Brain Injury (TBI). The current diagnostic code (DC 8045) is
very restrictive and promotes inadequate evaluations. In fact, VA
specifically noted that the current DC 8045 is 45 years old and
reflects a view that the various symptoms associated with TBI could be
due to malingering or hysteria. The American Legion commends VA for
recognizing this situation and for making an effort to revise the
current evaluation criteria for TBI.
Symptom Clusters
The current criteria limit subjective TBI symptoms to a 10 percent
rating evaluation without any consideration to the frequency and
severity of these symptoms. Although the new criteria under the
proposed regulation allow for ratings up to 40 percent for symptom
clusters, frequency and severity of the symptoms are still not
considered. Under the proposed rule, there must be at least three of
the listed symptoms present for a compensable evaluation to be
assigned. These symptom clusters include headaches, dizziness, fatigue,
malaise, sleep disturbance, cognitive impairment, difficulty
concentrating, delayed reaction time, behavioral changes, emotional
changes, tinnitus or hypersensitivity to sound or light, blurred
vision, double vision, decreased sense of smell and taste, and
difficulty hearing in noisy situations in the absence of hearing loss.
The disability percentage would be based on a specific number of
symptoms present (40 percent--9 or more symptoms; 30 percent--5-8
symptoms; 20 percent--3 or 4 symptoms).
The American Legion appreciates that VA now recognizes that these
symptoms could be due to subtle brain pathology. Unfortunately, because
VA proposes to replace the current 10 percent maximum evaluation with
rating levels of 20, 30, and 40 percent, we are concerned that this
rating formula would continue to promote unfair adjudications because,
just as in the current DC 8045, the frequency and severity of the
symptoms are ignored. This means that the maximum rating allowed would
be 40 percent no matter how severe or frequent the symptom clusters.
This 40 percent maximum rating makes it extremely difficult for a
veteran to receive a total rating based on IU due to TBI symptom
clusters because the proposed revised rating criteria do not allow for
a rating of 60 percent, which is required to satisfy the scheduler
requirements for IU under 38 C.F.R. 4.16(a). This means that the only
pathway to a 100 percent disability rating is if VA grants an extra-
scheduler rating under 38 C.F.R. 4.16(b). Because very few extra-
scheduler ratings are issued by VA (especially an extra-scheduler grant
of total disability rating based on IU), this proposed change is highly
unfair.
Last, the proposed regulation does not discuss the consideration of
the longitudinal history of the disability. For example, TBI symptoms
for some veterans may wax and wane. Therefore, some veterans may be
under evaluated if the history of their symptomatology is not
considered.
Evaluation of Cognitive Impairment
While the proposed regulation does attempt to define mild
impairment for the purposes of evaluating cognitive impairment, it does
not define the terms ``moderately impaired'' and ``severely impaired.''
We strongly recommend that VA define these terms with specificity to
promote consistency and fairness in adjudication.
In the opinion of The American Legion and the National Veterans
Legal Services Program (NVLSP), the formula used by the proposed
regulation to evaluate the 11 common major effects of cognitive
impairment would encourage much unfair adjudication. The proposed
regulation is unfair because the formula does not fairly capture the
impact of some of the major effects of cognitive impairment. For
example, suppose a veteran has a score of three because his or her TBI
causes the veteran to require assistance with the activities of daily
living some of the time (but less than half of the time). If the
veteran had only zero scores in the other major effects of cognitive
impairment, the veteran would be evaluated as only 10 percent disabled.
This is patently unfair, especially given the fact that veterans with a
mental condition that causes just mild memory loss could arguably
receive a 30 percent evaluation under 38 C.F.R. 4.130 (see the 9400
diagnostic code series).
Applicability Date
VA contends that the provisions of this proposed rule would be
applicable only to claims for benefits received by VA on or after the
effective date of the rule. Therefore, pending claims would have to be
adjudicated under the current unfavorable rule.
It does not make sense to apply the old rating criteria to a claim
that has not been initially adjudicated, or is pending re-adjudication
due to an appeal, simply because the claim was received prior to the
effective date of the new rule. VA should amend this portion of the
proposed rule to require claims and appeals filed prior to the
effective date of the rule, but pending at the time the rule takes
effect, to be adjudicated under the new rule.
Emotional and Behavioral Dysfunction and Comorbid Mental Disorders
It is clear, as admitted by VA in its comments, that many veterans
who suffer from TBI also suffer from secondary depression (or other
mental illnesses such as PTSD). Therefore, the proposed rule should be
amended to require the VA to consider whether the record reasonably
raises the issue whether service-connection is warranted for mental
disorders (especially mental disorders secondary to the TBI) whenever
service-connection is granted for TBI, and, if so, to adjudicate such a
separate claim. This should be done because it is fair and because many
veterans with mental disorders are already at a disadvantage when it
comes to prosecuting their claims.
Presumptions
The VDBC made the following recommendations regarding the
replacement of the current ``association'' standard with a ``causal
effect'' standard in the presumptive disability decisionmaking process:
The goal of the presumptive disability decisionmaking process
should be to ensure compensation for veterans whose diseases are caused
by military service and this goal must serve as the foundation for the
work of the Science Review Board. The Committee recommends that the
Science Review Board implement its proposed two-step process.
[Institute of Medicine (IOM) Rec. 4] (Recommendation 5.11; Chapter 5,
section II.1)
The Science Review Board should use the proposed four-level
classification scheme, as follows, in the first step of its evaluation.
A standard should be adopted for ``causal effect'' such that if there
is at least as much evidence in favor of the exposure having a causal
effect on the severity or frequency of a disease as there is evidence
against, then a service-connected presumption will be considered. [IOM
Rec. 5] (Recommendation 5.12; Chapter 5, section II.1)
Sufficient: The evidence is sufficient to conclude that
a causal relationship exists.
Equipoise and Above: The evidence is sufficient to
conclude that a causal relationship is at least as likely as not, but
not sufficient to conclude that a causal relationship exits.
Below Equipoise: The evidence is not sufficient to
conclude that a causal relationship is at least as likely as not, or is
not sufficient to make a scientifically informed judgment.
Against: The evidence suggests the lack of a causal
relationship.
When the causal evidence is at equipoise and above, an estimate
also should be made of the size of the causal effect among those
exposed. [IOM Rec. 7] (Recommendation 5.14; Chapter 5, section II.1)
The American Legion does not support these recommendations because
the ``association'' standard currently used in the presumption
determination process is consistent with the non-adversarial and
liberal nature of the VA disability claims process. Moreover, as is the
case of the 1991 Gulf War, there is often a lack of specific or
reliable exposure data. Due to improper recordkeeping, resulting in a
lack of reliable exposure data, during Operations Desert Shield and
Desert Storm, there is insufficient information to properly determine
servicemember exposure to the numerous environmental and other hazards
U.S. troops were exposed to in the Southwest Asia Theater of Operations
during the war. A lack of such data would clearly diminish the value
and reliability of a ``causation'' standard as recommended by the IOM.
It should also be noted by this Subcommittee that despite its
recommendation, the Commission stated that it was concerned that
``causation rather than association may be too stringent'' and
encouraged further study of the matter.
Evaluating Quality of Life
The American Legion supports specifically addressing in the
evaluation process the impact of a service-connected disability on a
veteran's quality of life. We do realize, however, that properly
evaluating and compensating for the impact of a service-connected
disability on an individual's quality of life is not an easy task and
we welcome further study on this matter, including the study VA has
recently commissioned that will address qualify of life matters.
Closing
Thank you again, Mr. Chairman, for allowing The American Legion to
present comments on these important matters. As always, The American
Legion welcomes the opportunity to work closely with you and your
colleagues to reach solutions to the problems discussed here today that
are in the best interest of America's veterans and their families.
Statement of Kerry Baker
Associate National Legislative Director, Disabled American Veterans
Mr. Chairman and Members of the Subcommittee:
I am pleased to have this opportunity to appear before you on
behalf of the Disabled American Veterans (DAV), to address the
Department of Veterans Affairs' (VA) Schedule for Rating Disabilities
(Rating Schedule).
The VA Rating Schedule is a key component in the process of
adjudicating claims for disability compensation. The Rating Schedule
consists of slightly more than 700 diagnostic codes organized under 14
body systems, such as the musculoskeletal system, organs of special
sense, and mental disorders. For each code, the schedule provides
criteria for assigning a percentage rating. The criteria are primarily
based on loss or loss of function of a body part or system, as verified
by medical evidence; although, the criteria for mental disorders are
based on the individual's ``social and industrial inadaptability.'' The
schedule also includes procedures for rating conditions that are not
among the 700 plus diagnostic codes. Ratings are combined into a single
overall rating when a veteran has more than one disability.
It is critical that the Rating Schedule be as accurate as possible
so that rating decisions based on it are valid, reliable, and fair. The
Rating Schedule is valid when it reflects accurately a veteran's degree
of disability. Likewise, it is reliable when veterans with the same
disability receive the same rating or when two raters would give the
same veteran the same rating. Additional factors, however, include the
quality and relevance of medical information, accuracy and ease of use
of information systems, training and experience of raters,
effectiveness of the quality review system, and number of raters and
other personnel involved in the claims adjudication process.
The present Rating Schedule was developed in 1945 and was based on
revisions of schedules dating from 1917, 1925, and 1933. According to
statute, the Secretary ``shall from time to time readjust this schedule
of ratings in accordance with experience'' (38 U.S.C. 1155). The 1945
Rating Schedule became effective on April 1, 1946. The first revision,
or ``extension,'' was issued on July 14, 1947. By 1956, when the
President's Commission on Veterans Pensions (Bradley Commission)
reported, there had been 14 extensions, most of them revising a
specific section.
In 1961, VA addressed a part of the Rating Schedule largely dating
from 1933. The designers of the 1945 schedule had kept the
classifications and nomenclature for mental disorders from the 1933
schedule. The 1961 revision adopted four classifications of mental
disorders: psychotic disorders, organic brain disorders, psychoneurotic
disorders, and psychophysiologic disorders. The 1961 revision also
updated the nomenclature; added up-to-date diagnoses from the
Diagnostic and Statistical Manual of Mental Disorders (DSM), such as
dissociative, conversion, phobic, obsessive-compulsive, and depressive
reactions; and dropped outmoded diagnoses.
In 1988, the General Accounting Office (GAO)--now the Government
Accountability Office--issued the report Need to Update Medical
Criteria Used in VA's Disability Rating Schedule based on medical
reports that a major overhaul was needed: citing outdated terminology;
diagnostic classifications that were outdated, ambiguous, or missing;
evaluation criteria made obsolete by medical advances, and out-of-date
specifications of laboratory tests. In response to the 1988 GAO report,
VA published its intent to update the entire Rating Schedule in a
series of Advance Notices of Proposed Rulemaking (ANPRM) in the Federal
Register beginning in August 1989. The ANPRM indicated that other body
systems would be subsequently scheduled for review until the medical
criteria in the entire rating schedule had been analyzed and updated.
The ANPRM also stated that this was ``the first step in a comprehensive
rating schedule review plan which will ultimately be converted into a
systematic, cyclical review process.'' (ANPRM, 54 Fed. Reg. 34,531
[August 21, 1989]).
In preparing proposed and final versions of the sections of the
Rating Schedule, VA considered the views of Veterans Health
Administration clinicians, Veterans Benefits Administration raters,
groups of non-VA medical specialists assembled by a contractor, and
comments received in response to the ANPRM and Notice of Proposed Rule
Making (NPRM). Revisions of nine body systems and the muscle injury
part of the musculoskeletal system were made final and published in the
Federal Register between 1994 and 1997. The audiology part of the
special senses was finalized in 1999, and a 10th body system, the
``skin,'' was finalized in 2002. In addition to the foregoing,
individual sections of the Rating Schedule that have been updated since
the beginning 1990 include, but are not limited to, the following:
Rating Schedule Part ``A''
----------------------------------------------------------------------------------------------------------------
38 C.F.R. 4.13: Effect of change of diagnosis October 1996
----------------------------------------------------------------------------------------------------------------
38 C.F.R. 4.16: Total disability ratings for August 1990
compensation based on July 1993
unemployability October 1996
----------------------------------------------------------------------------------------------------------------
38 C.F.R. 4.29: Ratings for service-connected May 2006
disabilities requiring hospital
treatment
----------------------------------------------------------------------------------------------------------------
38 C.F.R. 4.30: Convalescent ratings May 2006
----------------------------------------------------------------------------------------------------------------
38 C.F.R. 4.31: Zero percent evaluations October 1993
----------------------------------------------------------------------------------------------------------------
Rating Schedule Part ``B''
----------------------------------------------------------------------------------------------------------------
Principles of combined ratings for
38 C.F.R. 4.55: muscle injuries June 1997
----------------------------------------------------------------------------------------------------------------
38 C.F.R. 4.56: Evaluation of muscle disabilities June 1997
----------------------------------------------------------------------------------------------------------------
38 C.F.R. 4.71a: Schedule of ratings-- May 1996
musculoskeletal system July 2002
August 2002
August 2003
June 2004
----------------------------------------------------------------------------------------------------------------
38 C.F.R. 4.73: Schedule of ratings--muscle June 1997
injuries
----------------------------------------------------------------------------------------------------------------
38 C.F.R. 4.84a: Schedule of ratings--eye June 1992
----------------------------------------------------------------------------------------------------------------
38 C.F.R. 4.85: Evaluation of hearing impairment May 1999
----------------------------------------------------------------------------------------------------------------
38 C.F.R. 4.86: Exceptional patterns of hearing May 1999
impairment
----------------------------------------------------------------------------------------------------------------
38 C.F.R. 4.87: Schedule of ratings--ear May 1999
May 2003
----------------------------------------------------------------------------------------------------------------
38 C.F.R. 4.88a: Chronic fatigue Syndrome November 1994
----------------------------------------------------------------------------------------------------------------
38 C.F.R. 4.88b: Schedule of ratings--infectious July 1996
diseases, immune disorders and
nutritional deficiencies
----------------------------------------------------------------------------------------------------------------
38 C.F.R. 4.96: Special provisions regarding September 1996
evaluations of Respiratory
conditions
----------------------------------------------------------------------------------------------------------------
38 C.F.R. 4.97: Schedule of ratings--respiratory September 1996
system May 2006
----------------------------------------------------------------------------------------------------------------
38 C.F.R. 4.104: Schedule of ratings-- December 1997
cardiovascular system July 1998
----------------------------------------------------------------------------------------------------------------
38 C.F.R. 4.113: Weight loss May 2001
----------------------------------------------------------------------------------------------------------------
38 C.F.R. 4.114: Schedule of ratings--digestive May 2001
system
----------------------------------------------------------------------------------------------------------------
38 C.F.R. 4.115: Nephritis January 1994
----------------------------------------------------------------------------------------------------------------
Rating Schedule Part ``B''--Continued
----------------------------------------------------------------------------------------------------------------
Ratings of the genitourinary
38 C.F.R. 4.115a: system--dysfunctions Jan, Mar 1994
----------------------------------------------------------------------------------------------------------------
38 C.F.R. 4.115b:--------------------------------------Ratings of the genitourinary--------Jan, Mar, Sep 1994-
system--diagnoses
----------------------------------------------------------------------------------------------------------------
38 C.F.R. 4.116: Schedule of ratings--gynecological April 1995
conditions and disorders of the May 2002
breast
----------------------------------------------------------------------------------------------------------------
38 C.F.R. 4.117: Schedule of ratings--hemic and September 1995
lymphatic system
----------------------------------------------------------------------------------------------------------------
38 C.F.R. 4.118: Schedule of ratings--skin July, Sep 2002
----------------------------------------------------------------------------------------------------------------
38 C.F.R. 4.119: Schedule of ratings--endocrine May 1996
system
----------------------------------------------------------------------------------------------------------------
38 C.F.R. 4.124a: Schedule of ratings--neurological January 1990
conditions convulsive disorders October 1991
June 1992
December 2005
----------------------------------------------------------------------------------------------------------------
The foregoing list is not all-inclusive. Nonetheless, some of the
dates of changes listed incorporated only minor substantive changes or
substantially revised portions of a rating section rather than an
entire section. Still, others incorporated significant substantive
changes to rating sections.
The above information is provided in response to most of the
popular rhetoric of the past year in that VA must completely revise its
Rating Schedule and/or its entire disability compensation system. The
vast majority of support for such rhetoric stems from specious
propositions that VA's Rating Schedule, and essentially its entire
rating system, is well over 60-years old--it is not. VA's disability
system in 1945 was but a shell of today's system--one that has evolved,
as it should, with an ever-growing knowledge base of war's effect on
human life.
Each major war of the 20th century brought with it new challenges
to VA's disability compensation system. The end of World War II brought
about the advent of atomic veterans; the Korean war resulted in
thousands of severely frostbitten veterans; the Vietnam War left tens
of thousands struggling with sickness and disease 30 years after the
War's end due to the effects of dioxin; the Persian Gulf War brought
Gulf-War Syndrome; and now the current War is shedding new light on
traumatic brain injuries (TBI). In no previous war was there a need to
recreate VA's disability compensation system from scratch, nor does
such a need currently exist. The fluid nature of the law is such that
it is made to evolve when needs arise; VA's benefits delivery system is
no different. However, the DAV agrees that portions of VA's Rating
Schedule must be updated, such as, but not limited to, TBI residuals
and the mental health rating criteria under the General Rating Formula
for Mental Disorders.
Removing out-of-date Criteria, Traumatic Brain Injury, and Post
Traumatic Stress Disorder
The Institute of Medicine (IOM) recently conducted a study of the
Rating Schedule for the Veterans Disability Benefits Commission (VDBC).
The IOM report identified examples of conditions in need of updating,
including craniocerebral trauma (because, for example, a number of
chronic effects are not included), neurodegenerative disorders (because
some currently known disorders are not included while some disorders
now known to be autoimmune are included), spinal cord injury (because
it relies on an outmoded classification system), post traumatic
arthritis (because it requires x ray rather than more up-to-date
imaging techniques that provide much more information, such as
computerized tomography [CT] and magnetic resonance imaging [MRI]), and
mental disorders (because the rating criteria are based on sets of
symptoms that do not apply to all mental disorders).
Another IOM report reached a similar conclusion regarding post
traumatic stress disorder (PTSD), namely, that the rating criteria were
not appropriate for PTSD because they included some symptoms consistent
with other mental disorders but not PTSD. The problem with evaluating
disability caused by PTSD stems from the decision in the 1996 revision
of the mental disorders section of the Rating Schedule to use a single
rating formula to rate all mental conditions except eating disorders.
The 1961 revision of the mental disorders section had increased the
classifications of disorders from two to four; the 1996 revision
reclassified the conditions into eight categories to ``conform more
closely to the categories in DSM-IV, thus making it easier for rating
specialists to correlate the diagnoses given on VA and non-VA exams
with the conditions in the rating schedule'' (Proposed Rule: Schedule
for Rating Disabilities; Mental Disorders, 60 Fed. Reg. 54,825
[(October 26, 1995]). But in place of three rating formulas in the 1961
revision--for psychotic disorders, organic mental disorders, and
psychoneurotic disorders--VA implemented a single rating formula with
the intent of ``providing objective criteria based on signs and
symptoms that characteristically produce a particular level of
disability.''
The fundamental problem with the general rating formula for mental
disorders is the weak nexus between severity of symptoms and degree of
social and occupational disability, which make the inclusion of
symptoms in the criteria problematic in terms of determining
disability. The mixing of symptoms and functional measures is also a
weakness of the Global Assessment of Functioning Scale, which was
criticized in the IOM report, PTSD Compensation and Military Research,
which recommends looking at symptoms, function, and other dimensions of
PTSD separately. Another problem with the general formula is the
propensity for VA decisionmakers to deny claims for increased ratings
based on a veteran's failure to demonstrate certain symptoms required
for a higher rating, PTSD for example, when the lack of symptoms on
which VA bases a denial are not associated with PTSD at all. Therefore,
any update to the Rating Schedule with respect to mental disorders
should be based on condition-specific symptoms rather than a one-size-
fits-all rating criteria.
The IOM found the current criteria under diagnostic code 8045 for
rating craniocerebral trauma, or TBI, are not adequate for rating all
conditions in this classification, and therefore recommended the
criteria be updated. VA added diagnostic code 8045 to the Rating
Schedule in 1961 and has not changed it substantively since that time.
TBI, per se, is not rated directly; rather, it is rated according
to residual impairments. The guidance under diagnostic code 8045 gives
hemiplegia, epileptiform seizures, and facial nerve paralysis, which
are physical effects, as examples of conditions that could be rated
separately. The guidance limits a rating based on symptoms such as
headache, dizziness, and insomnia, to 10 percent. This made sense in
1961 because VA did not thoroughly understand the harmful effects of
even mild brain trauma on a person's cognitive and emotional condition
or the negative impacts of these effects on social and occupational
functioning.
Post-concussion effects are now recognized and under intense study.
The proposed clinical management edition of the International
Classification of Diseases, tenth revision (ICD-10) includes criteria
for postconcussional syndrome. The Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition (DSM-IV) identifies postconcussional
disorder as a potential diagnosis depending on further research. The
clinical criteria for postconcussional syndrome in ICD-10 call for a
history of TBI and the presence of three or more of the following eight
symptoms: (1) headache, (2) dizziness, (3) fatigue, (4) irritability,
(5) insomnia, (6) concentration difficulty, (7) memory difficulty, and
(8) intolerance of stress, emotion, or alcohol. The DSM-IV criteria
are: (1) a history of TBI causing significant cerebral concussion; (2)
cognitive deficit in attention, memory, or both; (3) presence of at
least three of eight symptoms--fatigue, sleep disturbance, headache,
dizziness, irritability, affective disturbance, personality change, or
apathy--that appear after injury and persist for 3 months; (4) symptoms
that begin or worsen after injury; (5) interference with social role
functioning; and (6) exclusion of dementia due to head trauma or other
disorders that better account for the symptoms.
Currently, the rating criteria for TBI do not refer to evaluation
of cognitive and emotional impacts through structured clinical
interviews or neuropsychological testing. Such impacts may be the only
manifestations of closed-head TBI. The guide for VA clinicians
performing compensation and pension (C&P) examinations and the
worksheet for brain and spinal cord examinations do not provide
guidance for assessments of the cognitive effects of TBI, but do call
for description of psychiatric manifestations. The IOM also recommended
that the Rating Schedule should be updated medically to ensure that:
The diagnostic categories reflect the classification of
injuries and diseases currently used in healthcare, so that the
appropriate condition in the Rating Schedule can be more easily
identified and confirmed using the medical evidence;
the criteria for successively higher rating levels
reflect increasing degrees of anatomic and functional loss of body
structures and systems (i.e., impairment), so that the greater the
extent of loss, the greater the amount of compensation; and
current standards of practice in assessment of
impairment are followed and appropriate severity scales or staging
protocols are used in evaluating the veteran and applying the rating
criteria.
VA has proposed to amend the Rating Schedule by ``revising that
portion of the Schedule that addresses neurological conditions and
convulsive disorders, in order to provide detailed and updated criteria
for evaluating residuals of TBI.'' 73 Fed. Reg. 432 (proposed Jan. 3,
2008) (to be codified at 38 C.F.R. 4.124a (diagnostic code 8045)).
The DAV commends VA for its efforts to improve the evaluation of
disability residuals for veterans with TBI. We nonetheless have serious
concerns or otherwise outright disagreements as to how VA is proposing
to structure the rating criteria for TBI. A copy of VA's proposed rule
change concerning the rating criteria for TBI as well as DAV's comments
can and will be provided immediately upon request.
The IOM's A 21st Century System for Evaluating Veterans for
Disability Benefits report recommended numerous improvements that were
endorsed by the VDBC and that are further supported by the DAV. One of
many primary recommendations supported by the DAV states:
The purpose of the current veterans' disability compensation
program as stated in statute currently is to compensate for
average impairment in earning capacity, that is work
disability. This is an unduly restrictive rationale for the
program and is inconsistent with current models of disability.
The veterans' disability compensation program should compensate
for three consequences of service-connected injuries and
diseases: work disability, loss of ability to engage in usual
life activities other than work, and loss in quality of life.
See A 21st Century System for Evaluating Veterans for Disability
Benefits, Chapter 4, for more specific recommendations on approaches to
evaluating each consequence of service-connected injuries and diseases.
Essentially, the DAV supports the VDBC via the IOM's recommendation
that VA undertake a comprehensive update of the Rating Schedule, devise
a system for keeping it up to date, and establish a disability advisory
Committee to assist in the updating process. VA should consider
updating the evaluation and rating of mental disorders, especially
PTSD, and TBI as its highest priority and first order of business
because of their prevalence among veterans currently returning from the
Global War on Terror.
To be clear, however, DAV's support does not extend to any plan
that would result in temporary or permanent dual compensation systems.
Such schemes are inherently dangerous for a multitude of reasons.
Likewise, the DAV will adamantly oppose any proposed change in law,
whether regulatory or statutory, aimed at, or consequently resulting
in, degradation of current benefits and/or rights provided to disabled
veterans.
Total Ratings for Compensation Based on Individual Unemployability
The purpose of total ratings for compensation based on individual
unemployability (``TDIU'' or ``IU'') is to provide VA with a mechanism
for compensating veterans with ratings that do not meet the Rating
Schedule's threshold for receiving the 100-percent rate and who are
unable to work because of their service-connected disabilities. To
provide a service-connected veteran with IU, VA evaluates the veteran's
capacity to engage in substantial gainful occupation as the result of
his or her service-connected disabilities. The definition for
``substantial gainful occupation'' is the inability to earn more than
the Federal poverty level.
In order to quality for IU, a disabled veteran with only one
disability must be rated 60 percent or more. However, if there are two
or more disabilities, then at least one disability must be rated at 40
percent or more resulting in a combined 70-percent rating. TDIU is not
provided to veterans who receive a 100-percent rating because it is not
necessary.
The adjudication of IU claims by VA raters takes into account the
veteran's current physical and mental condition and his or her
employment status, including the nature of employment, and the reason
employment was terminated. Some factors are beyond the scope of inquiry
for consideration of TDIU, such as age, nonservice-connected
disabilities, injuries sustained post-service, or voluntary withdrawal
from the employment market. VA instructs it raters that IU should not
be granted if the veteran retired from work for reasons other than for
their service-connected disability.
The VDBC asked the CNA Corp. (CNAC) to conduct an analysis of
service-connected disabled veterans who are receiving IU. The central
focus of CNAC's work revolved around determining whether the increases
in IU were due to veterans' manipulation of the system to get
additional compensation. To conduct their analysis, CNAC analyzed the
mortality rates of those with and without IU and who concurrently
receive Social Security Disability Insurance (SSDI) payments.
The CNAC discovered that certain body systems are more likely to
receive IU ratings. For example, 28 percent of those with IU have
musculoskeletal disorders and 29 percent have PTSD. The CNAC surmised
that this may be an area of implicit failure of the Rating Schedule.
Second, CNAC discovered that the growth in the IU population is mostly
a function of demographic changes. These changes have come about
because veterans with service-connected disabilities are facing
complications with those disabilities as they age. As a result, CNAC
concluded that the increase in IU is not due to veteran manipulation.
The VDBC stated that VA should consistently base TDIU decisions on
the impact of an individual's service-connected disabilities, in
combination with education, employment history, and medical effects of
an individual's age or potential employability. The VDBC recommended
that VA implement a periodic and comprehensive evaluation of IU-
eligible veterans, and authorize a gradual reduction in compensation
for IU recipients who are able to return to substantially gainful
employment rather than abruptly terminating disability payments at an
arbitrary level of earning.
The DAV is mindful of a desire to help unemployed disabled veterans
return to work when feasible. Most veterans desire to lead productive
lives in society rather than attempt to survive on nothing but VA
compensation, even when such compensation is paid at the 100-percent
rate. Nonetheless, the slightest misinterpretation by VA employees of
changes to the law regarding entitlement to and retention of benefits
under this program will result in an immeasurable number of
unemployable veterans receiving an unlawful denial of benefits, or
worse, a revocation of benefits. The DAV opposes the idea of allowing
``age'' to become a factor in VA decisions regarding claims for
entitlement to TDIU. Denials of benefits based merely on age will
result, and in those cases, relevant evidence will be ignored.
The VDBC also recognized that TDIU accommodates individuals with
multiple lesser ratings but who remain unable to work. Therefore, the
VDBC recommended that as VA revises the Rating Schedule, every effort
be made to accommodate such individuals fairly within the basic rating
system without the need for TDIU. To that extent, the DAV supports
updating the Rating Schedule to reflect the true nature of the
disability. For example, a veteran receiving IU because of service-
connected PTSD rated at 70 percent, or a spine disability rated 60
percent, may be more accurately rated at 100 percent. In that, we
certainly could not oppose revising the Rating Schedule to reflect a
veteran as 100-percent disabled when he or she is unable to work
because of disability. We nonetheless must emphasize that at the very
heart of the necessity for benefits based on IU is that no single
disability or group of disabilities will ever affect two veterans in
the same manner--what may render one unemployable may not the other.
Evidence-based Criteria for Presumptions
While not in the list of priority recommendations by the VDBC, the
issue of VA's establishment of presumptive conditions was addressed by
the Commission. The IOM conducted an analysis and recommended a new
approach for establishing which disabilities should be presumed related
to military service. Presumptions are currently established when there
is evidence that a sufficient number of veterans experience a condition
and it is reasonable to presume that all veterans in that group who
experience the condition acquired the condition due to military
service.
The IOM's suggested approach includes using a causal effect
standard for decisionmaking rather than a less-precise statistical
association. The Commission endorsed the recommendations of the IOM but
expressed concern about the causal effect standard. Likewise, the DAV
has equal, if not deeper, concerns over this proposal. For example,
numerous veterans of the first Gulf War in 1991 receive compensation
for disabilities related to service in the theater of operations. Many
of those ``Gulf War'' related diseases are ill defined, undiagnosed,
and usually produce a cluster of symptoms that cannot be attributed to
a specific etiology. To this day, research has not provided a specific
cause and effect analysis for any single symptom, much less the myriad
of symptoms experienced by veterans of the 1991 Gulf War.
Veterans of that war would have never received benefits for such
disabilities had VA utilized a cause-and-effect standard to determine
presumptive disabilities. Science is not exact enough to provide a
precise cause for every disability resulting from combat. A statistical
association is the fairest method of determining presumptive
disabilities resulting from military service.
Quality of Life
The VDBC recommended, as a priority, that Congress increase the
compensation rates up to 25 percent as an interim and baseline future
benefit for loss of quality of life, pending development and
implementation of quality of life measure in the Rating Schedule. In
particular, the Commission recommended the measure take into account
the quality of life and other non-work related effects of severe
disabilities on veterans and family members. The DAV fully supports
this recommendation.
Through lengthy, exacting, and comprehensive research, the CNAC
determined that disability compensation, at most, helped disabled
veterans achieve parity with their non-disabled counterparts to the
extent that compensation substitutes a disabled veterans' ``average
loss'' of earnings due to disability. This was not, however, the case
for veterans with mental health disabilities, younger veterans with
disabilities, and those with total ratings based on individual
unemployability--these three groups were found to be below parity when
compared to non-disabled veterans.
These findings are evident that VA compensation replaces only the
average in lost earnings for many veterans, but even much less for
others. In no event are disabled veterans being overcompensated. The
VDBC and other well-known studies have collectively agreed that
service-connected disabled veterans are not compensated for the
inability to engage in useful life activities that many able-bodied
people take for granted, nor does it compensate for reduction in
quality of life. All recommendations from such studies and commissions
have been for Congress to enact legislation ensuring that veterans are
compensated for such losses.
Essentially, the Rating Schedule compensates for work disability,
not for a loss in quality of life. It is therefore possible that
ratings under the current Rating Schedule and accurate quality-of-life
measures are not close. If this is so, then the question arises of how
not if VA should develop a way to compensate for each. (I.e., adapting
the current Rating Schedule to compensate for both, or creating a
separate Rating Schedule for each consequence.) These questions are yet
to be decided. Nonetheless, as stated earlier, the DAV opposes
recommendations for a dual compensation system.
Conclusion
The VDBC agreed that America has a solemn obligation, expressed
eloquently by President Lincoln, ``to care for him who shall have borne
the battle, and for his widow, and his orphan. . . .'' With this in
mind, the VDBC stated: ``It is the duty of Congress and VA to ensure
that the benefits and services for disabled veterans and survivors are
adequate and meet their intended outcomes.'' Based on these
obligations, the VDBC identified the following guiding principles.
1. Benefits should recognize the often enormous sacrifices of
military service as a continuing cost of war, and commend military
service as the highest obligation of citizenship.
2. The goal of disability benefits should be rehabilitation and
reintegration into civilian life to the maximum extent possible and
preservation of the veterans' dignity.
3. Benefits should be uniformly based on severity of service-
connected disability without regard to the circumstances of the
disability (wartime v. peacetime, combat v. training, or geographical
location.)
4. Benefits and services should be provided that collectively
compensate for the consequence of service-connected disability on the
average impairment of earnings capacity, the ability to engage in usual
life activities, and quality of life.
5. Benefits and standards for determining benefits should be
updated or adapted frequently based on changes in the economic and
social impact of disability and impairment, advances in medical
knowledge and technology, and the evolving nature of warfare and
military service.
6. Benefits should include access to a full range of healthcare
provided at no cost to service-disabled veterans. Priority for care
must be based on service-connection and degree of disability.
7. Funding and resources to adequately meet the needs of service-
disabled veterans and their families must be fully provided while being
aware of the burden on current and future generations.
8. Benefits to our Nation's service-disabled veterans must be
delivered in a consistent, fair, equitable, and timely manner.
These principles served as the moral fiber that directed the VDBC's
priorities throughout its work. They are also synonymous with the
mission of the DAV--``Building better lives for America's disabled
veterans and their families.'' Therefore, the DAV strongly suggests
that as Congress moves forward in implementing many of the Commission's
recommendations, it bears these principles in mind and employs them as
its lighthouse to navigate congressional action on the course set by
the VDBC.
Society and its laws are evolutionary, and as such, they are slow-
moving creatures. The Framers of the Constitution took great care in
ensuring that change does not come easy, but nonetheless provided for
its evolvement. Some in Congress today ignore this by acting hastily--
attempting expeditiously to push legislative agendas aimed more at
conserving the bottom line than conserving the benefits for which
disabled veterans spent the last 100 years fighting. Some of these
agendas would wipe VA's slate clean and force it to start over with the
shell of a compensation system it once had in 1933, all while claiming
we have come no farther since 1933. Some of these agendas would pit
veterans of today's wars against veterans of yesterday's wars--or
worse, pit veterans against their government.
We simply urge caution. VA's benefits delivery system must be
considered in the larger context of today's views on the rights of
individuals with disabilities to live as full a life as possible. It is
therefore essential to envision a more comprehensive evaluation of
veterans' needs, including medical, educational, vocational, and
compensation. We respectfully remind Congress that many of those that
came before you did their best to ensure that VA was a pro-claimant,
veteran-friendly, non-adversarial system where the disabled veteran
received the benefit of the doubt whenever doubt existed.
The DAV supports a vast majority of the VDBC's recommendations
because they are well-researched, carefully planned suggestions with a
potential of improving what is already a good system that cares for
disabled veteran. Once again, however, the DAV urges Congress to resist
hastily laid plans designed to do more undoing than doing, or else the
next battle we will fight in Congress will be the one against
unintended consequences.
We hope the Subcommittee will review the DAV's recommendations and
give them consideration for inclusion in your legislative plans. Mr.
Chairman, thank you for inviting the DAV to testify before you today.
Statement of Gerald T. Manar
Deputy Director, National Veterans Service
Veterans of Foreign Wars of the United States
CHAIRMAN HALL, RANKING MEMBER LAMBORN AND MEMBERS OF THE COMMITTEE:
Thank you for this opportunity to present the views of the 2.3
million veterans and auxiliaries of Veterans of Foreign Wars of the
United States on the state of the VA Schedule for Rating Disabilities.
Schedule for Rating Disabilities
Service connected disabilities are evaluated using criteria
contained in Part 4 of title 38 Code of Federal Regulations. The first
schedule for rating disabilities was written in 1921. The 1925 revision
attempted to adjust evaluations based on the occupation of veterans.
That approach proved far too cumbersome and inequitable to be of
practical value and the rating schedule was rewritten again in 1933.
The last complete revision was published in 1945.
A popular misconception is that the current rating schedule has not
been substantively revised since its last major overhaul in 1945. While
the Institute of Medicine and the Veterans Disability Benefits
Commission found that the rating schedule has been revised, often
substantively, since 1945, sections of it have been rarely touched and
many parts contain medical terminology and evaluative criteria which
are significantly out of date.
VA is charged with administering a compensation program that pays
veterans in excess of $30 billion per year for disabilities arising as
a result of or coincident with military service. Yet the VBA
Compensation and Pension Service has fewer than 140 people including
support staff assigned to run this program. When the 26 employees
conducting quality reviews of various types are subtracted, along with
the 28 people figuring out how to make computer software work more
efficiently, the remaining 86 are spread too thin to do most jobs
adequately. For many years in the late 1990s only one person was
assigned to review, revise and update the rating schedule. It is little
wonder that many sections of the rating schedule are not up to date.
To address this problem, the Commission adopted a number of
recommendations advanced by an Institute of Medicine Committee that the
Commission had contracted with to study the disability evaluation of
veterans. In its report, ``A 21st Century System for Evaluating
Veterans for Disability Benefits'', the IOM suggested that VA should
create a permanent ``disability advisory committee, ``staffed with
experts in medical care, disability evaluation, functional and
vocational assessment and rehabilitation, and include representatives
of the health policy, disability law, and veteran communities.'' The
Advisory Committee would meet regularly and offer direction and
oversight to the regular review and updating of the rating schedule. In
addition to this Committee, the IOM recommended that VA substantially
increase the number of staff members permanently assigned to
accomplishing the changes directed by the Advisory Committee.
We support these recommendations and believe that its first task
should amend the criteria for evaluating Post Traumatic Stress
Disorder. The criteria adopted many years ago by VA were intended to
encourage consistency in the evaluation of psychiatric disabilities.
Unfortunately, the debilitating symptoms experienced most often by
veterans with PTSD are not the same as those shown in the rating
schedule. As a consequence, rating specialists have been forced to
select an evaluation, based not on the symptoms, per se, but, rather,
on how disabling they believed those symptoms were. This led to great
frustration on the part of rating specialists and inconsistency in
evaluations assigned to veterans. This problem has been known for
years. It needs to be corrected now.
At the same time, an Advisory Committee could begin the process of
reviewing and suggesting changes to those sections of the Rating
Schedule that have not been updated in the last 10 years.
Some critics of the current disability compensation program have
suggested that the rating schedule can be thoroughly and completely
reviewed and updated in as little as 6 months. While it is true that
anyone can revise the rating schedule in a few weeks or months, the
result will simply be a different rating schedule, almost certainly not
a better rating schedule.
It is our considered belief that it will take years of hard work by
a competent staff of medical, vocational and legal experts to devise
new rating criteria for all the body systems which allow for the
accurate assessment of service connected disabilities.
Revision of the rating schedule cannot be a one-time project. A
permanent process must be devised and put in place to ensure that you
and your successors, and I and mine, never again have to discuss why
the primary tool for assessing veterans disabilities is inadequate and
antiquated.
Quality of Life
The Veterans Disability Benefits Commission adopted an Institute of
Medicine recommendation to ``research and develop a quality of life
measurement tool and study ways to determine the degree of loss of
quality of life, on average, of disabling conditions in the rating
schedule.'' We concur. Decreases in the quality of life resulting from
service-connected disabilities, certainly warrants investigation and
research. While VA and Congress have addressed quality of life losses
resulting from some disabilities through special monthly compensation,
a comprehensive study, or series of studies, should be conducted to
determine which disabilities, and level of disability, adversely affect
a veteran's quality of life. To the extent that studies show that
service connected disabilities limit the quality of life of veterans VA
should consider how best to adjust the Rating Schedule to ensure that
veterans are adequately compensated.
Individual Unemployability
The Dole/Shalala Commission recommended eliminating individual
unemployability. The Veterans Disability Benefits Commission agreed
that VA should retain the ability to decide that a veteran's service
connected disabilities make them unemployable. It further recommended
that the rating schedule be adjusted, allowing more veterans rendered
unemployable by their service-connected disabilities, particularly
psychiatric disabilities, should be rated 100 percent.
The Center for Naval Analysis found no statistical evidence that
veterans were ``gaming'' the system in order to obtain increased
benefits. Increases in the numbers of those receiving individual
unemployability are attributed to increasing disabilities as the
veteran population ages.
Disability evaluations under the rating schedule are designed to
compensate veterans for the average loss of earnings impairment. The
rating schedule is not intended to look a veteran's vocation; whether
they practiced law, drove trucks, programmed computers, fixed plumbing
or any other occupation prior to or post their disabled. Disability
evaluations are assigned based on the severity of disabilities and
represent average impairment.
Individual unemployability is the one regulation that allows VA to
look at the individual person assessing their education, vocational
skills, job history, and experiences to determine whether their service
connected disabilities keep them from gainful employment. In our view,
this little bit of flexibility allows the VA to adjust evaluations to
address any inequities that may result from the automatic application
of the rating schedule. This is a good thing. We believe that
Individual Unemployability is appropriate, as it currently exists.
It has been suggested that veterans seeking a total evaluation
based on Individual Unemployability should be given a vocational
assessment. We do not oppose this idea. We agree that it may provide
additional information which will help rating specialists make the most
correct decision. However, we believe that sufficient resources must be
devoted to these assessments so that veterans will experience no delays
in entitlement decisions. As we stated in testimony before the Veterans
Disability Benefits Commission in July 2007:
``While we do not oppose an employment assessment for veterans
who are applying for total benefits based on Individual
Unemployability, we do have some concerns about the
implementation of this option.
It is axiomatic that veterans who apply for
IU are either unemployed or marginally employed.
Generally, these individuals have been unemployed for
many months before they apply for benefits. Whatever
economic well-being they enjoyed before becoming
unemployed has evaporated and most are in serious
financial distress. Any action on the part of the
government resulting in a delay of a decision on IU
should be avoided at all costs. Therefore, we believe
that it is absolutely essential that the staff of VR&E
be expanded and trained long before a requirement
mandating an employment assessment is implemented.
Individuals who are denied Individual
Unemployability should be offered, at a minimum,
vocational counseling and employment services.''
Traumatic Brain Injury
VA recently published proposed regulations to amend the criteria
for evaluating traumatic brain injury (TBI). We view that proposal as a
good first attempt at better assessing the impairments caused by TBI.
We understand that VA received significant comments to its proposal.
We suggest that the VA publish its next set of regulations as
``interim-final'' regulations. Considering the increasing number of
veterans suffering from TBI, and the difficulty that exists in writing
appropriate rating criteria for this multi-faceted problem, leaving the
door open to further adjust this regulation makes perfect sense given
the evolving nature of this injury.
Presumptions
In August, 2007, the Institute of Medicine Committee Report titled
``Improving the Presumptive Disability Decision-Making Process''
released. Our views concerning this report, expressed to the Veterans
Disability Benefits Commission on August 22, 2007, are as appropriate
today as they were then.
Here we have a seminal work: a report from academicians who took
your charge seriously: they analyzed the methodologies used to
establish a number of presumptions currently written in law and
regulation to help VA determine whether diseases were incurred while on
active duty, discussed in depth different approaches used by scientists
to determine whether a disability is related to various exposures and
recommended a structured approach for determining, in the future,
whether a disease is caused by some event experienced by veterans while
they performed military service.
We do not disagree with the historical analysis of presumptions;
nor do we take issue with the structure recommended by the Committee
for creating presumptions in the future. We agree that the government
cannot simply throw open the doors of Fort Knox to every person who
alleges a disability and has a discharge paper. However, we believe
that this IOM Committee may be setting the bar too high for men and
women who served their country in both peace and war.
You know that many who left to serve never returned and, of those
who did, hundreds of thousands returned with wounds and other injuries
of both body and mind. Some of those who apparently returned unscathed
did not escape their service wholly intact but, in fact, were often
found many years later to have diseases acquired while performing
military duty.
These men and women should not have to wait years, perhaps decades,
suffering painful, debilitating and often deadly conditions, while
scientists ponder whether ``the evidence is sufficient to conclude that
a causal relationship is at least as likely as not, but not sufficient
to conclude that a causal relationship exists.''
The Committee acknowledges that causation is a higher standard than
association. It states that while the evidence may show that a
disability is associated with an event or exposure in military service,
it does not mean that the disability was caused by that event or
exposure. According to the Committee, determining that an association
exists is only ``prima facie evidence of causation but is not
sufficient by itself for proving a causal relationship between exposure
and disease'' and they would have veterans endure additional years of
pain and suffering before they might receive medical care and
compensation for their service ``caused'' conditions.
Presumptions are a legal tool; they fill an evidentiary gap or
shift an evidentiary burden from one party to another. In the area of
veteran's benefits, they are created as often to ease the burden on the
government as well as the veteran. The government's approach to
herbicide exposure in Vietnam and disabilities related to herbicide
exposure illustrates these presumptions.
Millions of gallons of herbicides were sprayed over diverse areas
of Vietnam from the early 1960's to 1971. It was sprayed by plane,
helicopter and by hand. Nearly all uses were designed to deny cover to
the enemy. It was an extremely useful tool and doubtless saved
hundreds, perhaps thousands of American and allied soldiers' lives.
The Department of Defense maintains records of those areas targeted
for defoliation. However, we know that because of weather, poor
navigation, mechanical malfunction or aircraft emergencies requiring
inaccurate or premature dumping of defoliants, we cannot know with any
degree of certainty exactly where all these chemicals were dropped.
Further, loss of records, or, in the case of hand spraying, failure to
keep accurate records, means that we will never know precisely where
and when defoliants were used. Finally, although we may know generally
where various units were operating during any given period, the
military cannot know where every soldier or Marine performed duty while
they were in Vietnam.
Consequently, it is not possible to state with any degree of
certainty whether a particular servicemember was exposed to herbicides
during their service in Vietnam. Nor is it possible to determine the
quantity or level of exposure.
Without a presumption of exposure for those who served in Vietnam,
the government would be forced to undertake the Herculean task of
determining where each veteran-claimant was located while in Vietnam.
As well as, whether patterns and to what degree he or she was exposed
to herbicides.
As a consequence of these uncertainties, and to save our government
the millions of dollars it would cost to attempt to verify the location
of individual veterans and the exposure they received, a presumption
was created that conceded that all those who served in Vietnam during
certain periods were exposed to herbicides.
Exposure without a disability is simply an exposure; exposure is
not a disability under the law. However, we know that Vietnam veterans
started experiencing rare cancers and other maladies within a decade of
their leaving Vietnam. Casting about for possible causes, these
veterans, their advocates and healthcare providers looked for
commonalities to explain these departures from normal health. The one
constant soon became apparent: service in Vietnam.
The Agent Orange Act 1991 was the law, which created the mechanism
used today to determine whether a disease should be considered by the
Secretary of Veterans Affairs to be presumptively related to herbicide
exposure while in the military service.
So long as presumptions of service connection was created for a few
rare cancers no one cared to use the term found in the Committee's
report, a few ``false positives'' were compensated along with veterans
whose cancers were caused by exposure to herbicides. However, with the
extension of presumptive service connection to lung cancer, prostate
cancer and, finally, diabetes, legislators and others became
increasingly concerned when thousands of Vietnam veterans sought
service connection, medical treatment and compensation for these
conditions.
The VFW is not deaf to the cacophony of criticism. The GAO, Members
of Congress, and others believe that the presumptions granting medical
treatment and compensation to Vietnam veterans with lung cancer,
prostate cancer and diabetes are too costly. In these cases, if we wait
for evidence of causation most of these veterans would be dead before
the evidence is obtained. Further, their survivors would not just
suffer the premature loss of the veteran but would also be denied
survivors benefits for years, perhaps decades, while scientists study
``causation''.
We speak about Vietnam presumptions because it is the specter of
thousands of Vietnam veterans flooding the VA with claims for benefits
and the medical system that concern our legislators. They are concerned
that many of the men and women who volunteer, train, fight, suffer and
survive from the conflicts of the present will return asking whether
their diseases could somehow be related to their military service.
We should not tell them, as we did in the 1970's, that since there
is no medical evidence showing that their disability was ``caused'' by
their military service we cannot help them. We should not deny them
healthcare and benefits even when studies show that an association
exists between their disability and service. We accept everything in
this report except the bar calling for ``causation.'' ``Causation'' is
not a hurdle to jump over; it is a scientific bar to benefits.
We urge that you adopt the standard found in the Agent Orange Act
1991 and use it in the same manner as it is today. We urge that
presumptive service connection be granted when the Science Review Board
suggested by the IOM Committee finds that an association exists between
an exposure in military service and a disease arising after service.
Statement of Bradley G. Mayes
Director, Compensation and Pension Service
Veterans Benefits Administration, U.S. Department of Veterans Affairs
Mr. Chairman and Members of the Subcommittee, I am pleased to
appear before you today to speak on the subject of revising the
Department of Veterans Affairs (VA) schedule for rating disabilities. I
am accompanied by Dr. Patrick Joyce, Chief of the Occupational Health
Clinic and Chief Physician, Compensation and Pension (C&P) Program, at
the Washington, D.C., VA Medical Center; Dr. Steven Brown, Director of
the Compensation and Pension Examination Program Office, Veterans
Health Administration; Mr. Tom Pamperin, Deputy Director for Policy,
Compensation and Pension Service; and Mr. Richard Hipolit, Office of
the General Counsel.
Within VA, the mission of providing C&P disability benefits to
veterans relies on the regulatory scheme embodied in 38 Code of Federal
Regulations (CFR), Part 4--Schedule for Rating Disabilities (rating
schedule). This rating schedule serves to provide an organized and
coherent system for evaluating disabilities and for providing equitable
and consistent compensation for service-connected injuries and diseases
to our Nation's veterans. We are aware that the schedule must continue
to ``evolve,'' and, as you know, the President has sent to Congress a
bill, ``America's Wounded Warriors Act,'' to implement the
recommendations of the President's Commission on Care for America's
Returning Wounded Warriors, including the Commission's recommendation
that VA should update its disability rating schedule to reflect current
injuries and modern concepts of the impact of disability on quality of
life.
Also, as you noted in your letter inviting us to testify today, the
Veterans Disability Benefits Commission (VDBC) has made several
recommendations about how to improve the VA rating schedule. In
addition, the Center for Naval Analyses (CNA) and the National
Academies' Institute of Medicine (IOM) have recently evaluated the
rating schedule. We welcome the congressional interest in C&P and the
issue of rating schedule improvement because we share the common goal
of improving benefits and service to veterans.
Rating Schedule History
The current rating schedule is the product of many years of
development and is an expression of our Nation's desire to acknowledge
the sacrifices made by veterans and to compensate them for disabilities
resulting from military service. Early in our Nation's history, the
Continental Congress of 1776 passed the first pension laws and
administrative directives for veterans disabled during military service
as a means to encourage enlistment and curtail desertion. These laws
remained in effect, with some modifications, until after the Civil War,
when additional benefits were introduced due to the activity of newly
formed veterans organizations. During this period, the basis for
pension payment amounts shifted from the veteran's service rank to the
degree of disability. Until 1890, pensions were granted only to
veterans discharged because of illness or injury resulting from
military service. In that year, Congress substantially broadened the
scope of eligibility to include veterans incapable of manual labor. In
1912, veterans of the Mexican War and Union veterans of the Civil War
became eligible for pension at age 62, even though not sick or
disabled.
The War Risk Insurance Act 1917 provided for the first significant
rating schedule as well as the idea of compensating veterans for
service-connected aggravations of pre-existing conditions. This
legislation introduced compensation based on the average loss of
earning capacity. Section 302 of the act stated the following:
``A schedule of ratings of reductions in earning capacity from
specific injuries or combinations of injuries of a permanent nature
shall be adopted and applied by the bureau [of War Risk Insurance].
Ratings may be as high as one hundred per centum. The ratings shall be
based, as far as practicable, upon the average impairments of earning
capacity resulting from such injuries in civil occupations and not upon
the loss of earning capacity in each individual case, so that there
shall be no reduction in the rate of compensation for individual
success in overcoming the handicap of permanent injury. The bureau
shall from time to time readjust this schedule of ratings in accordance
with actual experience.''
A 1918 amendment to the Act provided for the presumption of
soundness in health for those ``examined, accepted, and enrolled in
service.'' In 1921, a Veterans Bureau was established and the first
codified rating schedule was drafted. The 1921 Rating Schedule adopted
the average loss of earning capacity standard. It also modified the
presumption of soundness to exclude defects, disorders, or infirmities
recorded at the inception of active service and provided for the first
presumptions of service connection for tuberculosis and
neuropsychiatric conditions. In addition, local rating boards were
established around the country to replace a single rating board in
Washington D.C.
The World War Veterans' Act 1924 created a new rating schedule,
based on the California workmen's compensation system, which became
known as the 1925 Rating Schedule. It provided for disability
evaluation percentages in increments of 1 percent and introduced a
disability indexing system that became the basis for diagnostic codes.
It also departed from the average loss of earning capacity standard and
adopted the idea of a disability compensation system based on
assumptions about the loss of skills and functions needed for specific
occupations. This led to rating decisions, for example, which would
compensate a veteran, whose occupation required reading and writing
skills, at a higher rate for visual impairment than a veteran engaged
in manual labor. This focus on specific occupations provided the
initial rational for including an occupational specialist on the rating
board. However, the emphasis on specific occupations was short-lived.
The Economic Act 1933 authorized the next version of the rating
schedule. Disability percentage evaluations were now determined in 10
percent increments, prior differences between temporary and permanent
evaluations were eliminated, and additional compensation was provided
for bilateral anatomical loss. Most important, the 1933 Rating Schedule
eliminated ratings based on occupational variance and reintroduced the
concept of average impairment in civilian occupational earning capacity
as the basis for disability compensation.
As a result of medical and technological advances resulting from
World War II, the 1945 Rating Schedule was created. This schedule
maintained the average loss of earning capacity standard and, with
periodic updates of medical evaluation criteria, is the rating schedule
in use today.
Elements of the Current Rating Schedule
Development of the current rating schedule is based on the
Congressional mandate provided in 38 U.S.C. 1155, Authority for
schedule for rating disabilities, which states that the ``rating shall
be based, as far as practicable, upon the average impairments of
earning capacity resulting from [specific injuries or combination of
specific] injuries in civil occupations.'' As a result of this
directive, the rating schedule compensation system is viewed primarily
as a means to replace work-related lost wages resulting from a service-
connected disability. The basic elements of the rating schedule are
described below.
The current rating schedule brings together more than 700
diagnostic codes representing distinct physical and mental impairments
that are grouped by body systems or like symptoms. Covered body systems
include the musculoskeletal, visual, auditory, respiratory,
cardiovascular, digestive, genitourinary, hemic and lymphatic, skin,
and endocrine systems. Also covered are gynecological and breast
disorders, neurological and convulsive disorders, dental and oral
disorders, and mental disorders. Each diagnostic code is broken down
into levels of impairment severity, with disability percentages
assigned to each level. These range from less severe to more severe,
with higher percentages assigned to more severe levels. Disability
percentage numbers range from 0 to 100 percent, in 10 percent
increments, throughout the rating schedule, although individual
diagnostic codes vary in the incremental progression and the maximum
available disability percentage.
If the veteran's impairment is not listed in one of the specific
diagnostic codes, it is rated under a hybrid code representing an
analogous anatomical location or symptomatology. When a veteran has
more than one service-connected disability, the percentages for each
disability are combined, rather than added, under a numerical table
provided at 38 CFR 4.25, Combined Rating Table. In a case with an
exceptional or unusual disability picture where application of the
rating schedule does not adequately compensate a veteran for functional
loss, the case may be sent to the C&P Service for consideration of an
extra-schedular rating. If a veteran's disability cannot be rated at
100 percent under the regular schedule, but the veteran is unable to
secure or follow a substantially gainful occupation as a result of the
veteran's service-connected disabilities, then an extra-schedular 100
percent can be assigned under the regulation providing for a total
disability rating based on individual unemployability. In cases where
the veteran's disability is rated at 100 percent, but it is severe
enough that a veteran is permanently bedridden or has a regular need
for aid and attendance, or where anatomical loss or loss of use is
involved, additional special monthly compensation payments are
available.
America's Wounded Warriors Act
Title II of the President's draft bill, America's Wounded Warriors
Act, would require VA to complete a study regarding creation of a
schedule for rating disabilities based upon current concepts of
medicine and disability, taking into account loss of quality of life
and loss of earnings resulting from specific injuries. The legislation
requires VA, within 7 months after entering into a contract for the
study, to submit a report to Congress that includes VA's findings and
conclusions with respect to the creation of a disability rating
schedule based on loss of quality of life and loss of earnings
resulting from specific injuries.
The legislative proposal provides the framework for VA to pay
disability compensation for the loss of quality of life attributable to
an eligible veteran's service-connected disabilities at rates to be
determined pursuant to the Secretary's report to Congress. Current law
only allows the VA to compensate for loss of earning capacity.
VA Plan for Rating Schedule Improvement
To address the recommendations of the Dole-Shalala Commission, as
well as various commissions, organizations, and interest groups that
have offered suggestions for improving the current rating schedule, VA
has developed the following plan to update the schedule and to adopt
various suggestions that have been made.
I. Contract for Study
The Department entered into a contract on January 25, 2008, for a
study analyzing the nature of specific injuries and diseases for which
disability compensation is payable under various disability programs of
Federal and State Governments and other countries, including VA's
program. The study will examine specific approaches and the usefulness
of currently available instruments for measuring disabilities' effects
on an individual's psychological state, loss of physical integrity, and
social inadaptability. The study will make findings and recommendations
on the following: (1) the service-connected disabilities that should be
included in the schedule for rating disabilities; (2) the appropriate
level of compensation for loss of quality of life and for loss of
earnings; and (3) the appropriate standard(s) for determining whether
an injury or disease, or combination of injuries and diseases, has
caused a loss in a veteran's quality of life or loss of a veteran's
earnings. The study will take into account the impact of medical
advances on disability functioning. We expect that the study will be
completed by August 2008.
II. C&P Staff Development and Contract Assistance
Meaningful changes to the rating schedule will require strong
leadership and the input of competent personnel who possess the
knowledge and skills required to interpret, understand, and write
regulations on complex medical concepts. The C&P Service is in the
process of recruiting key personnel and expanding our Policy staff. One
important aspect of this resource development is our effort to recruit
physicians who can bring their medical expertise to improving the
rating schedule. Physicians possess the medical knowledge necessary to
assist in the effective management of a systematic, ongoing Rating
Schedule review process. The hiring of physicians and other qualified
individuals is the foundation for the future integration and
standardization of this review process. In addition to augmenting the
C&P Policy staff as described, we intend to seek assistance from
organizations such as the National Academies' Institute of Medicine. We
want to leverage the work already accomplished for the Veterans
Disability Benefits Commission, and it is important to ensure that our
review of the schedule is based on the latest science regarding
compensation for disability. The Institute of Medicine already has a
process of peer review of literature in place that will help as we move
forward in this area.
III. Continue with Rating Schedule Changes under the Current Construct
Revision of the rating schedule has actually been underway since
the nineties, and will continue. A deliberative process is in place
that includes input from sources such as the Veterans Health
Administration, non-VA medical experts, and veterans service
organizations. The general public has opportunity to comment on
proposed changes to the schedule in compliance with the Administrative
Procedure Act. To date, 12 of the 16 body system sections in the
schedule have been revised, and a 13th is nearing publication. The
remaining three body systems are in various stages of development.
Major changes that have been made include: addition of new
disabilities; deletion of obsolete and rarely used disabilities;
updating of medical terminology; and most important, development of
more objective criteria based on current medical knowledge. Partial
revisions of body systems in the rating schedule are being carried out
on an ongoing basis. This process continues.
The VDBC specifically recommended that the C&P Service generate
changes to the rating schedule criteria for traumatic brain injury
(TBI) and post-traumatic stress disorder (PTSD). The C&P Service
created a new set of criteria for evaluating TBI and published proposed
criteria in the Federal Register for public comment. New rating
criteria for evaluating the severity of PTSD are being developed. The
criteria will incorporate the criteria for evaluation PTSD identified
in the Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition, published by the American Psychiatric Association. These
specific criteria will replace the general criteria used for evaluating
all mental disorders and will promote equity and consistency in the
assignment of disability percentages for PTSD.
IV. Periodic Reviews of the Rating Schedule
Periodic reviews and studies of the rating schedule are a valuable
source of information for assessment and improvement. We plan to
continue supporting the tradition of reviews established by the Bradley
Commission in 1956. That commission conducted studies of the rating
schedule that included a survey of 169 medical specialists on the
currency and validity of the schedule and a survey and comparative
analysis of the earnings of 12,000 veterans receiving compensation and
7,000 veterans not receiving compensation. The survey of medical
specialists indicated a consensus that the schedule generally did
provide an equitable compensation for earning loss but that much of the
evaluation criteria had not kept pace with modern medical diagnostic
and treatment practices. The comparative study of earnings indicated
that compensation was generally equivalent to lost wages. However, the
commission reported that further studies were desirable. This
commission served as the impetus to update many of the diagnostic
codes. Another review, initiated by VA in 1961, was responsible for
modernizing the classifications and nomenclature of the rating
schedule's mental disorder section, which incorporated diagnoses from
the first Diagnostic and Statistical Manual of Mental Disorders.
In 1971, VA submitted to Congress an important review and study was
conducted by VA, referred to as the Economic Validation of the Rating
Schedule (ECVARS). The study was a response to the Bradley Commission's
recommendations and recurrent criticism that ratings in the schedule
were not accurate. The ECVARS report noted that the 1945 rating
schedule was created during a period when most workplace activity
involved physical labor, but the ``muscle-oriented society of the World
War II era no longer exists, and the instrument that served so well as
a yardstick to measure disablement in that era must now be updated and
refined.'' An earnings survey of 485,000 veterans receiving
compensation and 14,000 veterans not receiving compensation was
conducted and analyzed. The results showed that under many diagnostic
codes, especially those involving mental disorders, economic loss
exceeded compensation. On the other hand, under some musculoskeletal
codes, there appeared to be an over-compensation. VA revised the rating
schedule based on the ECVARS findings, with higher compensation
provided under some codes and lower compensation under others, and
submitted it to Congress in 1973. However, VA did not adopt the revised
schedule.
After the failure of ECVARS to affect the rating schedule, the VA
review and revision process concentrated on improving the clarity,
accuracy, and appropriateness of conditions in the schedule rather than
attempting to ensure that economic loss compensation for the conditions
was validated. In 1988 the General Accounting Office (GAO) [now the
Government Accountability Office] published a report on the need to
update the medical criteria used in the schedule. This led to the
comprehensive revisions described above. In 1997, the GAO published
another report on the rating schedule. This report focused on the idea
that disability ratings may not reflect veterans' actual economic
losses. The recent CNA Corp. study provides the foundation for
assessing the effectiveness of the VA Rating Schedule in compensating
for average loss of earnings as recommended by the GAO in its 1997
review.
The most recent initiative for rating schedule review and research
has come from VDBC's report issued in 2007, which included input from
CNA, IOM, and other groups. As mentioned, CNA analyzed the
effectiveness of VA disability compensation as a replacement for
average loss of earning capacity. It was determined that ``VA
compensation on average is about right relative to earned income
losses.'' . . . It is about right given the average age at which
service-disabled veterans come into the VA system,'' i.e., age 50,
``and it is about right when we consider all disability types and
ratings as a whole.'' However, the study also found that veterans
entering the system at younger ages are generally under-compensated,
while those entering at older ages are generally over-compensated. In
addition, while those veterans with physical disabilities are properly
compensated, those with mental disabilities are under-compensated. This
study provides VA with an empirical basis for developing ways to
correct rating inconsistencies identified.
The Dole-Shalala Commission, the VDBC, and various other
commissions and groups discussed the need for continuous review and
updating of the schedules.
As part of our plan for improving the rating schedule, we are
committed to responding in a positive manner to recommendations from
reviews and studies provided by commissions and organizations concerned
with the welfare of veterans. We are also committed to conducting our
own reviews and studies as needed to implement improvements in a
practical and efficient manner.
V. Quality of Life Compensation
In addition to the Dole-Shalala Commission, recent studies and
commission reports, have also recommended that compensation should also
be provided for losses incurred in other aspects of a veteran's life.
These aspects are generally referred to under the term ``quality of
life'' and include losses in the social and psychological realms. As
explained, the recent contract awarded by VA will study the
alternatives for incorporating a quality of life component into the
disability evaluation scheme. In addition, meetings have been scheduled
with representatives of the World Health Organization and the American
Medical Association to obtain their views on how quality of life is
impacted by physical and mental disability. We stand ready to consider
any viable and practical compensation construct that would assist
disabled veterans in the quality of life realm. However, as noted
above, if VA is to comprehensively incorporate diminution of quality of
life resulting from disability into the rating schedule as proposed in
the Administration's legislation, it will require additional statutory
authority from Congress.
Mr. Chairman, this concludes my prepared remarks. I and others on
the panel would be pleased to answer any questions you and Members of
the Subcommittee might have.
Statement of Major General Joseph E. Kelley, M.D., USAF (Ret.)
Deputy Assistant Secretary of Defense for Clinical and
Program Policy (Health Affairs), U.S. Department of Defense
Mr. Chairman, Ranking Member Lamborn, and Members of the Committee,
the Administration has worked diligently - commissioning independent
review groups, task forces and a Presidential Commission, which have
made recommendations concerning the adequacy and application of the
Department of Veterans Affairs (VA) Schedule for Rating Disabilities
(VASRD). Central to our efforts, a closer partnership between our
respective Departments was strengthened by formation of the Senior
Oversight Committee (SOC), cochaired by Deputy Secretaries of Defense
and Veterans Affairs, to identify immediate corrective actions and to
review and implement recommendations of the external reviews. Some of
these recommendations were focused on VA's efforts to update and
improve the VASRD.
The driving principle guiding SOC efforts is the establishment of a
world-class seamless continuum that is efficient and effective in
meeting the needs of our wounded, ill, and injured servicemembers,
veterans and their families. In short, the SOC brings together on a
regular basis the most senior decisionmakers from DoD and VA to ensure
wholly informed, timely action. As such, many of the issues between the
two Departments on the application and revisions of the VASRD are now
being worked in a collaborative and productive manner.
An updated VASRD is critical to the Department of Defense's
Disability Evaluation System as it is the rating schedule utilized in
the Physical Evaluation Board (PEB) Adjudication. On the basis of a
preponderance of the evidence, the PEB determines whether the
individual is fit or unfit to perform adequately the duties of their
office, grade, rank or rating. As a product of the PEB process and
according to title 10, servicemembers found unfit for continued
military service will be awarded a disability rating percentage for the
military unfitting condition, in accordance with the rating guidance
established in the VASRD. This disability rating determines entitlement
to separation or retirement benefits. Consistency of application across
the Services has sometimes been problematic in the Department. As part
of complying with the NDAA for Fiscal Year 2008, the DoD is working
with VA to begin joint VASRD training and to develop clarifying
guidance for the Services to use in the Department. This training and
guidance is important as it provides clarification on how to measure
and rate conditions that do not neatly fit the schedules. VA is also
providing the Department of Defense with all court decisions related to
the VARSD so that the Departments are consistent in the interpretation
of the specific schedules. Consistency of decisions and application of
ratings across the Departments will synergistically improve as we work
on joint development of training programs and reporting mechanisms,
especially when it comes to how to apply the ratings in the VASRD.
It cannot be overstated that an updated and clear VASRD is
fundamental to consistent application of the Disability Evaluation
System. In fact, consistent application is a key criterion in the
Disability Evaluation System (DES) Pilot test which was implemented in
November 2007 for disability cases originating at the three major
military treatment facilities in the National Capitol Region (Walter
Reed Army Medical Center, National Naval Medical Center Bethesda, and
Malcolm Grow Medical Center). Key features include both a single
disability/transition medical examination and single source disability
rating by VA experts and fulltime professionals who apply the VASRD to
medical conditions. The pilot is testing, along with many other facets,
whether the Department of Defense can accept the single-source rating
from VA without modification.
The pilot is part of the larger SOC effort including medical
research into the signature injuries of the war and the corresponding
updating of the VASRD. Proposed regulations to update the VASRD for
Traumatic Brain Injury and burns were published in the Federal Register
on January 3, 2008. The VASRD, in regard to Traumatic Brain Injury and
Burns, is being updated by VA to reflect advances in medical science.
The schedule proposes to clearly define VA's rating policies concerning
the evaluation of scars, including multiple scars. VA proposes to
incorporate ``burn scars'' into the title of the diagnostic codes most
appropriate for evaluating scars. Previously, burn scars were generally
rated only if they impacted motion and mobility. The schedule proposes
to also provide detailed and updated medical criteria for evaluating
residuals of Traumatic Brain Injury (TBI). VA has proposed to change
the title, provide guidance for the evaluation of the cognitive,
emotional/behavioral, and physical residuals of TBI, direct raters to
consider special monthly compensation for problems associated with TBI,
and revise the guidance concerning the evaluation of subjective
complaints. The Department of Defense lauds VA for this collaborative
and diligent effort to ensure the VASRD rates disabilities associated
with the war as accurately as possible.
The Departments are also participating in a reenergized Disability
Advisory Council (DAC) - a consortium of advisors from the Military
Departments, DoD agencies, and the Department of Veterans Affairs. The
DAC is a key instrument in the policy formulation, promulgation, and
management of the DES. The Departments have made great progress in
revitalizing the DAC so that it plays an active and strengthened role
in providing a venue to initiate collaborative discussions with VA on
VASRD issues, and a pathway for the Department of Defense medical
community to provide consultation and inputs for revisions. The DAC, in
turn, will inform the collaborative structure of councils (the Benefits
Executive Council and Joint Executive Council) on DES and VARSD issues
for decisions. These councils are cochaired by senior leadership of
both Departments.
One of the most significant recommendations from the task forces
and commissions is the shift in the fundamental responsibilities of the
Departments of Defense and Veterans Affairs. Among the core
recommendations of the Dole/Shalala Commission is the concept of taking
the Department of Defense out of the disability rating business so that
DoD can focus on the fit or unfit determination, and streamlining the
transition from servicemember to veteran. The Department believes this
recommendation is very sound. The application of the VARSD is best left
to the trained and professional experts who are from VA where the VARSD
is developed and refined.
We are pleased with the quality of effort and progress made on the
VASRD and understand that there is much more to do. We also believe
that the greatest improvement to the long-term care and support of
America's wounded warriors and veterans will come from enactment of
provisions recommended by Dole/Shalala. We have, thus, positioned
ourselves to implement these provisions through the Disability
Evaluation System Pilot and continue our collaboration with VA in
providing world-class support to our warriors and veterans.
Statement of American Medical Association
The American Medical Association (AMA) appreciates the opportunity
to provide the House Committee on Veterans Affairs Subcommittee on
Disability Assistance and Memorial Affairs with comments on reforming
the Veterans Disability System. Our comments follow our review of the
Institute of Medicine's (IOM) 2007 report entitled, A 21st Ccentury
System for Evaluating Veterans for Disability Benefits, which
highlights the significant shortcomings of the current, antiquated
veterans disability system.
The AMA supports reforms to the Veterans Disability System, as
demonstrated in the AMA's Guides to the Evaluation of Permanent
Impairment, Sixth Edition (Guides), which was published in December,
2007. This current edition defines a new international standard for
impairment assessment. A consistent, well-designed methodology was
adopted and applied to each chapter to enhance validity, improve
internal consistency, promote greater precision, standardize the rating
process, and improve inter-rater reliability. The goal is to provide an
impairment rating guide that is authoritative, fair, and equitable to
all parties. The editorial process used an evidence-based foundation
when possible and a modified Delphi panel approach to consensus
building. Additionally, the editorial process was undertaken by a panel
of experts and physician specialists in the field of impairment
assessment.
The traditional model of disablement was based on the International
Classification of Impairments, Disabilities and Handicaps (ICIDH). This
was a unidirectional model that does not address all facets of an
injury experience.
[GRAPHIC] [TIFF OMITTED] T1371A.003
The AMA Guides methodology applies the current state of the art
terminology and adopts an analytical framework based on the World
Health Organization's International Classification of Functioning,
Disability and Health (ICF):
ICF Model of Disablement
[GRAPHIC] [TIFF OMITTED] T1371A.004
In evaluating the severity of an illness or injury, a physician
typically considers four basic points:(1) what is the problem
(diagnosis); (2) what symptoms and resulting functional difficulty does
the patient report; (3) what are the physical findings pertaining to
the problem; and (4) what are the results of clinical studies. These
same considerations are used by physicians to evaluate impairment and,
therefore, are used as a guiding construct for the Guides. The Sixth
Edition is designed to encourage attention to, and documentation of,
functional consequences of the impairment as a part of each physician's
detailed history, to clarify and delineate key physical findings, and
to underscore essential clinical test results where applicable.
Based on the efforts of the AMA process, Diagnosis-based grids were
developed for each organ system. These grids arrange diagnoses into
five classes of impairment severity, according to the consensus-based
dominant criterion. The functionally based history, physical findings,
and broadly accepted clinical test results, where applicable, are then
integrated to determine severity grade and provide a corresponding
impairment value. Ratings are transparent, clearly stated, and
reproducible. The basic template of the diagnosis-based grid is common
to each organ system and chapter; thus, there is greater internal
consistency, facilitating the application of this new method.
[GRAPHIC] [TIFF OMITTED] T1371A.005
Each chapter in the Guides was written by a group of specialty-
specific, expert contributors, developing their respective chapter
within the scope of this established framework. The Sixth Edition of
the Guides reflects a significant revision and includes changes to all
chapters. The three most common organ system claims seen in the
Veterans Disability system-- Orthopedics, Psychiatry, and Hearing--are
all completely covered by the respective AMA Guides chapters. Further,
these specialty-specific chapters do not use any separate specialty-
specific resource outside of the Guides in their fields. As an example,
the common psychiatric claims for Post Traumatic Stress Disorder
(PTSD), other anxiety disorders, traumatic brain disorders, depressive
disorders, psychotic disorders, are all evaluated with the use of the
AMA Guides.
To assess impairment using the Mental and Behavioral Disorders
chapter of the Sixth Edition, the clinician must first make a
definitive diagnosis using standard psychiatric criteria, including
history, and adjunctive psychological, neuroradiological, or laboratory
testing. The Sixth Edition also supports the use of well-standardized
psychological tests that may improve accuracy and support the existence
of a mental disorder. The diagnosis (with the associated factors of
prognosis and course) will form the basis by which one assesses the
severity and predicts the probable duration of the impairment. The
Guides Sixth Edition also uses three scales by which mental and
behavioral impairment is rated: 1) the Brief Psychiatric Rating Scale
(BPRS), 2) the Global Assessment of Functioning Scale (GAF), and 3) the
Psychiatric Impairment Rating Scale (PIRS). The BPRS measures major
psychotic and nonpsychotic symptoms in patients with major psychiatric
illnesses. The GAF evaluates overall symptoms, occupational and social
function. The PIRS assesses behavioral consequences of psychiatric
disorders within various areas of functional impairment. The purpose of
including all three of these scales is to provide a broad assessment of
the patient with mental and behavioral disorders as the individual
scales focus on symptom severity and/or function. The objective of
making a reliable diagnosis and coupling it with the assessment of
these three scales is to arrive at a strongly supportable impairment
rating.
Any model used to determine disability for veterans will require a
comprehensive, regularly updated, commonly accepted rating method to
diagnose medical impairments and link them to basic functional
limitations. The AMA Guides offers a methodology to achieve this. Any
physician trained and experienced in Guides methodology within or
external to the VA can provide these assessments. This information is a
necessary first step in the comprehensive integrated determination of
work disability, non-work disability, individual unemployability, and
quality of life.
One of the most important changes to the Guides development process
was the establishment of the Guides Advisory Committee. This advisory
Committee is composed of representatives from certification
organizations, teaching organizations, workers' compensation systems,
or are members of the AMA's policymaking body known as the House of
Delegates (HOD), which is comprised of representatives from 109
national medical specialty societies and all the state medical
societies.
The Guides Advisory Committee is ongoing and meets annually to
discuss items of mutual concern and current issues in impairment and
disability. The Advisory Committee's primary objectives are to:
serve as a resource to the Guides Editorial Panel by
giving advice on impairment rating as relevant to the member's
specialty;
provide documentation to staff and the Editorial Panel
regarding the medical appropriateness of changes under consideration
for inclusion in the Guides;
assist in the review and further development of relevant
impairment issues and in the preparation of technical education
material and articles pertaining to the Guides; and
promote and educate the Membership of representative
organizations on the use and benefits of the Guides.
The Guides Advisory Committee will receive all recommendations for
changes to future editions of the Guides. Based on current scientific
and clinical evidence, the Advisory Committee Members will help
determine the scientific merit of each recommendation and use these to
form the foundation for subsequent editions of the Guides. The goals of
the new approach are to obtain broad input from stakeholders and to
develop a process for defining impairment that is supportable, high-
quality, efficient, and effective. If the Guides were to be used within
the VA system, the AMA would solicit representation from the Veterans
Administration to ensure our responsiveness to any particular Veterans
Administration need.
In conclusion, there are significant shortcomings of the current,
antiquated veterans disability system as highlighted by the IOM. The
current international science of disability places the World Health
Organization model as the centerpiece to approaching this discipline.
The AMA Guides has been specifically developed to be at the forefront
of the rating process and addresses the IOM reforms and virtually all
of the recommended enhancements to the impairment rating process. As
with all needed reforms to any aspect of our Nation's healthcare
systems, the AMA is prepared to offer the resources of our organization
to assist in the ongoing dialog of implementation and improvement.
United States General Accounting Office, GAO-03-1172T
Testimony Before the Committee on Veterans' Affairs, U.S. Senate
Statement of Cynthia A. Bascetta, Director
Education, Workforce, and Income Security Issues
Tuesday, September 23, 2003
VA Benefits: Fundamental Changes to VA's Disability Criteria Need
Careful Consideration
Mr. Chairman and Members of the Committee:
I am pleased to be here to discuss our past reviews of the
Department of Veterans Affairs (VA) disability programs as you consider
the fundamental issue of eligibility for benefits and the related issue
of concurrent receipt of VA disability compensation and Department of
Defense (DoD) retirement pay. Our work has addressed these issues in
addition to identifying significant program design and management
challenges hindering VA's ability to provide meaningful and timely
support to disabled veterans and their families. It is especially
fitting, with the continuing deployment of our military forces to armed
conflict, that we reaffirm our commitment to those who serve our Nation
in its times of need. Therefore, effective and efficient management of
VA's disability programs is of paramount importance.
As you know, in January 2003, we designated VA's disability
compensation programs, as well as other Federal disability programs
including Social Security Disability Insurance and Supplemental
Security Income, as high-risk areas.\1\ We did this to draw attention
to the need for broad-based transformation of these programs, which is
critical to improving the government's performance and ensuring
accountability within expected resource limits. In March 2003, we
cautioned that the proposed modification of concurrent receipt
provisions in the military retirement system would not only have
significant implications for DoD's retirement costs but could also
increase the demands placed on the VA claims processing system. This
would come at a time when the system is still struggling to correct
problems with quality assurance and timeliness. Moreover, we testified
that it would be appropriate to consider the pursuit of more
fundamental reform of the disability programs as the Congress and other
policy makers consider concurrent receipt.
---------------------------------------------------------------------------
\1\ U.S. General Accounting Office, High-Risk Series: An Update,
GAO-03-119 (Washington, D.C.: Jan. 1, 2003).
---------------------------------------------------------------------------
Today, as you requested, I would like to highlight the findings of
our related past work on VA's disability programs, including our 1989
report on veterans receiving compensation for disabilities unrelated to
military service. My comments are based on numerous reports and
testimonies prepared over the last 15 years as well as our broader work
on other Federal disability programs. (See Related GAO Products.):
In summary, VA needs to modernize its disability programs. In
particular, VA relies on outmoded medical and economic disability
criteria in adjudicating claims for disability compensation. In
addition, VA has longstanding problems providing veterans with
accurate, consistent, and timely benefit decisions, although recent
efforts have made important improvements in timeliness. However,
complex program design features, including eligibility, have developed
over many years, and solutions to the current problems will require
thoughtful analysis to ensure that efficient, effective, and equitable
solutions are crafted. Moreover, these solutions might need to take
into account a broader perspective from other disability programs to
ensure sound Federal disability policies across government programs and
to reduce the risks associated with the current programs.
Background
VA provides disability compensation to veterans with service-
connected conditions, and also provides compensation to survivors of
servicemembers who died while on active duty. Disabled veterans are
entitled to cash benefits whether or not employed and regardless of the
amount of income earned. The cash benefit level is based on the
percentage evaluation, commonly called the ``disability rating,'' that
represents the average loss in earning capacity associated with the
severity of physical and mental conditions. VA uses its Schedule for
Rating Disabilities to determine, based on an evaluation of medical and
other evidence, which disability rating to assign to a veteran's
particular condition. VA's ratings are in 10 percent increments, from 0
to 100 percent.
Although VA generally does not pay disability compensation for
disabilities rated at 0 percent, such a rating would make veterans
eligible for other benefits, including healthcare. About 65 percent of
veterans receiving disability compensation have disabilities rated at
30 percent or lower, and about 8 percent are 100 percent disabled.
Basic monthly payments range from $104 for a 10 percent disability to
$2,193 for a 100 percent disability.
VA's Disability Criteria Are Outmoded
In assessing veterans' disabilities, VA remains mired in concepts
from the past. VA's disability programs base eligibility assessments on
the presence of medically determinable physical and mental impairments.
However, these assessments do not always reflect recent medical and
technological advances, and their impact on medical conditions that
affect potential earnings. VA's disability programs remain grounded in
an approach that equates certain medical impairments with the
incapacity to work.
Moreover, advances in medicine and technology have reduced the
severity of some medical conditions and allowed individuals to live
with greater independence and function more effectively in work
settings. Also, VA's rating schedule updates have not incorporated
advances in assistive technologies--such as advanced wheelchair design,
a new generation of prosthetic devices, and voice recognition systems--
that afford some disabled veterans greater capabilities to work.
In addition, VA's disability criteria have not kept pace with
changes in the labor market. The nature of work has changed in recent
decades as the national economy has moved away from manufacturing-based
jobs to service-and knowledge-based employment. These changes have
affected the skills needed to perform work and the settings in which
work occurs. For example, advancements in computers and automated
equipment have reduced the need for physical labor. However, the
percentage ratings used in VA's Schedule for Rating Disabilities are
primarily based on physicians' and lawyers' estimates made in 1945
about the effects that service-connected impairments have on the
average individual's ability to perform jobs requiring manual or
physical labor. VA's use of a disability schedule that has not been
modernized to account for labor market changes raises questions about
the equity of VA's benefit entitlement decisions; VA could be
overcompensating some veterans, while undercompensating or denying
compensation entirely to others.
In January 1997, we suggested that the Congress consider directing
VA to determine whether the ratings for conditions in the schedule
correspond to veterans' average loss in earnings due to these
conditions and adjust disability ratings accordingly. Our work
demonstrated that there were generally accepted and widely used
approaches to statistically estimate the effect of specific service-
connected conditions on potential earnings. These estimates could be
used to set disability ratings in the schedule that are appropriate in
today's socioeconomic environment.\2\
---------------------------------------------------------------------------
\2\ U.S. General Accounting Office, VA Disability Compensation:
Disability Ratings May Not Reflect Veterans' Economic Losses, GAO/
HEHS-97-9 (Washington, D.C.: Jan. 7, 1997).
---------------------------------------------------------------------------
In August 2002, we recommended that VA use its annual performance
plan to delineate strategies for and progress in periodically updating
labor market data used in its disability determination process.\3\ We
also recommended that VA study and report to the Congress on the
effects that a comprehensive consideration of medical treatment and
assistive technologies would have on its disability programs'
eligibility criteria and benefit package. This study would include
estimates of the effects on the size, cost, and management of VA's
disability programs and other relevant VA programs and would identify
any legislative actions needed to initiate and fund such changes.
---------------------------------------------------------------------------
\3\ U.S. General Accounting Office, SSA and VA Disability Programs:
Re-- Examination of Disability Criteria Needed to Help Ensure Program
Integrity, GAO-02-597 (Washington, D.C.: Aug. 9, 2002).
---------------------------------------------------------------------------
Some Veterans Are Compensated For Disabilities Not Related To Military
Service:
A disease or injury resulting in disability is considered
serviceconnected if it was incurred or aggravated during military
service. No causal connection between the disability and actual
military service is required. In 1989, we reported on the U.S. practice
of compensating veterans for conditions that were probably neither
caused nor aggravated by military service.\4\ These conditions included
diabetes unrelated to exposure to Agent Orange,\5\ chronic obstructive
pulmonary disease, arteriosclerotic heart disease, and multiple
sclerosis. A review of case files for veterans receiving compensation
found that 51 percent of compensation beneficiaries had disabilities
due to injury; of these, 36 percent were injured in combat, or
otherwise performing a military task. The remaining 49 percent were
disabled due to disease; of these, 17 percent had disabilities probably
caused or aggravated by military service; 19 percent probably did not
have disabilities related to service; and for 13 percent, the link
between disease and military service was uncertain. We suggested that
the Congress might wish to reconsider whether diseases neither caused
nor aggravated by military service should be compensated as service-
connected disabilities.
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\4\ U.S. General Accounting Office, VA Benefits: Law Allows
Compensation for Disabilities Unrelated to Military Service, GAO/ HRD-
89-60 (Washington, D.C.: July 31, 1989).
\5\ In May 2001, VA issued a regulation identifying Type 2 diabetes
as a service-connected disability for veterans who served in Vietnam,
based on presumed exposure to Agent Orange.
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In March 2003, the Congressional Budget Office (CBO) reported that,
according to VA data, about 290,000 veterans received about $970
million in disability compensation payments in fiscal year 2002 for
diseases identified by GAO as neither caused nor aggravated by military
service. CBO estimated that VA could save $449 million in fiscal years
2004 through 2008, if disability compensation payments to veterans with
several nonservice-connected, disease-related disabilities were
eliminated in future cases. In August 2003, we also identified this as
an opportunity for budgetary savings if the Congress wished to
reconsider program eligibility.\6\
---------------------------------------------------------------------------
\6\ U.S. General Accounting Office, Opportunities for Oversight and
Improved Use of Taxpayer Funds: Examples from Selected GAO Work, GAO-
03-1006 (Washington, D.C.: Aug. 1, 2003).
---------------------------------------------------------------------------
Because of the complexities involved in a potential change in
eligibility, the details of how such a change would be implemented and
its ramifications are important to the Congress, VA, veterans, and
other stakeholders. For example, service connection is linked with
eligibility for other VA benefits, such as healthcare and vocational
rehabilitation. Moreover, efforts to change VA disability programs,
including eligibility reform, would benefit from consideration in the
broader context of fundamental reform of all Federal disability
programs.
Mr. Chairman, this concludes my prepared remarks. I would be happy
to answer any questions that you or Members of the Committee might
have.
Contact and Acknowledgments
For further information, please contact me at (202) 512-7101 or
Irene Chu at (202) 512-7102. Greg Whitney also contributed to this
statement.
Related GAO Products
Opportunities for Oversight and Improved Use of Taxpayer Funds:
Examples from Selected GAO Work. GAO-03-1006. Washington, D.C.: August
1, 2003.
Department of Veterans Affairs: Key Management Challenges in Health
and Disability Programs. GAO-03-756T. Washington, D.C.: May 8, 2003.
High-Risk Series: An Update. GAO-03-119. Washington, D.C.: January
1, 2003.
Major Management Challenges and Program Risks: Department of
Veterans Affairs. GAO-03-110. Washington, D.C.: January 1, 2003.
Veterans' Benefits: Quality Assurance for Disability Claims and
Appeals Processing Can Be Further Improved. GAO-02-806. Washington,
D.C.: August 16, 2002. SSA and VA Disability Programs: Re-Examination
of Disability Criteria Needed to Help Ensure Program Integrity. GAO-02-
597. Washington, D.C.: August 9, 2002.
Veterans' Benefits Claims: Further Improvements Needed in Claims--
Processing Accuracy. GAO/HEHS-99-35. Washington, D.C.: March 1, 1999.
VA Disability Compensation: Disability Ratings May Not Reflect
Veterans' Economic Losses. GAO/HEHS-97-9. Washington, D.C.: January 7,
1997.
VA Benefits: Law Allows Compensation for Disabilities Unrelated to
Military Service. GAO/HRD-89-60. Washington, D.C.: July 31, 1989.
QUESTIONS FOR THE RECORD
Committee on Veterans' Affairs
Subcommittee on Disability Assistance and Memorial Affairs
Washington, DC.
February 29, 2008
Vice Admiral Dennis Vincent McGinn, USN (Ret.)
Veterans' Disability Benefits Commission
U.S. Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, DC 20420
Dear Admiral McGinn:
In reference to our Subcommittee hearing on The VA Schedule for
Rating Disabilities on February 26, 2008, I would appreciate it if you
could answer the enclosed hearing questions by the close of business on
April 2, 2008.
In an effort to reduce printing costs, the Committee on Veterans'
Affairs, in cooperation with the Joint Committee on Printing, is
implementing some formatting changes for materials for all Full
Committee and Subcommittee hearings. Therefore, it would be appreciated
if you could provide your answers consecutively on letter size paper,
single-spaced. In addition, please restate the question in its entirety
before the answer.
Due to the delay in receiving mail, please provide your response to
Ms. Orfa Torres by fax at (202) 225-2034. If you have any questions,
please call (202) 225-3608.
Sincerely,
JOHN J. HALL
Chairman
__________
Veterans' Disability Benefits Commission
Established Pursuant to Public Law 108-136
Sunset December 1, 2007
March 31, 2008
Hon. John J. Hall
Subcommittee on Disability Assistance and Memorial Affairs
335 Cannon House Office Building
Washington, DC 20515
Dear Mr. Chairman:
As a follow up to my testimony on behalf of Commission Chairman
Scott before the Subcommittee on Disability Assistance and Memorial
Affairs on February 26, 2008, enclosed for the record are my written
responses to your post-hearing questions. Both my testimony and the
enclosed answers reflect my point of view and, where appropriate, my
understanding of the considerations. We used to reach consensus as a
Commission. As you know, we completed our work and submitted our report
in October 2007, closing the Commission's operations at the end of
November.
I hope the Subcommittee finds my testimony, the enclosed responses
to your questions, and the body of work produced by the Commission, and
the Institute of Medicine and the CNA Corp. on behalf of the
Commission, useful as you proceed with legislation and oversight aimed
at improving the disability compensation system for our Nation's
veterans and their families.
Sincerely,
Dennis Vincent McGinn VADM USN (Ret)
Member
Enclosure
__________
RESPONSE TO QUESTIONS FOR THE RECORD BY
DENNIS VINCENT MCGINN, VADM USN (RET), MEMBER
VETERANS' DISABILITY BENEFITS COMMISSION March 31, 2008
The answers I am providing reflect my views and not necessarily
those of all of the Members of the Veterans' Disability Benefits
Commission since the Commission completed its work in October 2007 and
submitted its report at that time.
Question 1: Presumption seems to be a contentious issue that will
require years of research to establish a scientific standard. Did the
Commission consider what we should do in the meantime for some of these
types of conditions?
Response: The Commission did not discuss in any detail an interim
approach to presumptions but we also did not envision that the changes
recommended by IOM would require years to implement. If there is one
immediate step that should be taken, I would recommend that VA document
the existing process and ensure that every effort is made to make the
process more transparent. IOM found that ``VA (1) has no formal
published rules governing this process, (2) does not thoroughly
disclose and discuss what ``other'' medical and scientific information
it considered, and (3) publishes abbreviated and insufficiently
informative explanations of why a presumption was or was not
granted.''\1\ This situation should not continue.
---------------------------------------------------------------------------
\1\ Institute of Medicine (IOM), Presumptive Disability Decision-
Making, 12-10.
Question 2: The Commission also differed with the IOM on PTSD re-
evaluation. Why did it think it necessary to make such a recommendation
when IOM and the VSOs saw it as ``discriminatory'' and ``stressful''
---------------------------------------------------------------------------
for those with mental health issues?
Response: The Commission was mindful of IOM's thoughts on the
subject of re-examination and was respectful of IOM's recognized
expertise. However, the Commission found that there is insufficient
monitoring and coordination between Veterans Benefits Administration
(VBA) and Veterans Health Administration (VHA) for veterans
experiencing PTSD. Very little is done to monitor these veterans and
encourage them to receive treatment. The mental health community
generally believes that PTSD can be successfully treated yet the IOM
concluded in a study of PTSD treatment\2\ completed after our report
that the evidence is inadequate to determine efficacy of treatment
modalities except for exposure therapy. IOM further stated that they
did not intend to imply that other modalities are inefficacious. IOM
also found that there is not even an agreed-upon definition of
recovery.
---------------------------------------------------------------------------
\2\ Institute of Medicine (IOM), Treatment of Post Traumatic Stress
Disorder: An Assessment of the Evidence, 2008.
---------------------------------------------------------------------------
Our Commission concluded that veterans with PTSD are not well
served by simply providing compensation without follow up and treatment
and without incentives to seek treatment. That is why we recommended a
holistic approach that couples compensation, treatment, and vocational
assessment and requires re-examination every 2 to 3 years to gauge
treatment effectiveness and encourage wellness.
Question 3:. According to the Commission's report, the recommended
Executive Oversight Group should be formed to oversee implementation of
the Commission's recommendations. Should this group's authority be
extended beyond your Commission to other Commissions and task forces?
a. How does the Commission envision the Executive Oversight Group
to function that is different from the Joint Executive Council (JEC)
that is already cochaired by VA and DoD?
Response: Yes, if properly constituted, the Executive Oversight
Group should be granted authority to oversee the implementation of
appropriate recommendations by other commissions and task forces. As an
illustrative example of how this might work, Chairman Terry Scott
briefed the DoD/VA Senior Oversight Committee (SOC) last December on
some of our key recommendations. He was in turn briefed on the SOC's
efforts to ensure that the recommendations of our Commission, the Dole-
Shalala Commission and the other commissions and task forces are acted
upon. The SOC is presently tracking all recommendations and has
assigned each one to a line of action Subcommittee for action and is
monitoring progress on a frequent basis. While the SOC, currently
cochaired by Deputy Secretary of Defense England and Deputy Secretary
of Veterans Affairs Mansfield, is making real progress, it may not
continue in operation after the upcoming change of administration. Its
progress reflects the results that are possible when the attention of
the two Departments is applied at the highest levels.
My understanding of the Joint Executive Council (JEC) is that it is
statutorily mandated and could reasonably be expected perform the
oversight role envisioned by our Commission to ensure prompt and
appropriate action. However, I recommend strong involvement and
oversight on a regular and consistent basis by Committees of Congress,
namely the Armed Services and Veterans' Affairs Committees of the
Senate and House of Representatives. The momentum and enthusiasm to
properly care for our disabled Veterans and their families must not be
allowed to diminish. Collectively, the several reports issued over the
past year illuminate the path of necessary improvements for disabled
servicemembers and veterans and their families. In this sense, they
also reflect the will of the people of this Nation to our duty to
fulfill our moral obligation to those who defend our freedom.
Committee on Veterans' Affairs
Subcommittee on Disability Assistance and Memorial Affairs
Washington, DC.
February 29, 2008
Lonnie Bristow, M.D.
Chair
Committee on Medical Evaluation of Veterans
For Disability Benefits
Institute of Medicine
500 5th Street, NW
Washington, DC 20001
Dear Dr. Bristow:
In reference to our Subcommittee hearing on The VA Schedule for
Rating Disabilities on February 26, 2008, I would appreciate it if you
could answer the enclosed hearing questions by the close of business on
April 2, 2008.
In an effort to reduce printing costs, the Committee on Veterans'
Affairs, in cooperation with the Joint Committee on Printing, is
implementing some formatting changes for materials for all Full
Committee and Subcommittee hearings. Therefore, it would be appreciated
if you could provide your answers consecutively on letter size paper,
single-spaced. In addition, please restate the question in its entirety
before the answer.
Due to the delay in receiving mail, please provide your response to
Ms. Orfa Torres by fax at (202) 225-2034. If you have any questions,
please call (202) 225-3608.
Sincerely,
JOHN J. HALL
Chairman
__________
Questions of the Honorable John J. Hall and Responses of Lonnie
Bristow, M.D., Following the Hearing on the VA Schedule for Rating
Disabilities Held February 26, 2008
Question 1: At the hearing there was discussion of implicitly
including a loss of quality of life component or scale into the Rating
Schedule based on your Committee's findings. Can you give me some idea
as to how VA could measure quality of life and what instruments are
already available that might be useful to achieve this goal in the
short-term?
Response: The Committee I chaired noted that the modern
conceptualization of disability can include loss of quality of life
(QOL) as well as impairment and functional limitations. We recommended
that VA expand the basis for disability compensation to explicitly
include limitations on ability to function in everyday life and loss of
quality of life, in addition to degree of medical impairment, which is
currently the basis of the Rating Schedule. Measures of functional
limitations, such as Activities of Daily Living and Instrumental
Activities of Daily Living, are well developed and commonly used in the
healthcare system. Measures of health-related QOL are also widely
used--the Veterans Health Administration uses a version of the tool
called the SF-36 that has been normed to the VA population (the SF-
36V)--but more work needs to be done to further develop and refine this
into a tool that can be used to determine an amount of compensation for
the loss of QOL associated on average with a given condition. The
Committee recommended that VA develop such a tool, which it is well
positioned to do, and then see if there are some conditions for which
loss of QOL is much more severe than is reflected within the rating
given by the existing Rating Schedule. It is possible that impairment
ratings and degree of loss of QOL already tend to track together, in
which case an analytical study would show those with greater loss of
QOL are already being given the highest ratings. If those are not the
findings from such a study, the committee recommended that VA develop a
method of compensating for the loss of QOL.
In response to the query about instruments already available, we
pointed to a very successful example in Canada that would prove useful.
On page 125 of our report, A 21st Century System for Evaluating
Veterans for Disability Benefits), it says: ``An example of quality-of-
life research is the noneconomic loss survey of approximately 12,000
injured workers who received benefits from the Ontario, Canada,
workers' compensation program, plus 300 individuals from the general
population of Ontario who served as a control group. Seventy-eight
medical conditions covering a wide range of impairments were selected
as subjects for videos. Each video portrayed the limitations and
adaptations to lifestyle required of the workers with a given
condition. The workers discussed their condition with a therapist and
demonstrated their capacity to perform various tasks of daily living.
The procedure used to ascertain the quality-of-life ratings was
described by Sinclair and Burton (1995):*
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\*\ Sinclair, S., and J. F. Burton, Jr. 1995. Development of a
schedule for compensation of noneconomic loss: Quality-of-life values
vs. clinical impairment ratings. In: Research in Canadian Workers'
Compensation, edited by T. Thomason and R. P. Chaykowski. Kingston, ON:
IRC Press of Queen's University.
---------------------------------------------------------------------------
Each survey respondent spent 30 minutes viewing 4 or 6 of the
videos, randomly assigned, excluding videos depicting his or
her condition. Respondents were asked to rate, on an ``opinion
meter'' scale, the loss of enjoyment of life they believed they
would suffer if they had the condition portrayed. These ratings
were on a scale of 0 to 100, with 0 representing normal health
and 100 representing death.''
This approach or format could be employed in the VA population by
studying three groups: a group of veterans with disabilities, a control
group of veterans without disabilities, and still another control group
taken from the general public of an age-matched group who have not
served in the military. The average scores assigned by the general
public would serve as a check that veterans are not given higher
scores, and therefore more compensation, than the general public
perceives as fair (and that they are not given a lot less, either).
Question 2: Currently, VA doctors are only involved in the exam
process and give an opinion that is then interpreted by a Rater who
assigned the percentage of disability. Should doctors be more involved
in rendering a decision on a level of disability severity?
Response: I believe our Committee recognizes that physicians are
well suited for determining the presence or absence of medical or
psychological impairment (and its degree), but usually are not trained
for interpreting the statutes and applicable government-derived levels
of severity of disability (for which the Raters are trained and have
expertise). Our Committee supports the concept that doctors should not
be involved in rendering decisions on a level of disability severity,
but strongly advocates changing the current process so that Raters have
truly ``ready access'' to doctors for advice on medical and
psychological issues that arise during the rating process, such as in
interpreting evidence, and determining the possible need for additional
exams or tests (this is Recommendation 5-5 in the report).
Question 3: Your Committee recommended that a Voc Rehab assessment
be done before IU is awarded. Did it consider the complexity of that
assessment and the resources that VCA would require?
Response: Recommendation 7-1 applies to those veterans already
deemed to have a disability, and who then apply for IU. This is because
Raters (who have no training in assessing functional limitations, which
often is an essential factor in assessing employability) currently are
usually attempting to make the determination of whether the veteran can
engage in normal work activities on the basis of medical reports and
the two-page application for IU. Those two pieces of information are
often woefully inadequate in providing information about functional
limitations, so necessary for a Rater to properly determine
employability, and this at times results in a disservice to the
veteran, the government, or both.
It is also our recommendation (6-1) that all individuals who apply
for disability status at the time of separation from the service should
be given a comprehensive medical, psycho-social, and vocational
evaluation. This would establish a much-needed focus on how to achieve
maximum success in the adjustment to civilian life for the veteran with
a disability.
The Committee has indeed considered the complexity and the
resources that would be required of VA, but believes that it is a
legitimate part of the indebtedness that a Grateful Nation (a phrase
repeated by Pres. George W. Bush in March 2008 while giving out a Medal
of Honor) has to its surviving disabled veterans. It is simply
modernizing an honorable legacy that began in the days of the
Revolutionary War.
Question 4: Do private sector disability evaluating physicians
already use automated systems in conducting their exams, such as
electronic exam templates and decision support software that can match
diagnosis and levels of impairment severity and loss of function or
quality of life?
Response: The Committee did not research whether private sector
disability programs use templates, and if they do, how they make use of
this tool. VA has been using the template tool since 1997, and the IOM
Committee believes its greatest utility lies in it being used to
measure and assess the Consistency and the Technical Accuracy of the
data collection during the C & P examinations. This is a very important
part (but not sufficient unto itself) required for assessing the
Quality of the Examination. Another part (yet to be developed) is
assessing the quality of the Content within the data collected. Having
both parts will then allow a determination of the true quality of the
examination, and possibly be useful in training examiners to
consistently provide the Raters with the information they need.
Currently, its major usefulness is as a tool to evaluate the
consistency and technical accuracy in the gathering of data by the C &
P examination.
There is substantial difference between disability programs in the
private sector and that of the VA. One illustration is that none of the
private-sector employment opportunities carry with them the substantial
risk to life and limb that military service carries--not even in our
police and fire departments. Additionally, very often the types of
injuries and diseases which servicemembers experience are not often
encountered in the private sector. Accordingly, what may be perfectly
appropriate in the assessment and compensation of a private-sector
disability program may not be easily transferable to the setting
involving our veterans of military service. For those reasons, it is my
opinion that this process of decisionmaking about disability may,
someday in the far distant future, eventually be helped by decision
support software, but the current process of using a trained individual
to make that judgment should not be supplanted any time soon.
Committee on Veterans' Affairs
Subcommittee on Disability Assistance and Memorial Affairs
Washington, DC.
February 29, 2008
Dean Kilpatrick, Ph.D.
Committee on Veterans' Compensation For
Post-traumatic Stress Disorder
Institute of Medicine
500 5th Street, NW
Washington, DC 20001
Dear Dr. Kilpatrick:
In reference to our Subcommittee hearing on The VA Schedule for
Rating Disabilities on February 26, 2008, I would appreciate it if you
could answer the enclosed hearing questions by the close of business on
April 2, 2008.
In an effort to reduce printing costs, the Committee on Veterans'
Affairs, in cooperation with the Joint Committee on Printing, is
implementing some formatting changes for materials for all Full
Committee and Subcommittee hearings. Therefore, it would be appreciated
if you could provide your answers consecutively on letter size paper,
single-spaced. In addition, please restate the question in its entirety
before the answer.
Due to the delay in receiving mail, please provide your response to
Ms. Orfa Torres by fax at (202) 225-2034. If you have any questions,
please call (202) 225-3608.
Sincerely,
JOHN J. HALL
Chairman
__________
Dr. Dean Kilpatrick's responses to questions posed by the
Honorable John J. Hall, Chairman, Subcommittee on Disability
Assistance and Memorial Affairs, pursuant to the
Hearing on the VA Schedule on Rating Disabilities, February 26, 2008
Question 1: There has been discussion on PTSD and TBI having
overlapping symptoms. How can the Rating Schedule capture that?
Response: The issue of potential overlap between PTSD and TBI
symptoms was not discussed by the Institute of Medicine Committee on
Veterans' Compensation for Posttraumatic Stress Disorder. Nor was the
issue of how this could be addressed by the Rating Schedule
specifically covered by our Committee. Therefore, my response to this
question is based on my opinion and does not represent that of the
Committee.
I believe it is useful to make four points.
First, the issue of potential overlap of some symptoms between PTSD
and TBI is less important than understanding that both PTSD and TBI
could result from the same type of combat incident. TBI can result from
numerous types of events that happen in combat, including blast
concussions from improvised explosive devices, penetrating head wounds
from gunfire or shrapnel, and vehicle accidents. Our Committee report
documented evidence that being wounded or injured is a substantial risk
factor for developing PTSD (see Table 3-2 of the 2007 Institute of
Medicine report PTSD Compensation and Military Service, ``Risk Factors
for PTSD in Military Populations'', p. 76). Brain injury is no
exception to the general principle that those injured or wounded in
combat are more likely to develop PTSD. Therefore, the same incident
that produces a TBI in the veteran might well produce a case of PTSD.
In my opinion, it is important to consider whether veterans who have
been injured sufficiently to produce TBI may also have PTSD and to
conduct a careful examination to evaluate for PTSD in such cases.
Second, there is some overlap between TBI symptoms and PTSD
symptoms, particularly with respect to memory problems surrounding the
event that produced the TBI or PTSD. Specifically, some cases of TBI
involve retrograde amnesia (that is, lack of ability to remember events
that happened before the injury-producing event) or anterograde amnesia
(the inability to remember the injury-producing event or things that
occurred after it happened). One PTSD symptom is ``inability to recall
an important aspect of the trauma'' (DSM-IV-TR PTSD diagnostic
criterion C, symptom 3). If a veteran sustained a head injury
sufficient to produce TBI and/or PTSD and they cannot remember what
happened during the traumatic event that produced the injury, their
inability to recall details may be the result of the brain injury,
psychological trauma, or some combination of the two. In TBI cases
where veterans have numerous PTSD symptoms but there is a question as
to whether inability to recall details of the event stems from TBI or
PTSD, I think it is counterproductive to spend a great deal of time and
effort trying to establish the exact cause of this memory problem.
Third, common effects of TBI are post concussive symptoms which
include concentration deficits, headaches, and fatigue. Obviously, more
severe brain injuries are more likely to produce more severe deficits
in functioning than less severe brain injuries, and the location of the
brain injury also has an impact on the types of problems observed (for
example, individuals with injuries to the frontal lobes may exhibit
impairments in impulse control or increased anger). Some of these TBI
consequences may overlap with PTSD symptoms of ``difficulty
concentrating'' (diagnostic criterion D, symptom 3) or ``irritability
or outbursts of anger'' (criterion D, symptom 2). Thus, it is possible
for a veteran with TBI to have concentration problems as well as
irritability, and outbursts of anger. Veterans with PTSD can also have
these symptoms, as can veterans with TBI and PTSD.
Fourth, in my opinion, if a veteran has a war zone history that
includes exposure to an event that is capable of producing TBI, that
person should be evaluated clinically for both TBI and for PTSD. If
they have both TBI and PTSD, you would expect to have some symptom
overlap as described above. Trying to determine whether potentially
overlapping symptom should be assigned to TBI, to PTSD, or to TBI/PTSD
is difficult, although it is required in the current Department of
Veterans Affairs disability compensation system. As our report noted,
The Committee's review of the literature found no scientific
guidance addressing the separation of symptoms of comorbid
mental disorders for the purpose of identifying their relative
contributions to a subject's condition. . . . The parsing is
instead an artifact of a VA system built around the harsh
realities of polytraumatic injuries encountered in warfare.
Partitioning of symptoms among comorbid conditions is not
useful from a clinical perspective, and research on it is has
therefore not been given any priority. Clinicians are often
able to offer an informed opinion on this question, but this is
a professional judgment, not an empirically testable finding.
(p.96)
In order to reduce the difficulties encountered in situations where
multiple disorders co-exist, the report recommended that a national
standardized training program be implemented for clinicians who conduct
compensation and pension psychiatric evaluations. While this
recommendation was focused on PTSD and other mental disorders, I
believe it applies equally to conditions like TBI where physical
injuries may produce overlapping symptoms.
Question 2: The IOM discusses the Best Practices Manual for PTSD
C&P Exams, but did not take a position on using it. Should VA mandate
the manual?
Response: As you note, the Institute of Medicine Committee on
Veterans' Compensation for Post Traumatic Stress Disorder did not take
a position on this issue. I am happy to offer my personal opinion with
the understanding that it should not be attributed to others on the
Committee or to the Committee as a whole.
My Committee's review of compensation and pension (C&P)
examinations for PTSD quotes the VA's Best Practice Manual for Post
Traumatic Stress Disorder (PTSD) Compensation and Pension
Examinations(http://www.avapl.org/pub/PTSD%20Manual%20final%206.pdf) at
length. The Manual recommended using assessment tools that appear to
tap virtually all of the information needed to conduct a thorough exam.
In my opinion, the Best Practice Manual is an excellent starting point
for the VA if it wishes to mandate best practices for PTSD C&P exams.
However, our IOM Committee report as well as other recent efforts (the
2008 IOM report A 21st Century System for Evaluating Veterans for
Disability Benefits and the reports issued by the Veterans' Disability
Benefits Commission and President's Commission on Care for America's
Returning Wounded Warriors) recommended changes in the process that
have implications for the content of future C&P exams in areas such as
the assessment of quality of life. Therefore, it is my opinion that the
examination procedures described in the Best Practice Manual should not
be mandated as is. Instead, I believe that the VA should request the
National Center for PTSD to update the Manual to incorporate changes
recommended in our Committee's and others reports as well as any other
changes that are warranted by advances in the science regarding PTSD.
After such revisions have been made and independently reviewed, I
believe that it would be appropriate to mandate the Manual's use.
Question 3: Are VA Mental Health examiners and contractors
adequately training in conducting C&P exams?
a. Should there be a required certification for physician
examiners as well or just raters?
b. How should training and certification be developed?
Response: Our Committee did not explicitly address whether all
mental health examiners and contractors were adequately trained in
conducting C&P exams for PTSD. However, some of the data and testimony
we reviewed suggests that this may not be the case. First, we heard
testimony that some exams were being conducted in an hour or less.
Given that the Best Practice Manual outlines an assessment that may
take several hours to complete, this suggests that some C&P examiners
may lack sufficient training to know what a comprehensive exam consists
of and the skills to conduct it. Second, we reviewed evidence that
there were substantial variations in PTSD disability ratings across VA
regions. The basic data used by raters to establish disability ratings
is that provided by the mental health professionals in their C&P exams.
Therefore, it is reasonable to assume that some of the variability in
PTSD disability ratings may be associated with variability in the
mental health professional's training and skills in how to do a PTSD
C&P exam. In my opinion, it is highly likely that not all examiners are
sufficiently well trained in how to conduct these exams.
Question 3a: Should there be a required certification for physician
examiners as well or just raters?
Response: Our Committee did not address this question. In my
opinion, physicians and other mental health professionals who conduct
PTSD C&P exams should be required to have appropriate training and
experience in PTSD in military populations. It is unclear to me whether
formal certification is required or whether the successful completion
of coursework and clinical training--or the equivalent experience--
would suffice to demonstrate the competency needed to carry out high-
quality, thorough exams. Standardizing coursework and training
requirements for examiners would foster consistent exams throughout the
VA system, and should lead to more consistent ratings.
Question 3b: How should training and certification be developed?
Response: Our Committee did not address this question, but here are
some of my thoughts. First, the VA needs to specify more carefully the
types of information that should be gathered in C&P exams for PTSD as
well as the assessment tools that should be used to help gather the
needed information. The Best Practice Manual, if revised as I suggested
above, would be a good starting point for generating this material.
Second, core content information about PTSD in general combat and
military sexual trauma--related PTSD should be developed. This should
include what is known about how PTSD impacts quality of life as well as
ability to function in educational, work, and relationship settings.
Once this information is gathered, appropriate educational and
clinical experience requirements should be set by a panel consisting of
experienced VA clinicians (both physicians and other mental health
professions) and outside experts. The agreed-upon requirements should
be regularly reviewed and revised to insure that they reflect the best
practice.
Committee on Veterans' Affairs
Subcommittee on Disability Assistance and Memorial Affairs
Washington, DC.
February 29, 2008
Jonathan Samet, M.D.
Chair, Committee on Evaluation of the
Presumptive Disability Decision-Making Process for Veterans
Institute of Medicine
500 5th Street, NW
Washington, DC 20001
Dear Dr. Samet:
In reference to our Subcommittee hearing on The VA Schedule for
Rating Disabilities on February 26, 2008, I would appreciate it if you
could answer the enclosed hearing questions by the close of business on
April 2, 2008.
In an effort to reduce printing costs, the Committee on Veterans'
Affairs, in cooperation with the Joint Committee on Printing, is
implementing some formatting changes for materials for all Full
Committee and Subcommittee hearings. Therefore, it would be appreciated
if you could provide your answers consecutively on letter size paper,
single-spaced. In addition, please restate the question in its entirety
before the answer.
Due to the delay in receiving mail, please provide your response to
Ms. Orfa Torres by fax at (202) 225-2034. If you have any questions,
please call (202) 225-3608.
Sincerely,
JOHN J. HALL
Chairman
__________
Institute of Medicine
Washington, DC.
March 18, 2008
Hon. John J. Hall
Chairman, Committee on Veteran's Affairs
U.S. House of Representatives
Washington, DC 20515
Dear Chairman Hall:
I am writing in response to your letter of February 29, 2008, that
provided four questions in followup of my testimony before the
Subcommittee on February 26, 2008. Attached, please find my responses.
I appreciated the opportunity to speak to the Subcommittee. Please
do not hesitate to contact me if I can be of further assistance as you
consider and use the report of the Committee on Evaluation of the
Presumptive Disability Decision-Making Process for Veterans.
Sincerely,
Jonathan M. Samet, MD, MS
Professor and Chairman
Jacob I and Irene B. Fabrikant Professor in Health, Risk, and
Society
JMS/dvw
__________
Responses to Questions of the Honorable John J. Hall Chairman
Subcommittee on Disability Assistance and Memorial Affairs
Question 1: The VDBC did not fully accept the standards for
presumption the IOM proposed in its report. What is your reaction to
the direction the VDBC chose to go with presumptions?
Response: This question refers to the uncertainty of the VDBC with
regard to whether the ``standard'' for presumption should be
association or causation. Both the report of the IOM PDDM Committee and
of the VDBC noted the inconsistency in use of standards based on
association and causation across presumptive decisions made under
various laws. Most recently, the Institute of Medicine Agent Orange
Committees have provided a judgment as to the strength of evidence for
association, and that judgment has appeared to guide decisionmaking by
the VA. The VDBC notes that this issue needs to be clarified.
In proposing that causation rather than association should be the
standard, the IOM Committee recognized that some might view this
approach as ``raising the bar'' for the strength of evidence needed.
However, it should be noted that the Committee's classification of the
strength of evidence does not call for full certainty as to causation,
but simply that the balance point of the evidence be at a 50 percent
level of certainty or above. Additionally, we propose a schema for
evidence review that would give appropriate weight to evidence from
non-epidemiological sources, such as the findings of new types of
toxicologic assays that will likely become the mainstay of toxicity
testing. The Committee thought that its framework could be used
consistently across various types of exposures, even lacking
epidemiological evidence on association.
The VDBC stated that it ``. . . agrees with this scheme proposed by
IOM, but cautions VA not to ignore evidence that shows an association
between a condition and an environmental or occupational hazardous
exposure.'' We also call for flexibility in the VA's response to
findings. For example, even if evidence has not reached the bar of
equipoise or above for causality, benefits might be offered, such as
medical care coverage.
This matter of association of causation, which is embedded in
different ways and with some vagueness in various laws, might be
revisited by the Congress to insure that intent is clear.
Question 2: It seems that many of your Committee's recommendations
were based on the need for additional surveillance, which DoD would
need to do, and then for VA to study a broad spectrum of evidence of
environmental and occupational hazards. Given that we have heard so
much about the lack of information technology interoperability between
DoD and VA with medical and service records, how transferable would
that information be from DoD to VA?
Response: This question appropriately addresses the reality of
trying to achieve a smooth transfer of information between DoD and VA.
The IOM PDDM Committee carefully assessed the present status of
information systems and planned changes. We recognize that a seamless
flow of information from DoD to VA is a goal to be achieved. On the
other hand, Veterans will be best served if their health can be tracked
continually so that the consequences of exposures received during
service can be assessed. We urge that this interoperability between DoD
and VA be considered a goal. Our Committee did not make a technical
assessment of how should be achieved.
Questions 3: The Committee report noted that, ``Exposures to
stressors and to the circumstances of combat have not yet been
developed.'' You recommend more research. But with that lacking and
based on the DSM guidance for PTSD and how it defines a stressor, what
do you think of creating a stressor presumption for combat zone
service?
The IOM Committee recognized that the stressors of combat are real,
but that exposures to such stressors are not well documented. For those
serving in a combat theater, there is inevitably the process of
exposure to the many stressors associated with combat. We did not
specifically take on the task of determining if a presumption should be
made for stressors received in combat zone service.
Question 4: Developing the level of evidence as described in your
report could take years. What should we do about getting veterans their
benefits in the meantime?
Response: We recognize that achieving the full approach recommended
by our Committee will take years. We offer a model that VA and DoD
should always have in sight as they move toward a more firmly evidence-
based system for determining benefits for Veterans. We note that
aspects of our approach could be implemented immediately.
With regard to understanding the health consequences of military
service, evidence will always be accruing. For some diseases, there may
be a lengthy period between exposure and the appearance of excess risk.
We point out repeatedly, that decisions need to be made while evidence
is accumulating, and that changes in benefits might be made as the
evidence becomes more certain.
Committee on Veterans' Affairs
Subcommittee on Disability Assistance and Memorial Affairs
Washington, DC.
February 29, 2008
Joyce McMahon, Ph.D.
Managing Director, Center for Health Research and Policy
Center for Naval Analysis (CNA) Corporation
4825 Mark Center Drive
Alexandria, VA 22311
Dear Dr. McMahon:
In reference to our Subcommittee hearing on The VA Schedule for
Rating Disabilities on February 26, 2008, I would appreciate it if you
could answer the enclosed hearing questions by the close of business on
April 2, 2008.
In an effort to reduce printing costs, the Committee on Veterans'
Affairs, in cooperation with the Joint Committee on Printing, is
implementing some formatting changes for materials for all Full
Committee and Subcommittee hearings. Therefore, it would be appreciated
if you could provide your answers consecutively on letter size paper,
single-spaced. In addition, please restate the question in its entirety
before the answer.
Due to the delay in receiving mail, please provide your response to
Ms. Orfa Torres by fax at (202) 225-2034. If you have any questions,
please call (202) 225-3608.
Sincerely,
JOHN J. HALL
Chairman
__________
Questions of the Honorable John J. Hall
Chairman, Subcommittee on Disability Assistance and Memorial Affairs
Hearing on the VA Schedule for Rating Disabilities
Question 1: CNA reported that the level of life satisfaction or
quality of life among disabled veterans is so low. Do you think the
best way to address those issues would be to make this a more explicit
part of the Rating Schedule from a strictly compensation point of view?
Response: In our opinion, it would be more appropriate to keep the
quality of life scale as a separate element rather than combine it with
the earning compensation rating process. If the quality of life were to
be incorporated into the current rating criteria, this would add
another complexity to the rating system of compensation that is already
quite difficult for veterans to understand. The current system of
compensation is to make up for lost earnings capacity. It would be best
not to layer another different purpose on top of that until we
understand more about which categories of disabled veterans will be
entitled to a quality of life adjustment, and how that adjustment will
be determined (e.g., based on average quality of life, based on
combined disability rating, based on combined disability rating and
primary type of disability, etc.).
In addition, in the Raters and VSOs surveys, we asked the
respondents how they felt about the possibility of separately rating
the impact of a disability on lost earning capacity and the quality of
life of veterans during the claims process. In general, this suggestion
was not supported by either raters or VSOs.
Question 2: At one point in your testimony you mentioned that your
analyses pertained to earnings ratios of male veterans. How did female
veterans fare? Are they being treated equitably by VBA?
Response: Note that none of our comparisons combine male and female
veterans. This is necessary because the earned income profiles are
substantially different by gender and the gender mix is not constant
across age groups. For example, women account for 25 percent of
service-disabled veterans under age 30 but only 2 percent for those 50
years and older. Hence, combining the genders would bias our results.
To facilitate an easy comparison between service-disabled veterans
and their peers, we computed the ratio of earned income plus VA
compensation of service-disabled veterans to the earned income of non-
service-disabled veterans. Values less than 1 mean that VA compensation
doesn't make up for earned income losses, and values greater than 1
mean that VA compensation more than makes up for losses. A value of 1
represents parity.
For male service-disabled veterans, the data yielded an earnings
ratio of 0.99. For female service-disabled veterans, the earnings ratio
was 1.01. Overall, female veterans fared as well as male veterans with
regard to how well VA compensation makes up for earned income losses.
Question 3: It sounds like the surveys you did with the Raters and
the VSO Representatives gave you great insight as to what is going on
in the field among the people who are doing the actual claims
processing. So, based on that feedback, what changes would facilitate
making this a better system for compensating our Nations' disabled
veterans?
Response: The raters and VSOs report that many veterans find the VA
disability claims process to be confusing, time-consuming, and
frustrating. Simplifying the process would be a good start, along with
improving communication to the veterans who are applying for benefits.
In addition, the surveys showed that the raters and VSOs agreed that
the veterans had unrealistic expectations of how the claims process
would work and the benefits they would receive. Another improvement
might be to increase the clarity of the process so that veterans would
have more realistic expectations with respect to the time it will take
for a claim to be processed, the information that they will be required
to provide, and the overall nature of the benefits that they are
eligible to receive.
The respondents' answers to the Raters and VSO surveys yielded
specific suggestions as to how the claims process could be improved.
Both raters and VSOs felt that additional clinical input would be
useful, and that clinical input from physicians of appropriate
specialties and from mental health professionals would be especially
useful. VSOs also identified input from rehabilitation specialists and
medical records specialists as being a potentially useful source of
information.
The raters and VSOs reported a wide range of variation in how they
perceived the adequacy of their training and their proficiency in
knowledge, skills and abilities. In addition, their years of experience
also made a difference to the raters' perceptions about their abilities
to implement the claims process and their ease at rating and deciding
claims. Raters who reported feeling that they were not well-trained for
their specific role, and those with fewer years of rating experience,
found the rating process difficult. In addition, those feeling they
were not well trained or lacking in experience felt that they had
inadequate resources to help them decide claims--such as computer
system support, information and evidence, time, and administrative,
managerial and clerical support. Those who felt that they had good
training were more likely to feel that they had adequate resource
availability. In this sense, good training is a very important issue,
but actual experience on the job also seems to yield a sense of
confidence for the raters.
The raters and VSOs indicated that they felt that rating or
deciding mental disorder claims was in general more problematic than
rating or deciding physical condition claims. They perceived that
claims with mental disorder issues, especially PTSD, required more
judgment and subjectivity than claims with physical condition issues.
In addition, they indicated that consistency was likely to be an issue
for mental claims, in that mental disorder claims rated by different
raters at the same VA Regional Office might not receive similar
ratings. These factors might indicate that specialized resources and
training should be provided for raters working on mental disorder
claims. In addition, for the sake of consistency, it might be
appropriate to have specially trained raters that would be assigned to
deal with all claims relating to a mental disorder.
Among physical conditions, raters felt that neurological and
convulsive disorders, musculoskeletal disorders (especially involving
muscles), and disorders of special sense organs (especially eyes) were
the most difficult and time consuming to rate. Specific training in how
to gather information and rate these types of physical disorders might
improve the raters' confidence in conducting the rating process.
A significant majority of raters indicated that the criteria
currently used to determine IU status are too broad. They would like
more specific decision criteria or more specific evidence guidelines.
Raters also reported that they are not given sufficient time to
rate or decide a claim, and both raters and VSOs reported that there
was too much emphasis on speed relative to accuracy. Raters especially
feel that they are time-constrained when they are evaluating complex
claims, and that the claims they see are getting more complex over
time. This may provide support for increasing the size of the raters'
work force, given that individual raters feel that they are being
hurried to decide claims, and yet the overall time to decide claims is
already considered to be unacceptably long.
Raters also reported challenges in obtaining evidence to decide
claims--especially in obtaining needed evidence from medical
examinations (particularly from private examiners). They indicated that
the use of standardized assessment tools and more specific criteria or
guidelines would also be helpful, especially for deciding claims
regarding mental health issues--and in particular for PTSD claims.
To summarize, as indicated earlier, the VA claims process appears
to be difficult for most veterans to understand and navigate. A
majority of VSOs reported that they don't feel the process is
satisfactory to most of their clients. Raters and VSOs are in agreement
that veterans have unrealistic expectations with respect to the process
and the benefits they expect to receive. However, in general most
raters and VSOs believe that in the end, the claims rating process
generally arrives at fair and correct decisions for veterans.
Committee on Veterans' Affairs
Subcommittee on Disability Assistance and Memorial Affairs
Washington, DC.
February 29, 2008
Dr. Mark Hyman, M.D.
American Academy of Disability Evaluating Physicians
223 W. Jackson Boulevard, Suite 1104
Chicago, IL 60606
Dear Dr. Hyman:
In reference to our Subcommittee hearing on The VA Schedule for
Rating Disabilities on February 26, 2008, I would appreciate it if you
could answer the enclosed hearing questions by the close of business on
April 2, 2008.
In an effort to reduce printing costs, the Committee on Veterans'
Affairs, in cooperation with the Joint Committee on Printing, is
implementing some formatting changes for materials for all Full
Committee and Subcommittee hearings. Therefore, it would be appreciated
if you could provide your answers consecutively on letter size paper,
single-spaced. In addition, please restate the question in its entirety
before the answer.
Due to the delay in receiving mail, please provide your response to
Ms. Orfa Torres by fax at (202) 225-2034. If you have any questions,
please call (202) 225-3608.
Sincerely,
JOHN J. HALL
Chairman
__________
Mark H. Human, M.D., Inc., F.A.C.P., F.A.A.D.E.P.
Los Angeles, CA
Hon John J. Hall
Chairman, Subcommittee on Disability Assistance and Memorial Affairs
c/o Orfa Torres
Via email and FAX
__________
Response to Hearing Questions from February 26, 2008
Question 1: Can you describe in more detail how you, as a
physician, conduct disability exams for other jurisdictions using the
AMA Guides, CPT and ICD codes to create an evaluation? Tell me more
about these Guides. What steps do you take in the process? How would
you determine if an injury or illness was job related? How would you
diagnose and rate level of impairment? Is this an automated process?
Response: A patient is scheduled to be seen by administrative
personnel who are overseeing the claim. At the time of scheduling the
appointment, notice is given by my office requesting all available
medical records. Records are received and reviewed prior to the
claimant's arrival. Upon presenting to my office, the claimant fills
out questionnaires pertinent to the evaluation including basic
demographic data, HIPAA compliance information, job duty summaries,
past medical history, family history, social history, review of
systems, activities of daily living and pain questionnaires. The
paperwork process takes from 20 minutes to an average of 45 minutes.
I then take a history from the patient which takes about 30 to 45
minutes. I examine the patient which takes about 10 to 15 minutes. The
patient then undergoes any needed diagnostic testing which follows the
CPT classification. The testing that is required reflects their
presumed diagnoses, as well as what is recommended by the Guides to
arrive at a proper impairment rating.
The diagnoses are based on the ICD classification system.
When I arrive at a diagnosis, I consult the appropriate chapter and
section of the Guides for this condition. The instructions and Tables
provide a structured format to follow.
Job relatedness determinations come from a careful history, and are
usually determined 90 percent of the time based on the history and
facts of the case.
Automated processes are available both from the AMA as well as
private vendors. I can not underscore enough the necessity for the
evaluating physician to receive proper training in use of the Guides
from nationally recognized, AMA delegated society. I strongly endorse
AADEP for this purpose.
Question 2: When you conduct an evaluation are you also ratings a
degree of severity, such as the VA's 0-100 percent system?
Response: Yes, the Guides Tables take you step by step through a
process that asks for a diagnosis and then modifies the rating based on
the history, clinical examination and any associated laboratory
testing.
Question 3: In your opinion, should VA be involving doctors more in
the rating process rather than in only asking them for medical opinions
that are then interpreted by a non-medical rating official? How should
this information be conveyed between the examiner and the Rater?
Response: The ideal scenario is what I have outlined in question 1.
The approach of using a physician evaluator is central to the process
of arriving at a proper diagnosis. The physician then must have a
thorough training and working knowledge of the Guides, in order to
translate the findings into the appropriate impairment rating. The
report has to have a final section where the diagnosis, impairment
rating, and the table that was used in the determination are cited. A
rater can then take this rating and convert whatever particular
modifiers are required by the VA to arrive at the ultimate award.
Examples of a VA modifier might be age, sex, prior occupations, years
of service, etc.
Question 4: In your testimony, you mentioned that it took the State
of California only 8 months to revise its workman's compensation
system. Can you expand more on that processes and how they accomplished
this so quickly?
Response: Governor Schwarzenegger made workers compensation reform
a major item on his campaign. He held meetings just as you are doing.
All stakeholders had input into the process. As with any change, there
were groups that were resistant as well as claiming that the changes
were not in the best interests of injured workers. However, those
protests were much less about the Guides themselves and more about
other claims handling changes specific to California. However, once
passed into law, which was in April of 2004, the law took effect on
January 1, 2008. While there were bumps, the process has proceeded well
and continues to provide a common language for disability evaluation.
Please feel free to contact me with any further questions you may
have. I would be willing to serve on the advisory Committee to assist
in your transitions.
Committee on Veterans' Affairs
Subcommittee on Disability Assistance and Memorial Affairs
Washington, DC.
February 29, 2008
Sidney Wiessman, M.D.
Committee on Mental Healthcare for Veterans and Military Personnel
American Psychiatric Association
1000 Wilson Boulevard, Suite 1825
Arlington, VA 22209
Dear Dr. Weissman:
In reference to our Subcommittee hearing on The VA Schedule for
Rating Disabilities on February 26, 2008, I would appreciate it if you
could answer the enclosed hearing questions by the close of business on
April 2, 2008.
In an effort to reduce printing costs, the Committee on Veterans'
Affairs, in cooperation with the Joint Committee on Printing, is
implementing some formatting changes for materials for all Full
Committee and Subcommittee hearings. Therefore, it would be appreciated
if you could provide your answers consecutively on letter size paper,
single-spaced. In addition, please restate the question in its entirety
before the answer.
Due to the delay in receiving mail, please provide your response to
Ms. Orfa Torres by fax at (202) 225-2034. If you have any questions,
please call (202) 225-3608.
Sincerely,
JOHN J. HALL
Chairman
__________
American Psychiatric Association
Arlington, VA.
April 4, 2008
Chairman John J. Hall
House Committee on Veterans' Affairs
Subcommittee on Disability Assistance and Memorial Affairs
335 Cannon House Office Building
Washington, D.C. 20515
Ranking Member Doug Lamborn
House Committee on Veterans' Affairs
Subcommittee on Disability Assistance and Memorial Affairs
335 Cannon House Office Building
Washington, D.C. 20515
Dear Chairman Hall and Ranking Member Lamborn:
Thank you for the opportunity to speak before the House
Subcommittee on Disability Assistance and Memorial Affairs on February
26, 2008 regarding the Department of Veterans Affairs Schedule for
Rating Disabilities.
In reference to my testimony on Post-traumatic Stress Disorder in
the Diagnostic and Statistical Manual of Mental Disorders, which is now
in its fourth edition (DSM-IV), I was asked three followup questions by
Members of the Subcommittee and I would like to submit my answers for
the record.
The questions were as follows:
Question 1: Should VA have more than one code for rating all of
mental health conditions that veterans may experience as disabling?
Response: I assume that this question means may a veteran have more
than one diagnostic code for their condition when being rated for a
disability. If one looks at the DSM it is already the case that one can
have a diagnosis on axis one, axis two and axis three. Each of these
conditions would or could relate to the veteran's functional capacity
and they would have one score on axis five, the GAF. It would be
equally possible that a veteran could meet the diagnostic criteria for
two distinct diagnoses on axis one. The score on the GAF would be
related to their functioning, not the Axis one diagnoses.
For example:
Axis One: PTSD, Major Depression
Axis Two: no diagnosis
Axis Three: Post Concussion
Axis Four: State of loss of consciousness following destruction of his
HUMVE with broken arm
Axis Five: GAF 50
The critical issue is not the existence of one or more diagnoses
but the evaluation of the veteran's functioning in determining the GAF.
Only one GAF would exist.
Question 2: Should there be a presumption of a stressor if a
veteran served in a combat zone?
Response: This question does not define what is meant by a combat
zone. In Vietnam and Iraq it is safe to say wherever you were you were
in danger. Thus if one defines being in Iraq as being in a combat zone,
I would urge that all veterans be considered to be under the stress and
threat of attack in that combat zone.
However if we were to look at the Korean war, there were sites late
in the War if the country were considered a combat zone, where one
would not have been under stress.
Briefly I would consider all soldiers in Iraq and Afghanistan as
being under stress of potential attack, so my answer would be yes.
Question 3: During the hearing you differed greatly from the IOM's
conclusions on the use of the GAF in assessing PTSD disability. Can you
clarify your position in greater detail?
Response: Page 3 of the written testimony submitted by Dean G.
Kilpatrick, Ph.D. at the hearing states ``Currently, the same set of
criteria are used for rating all mental health disorders.'' (I believe
this refers to the GAF score). ``They focus on symptoms from
schizophrenia, mood, and anxiety disorders. The Committee found the
criteria are at best a crude and overly general instrument for the
assessment of PTSD disability.''
The DSM instructions for the use of the GAF are explicit and would
cover all of the areas of concern in assessing disability from PTSD not
limiting it only to work impairment.
From the GAF:
``Consider psychological, social, and occupational functioning on a
hypothetical continuum of mental health-illness. Do not include
impairment of functioning due to physical (or environmental)
limitation.''
The GAF is then presented in a scale from 1 to 100. In the text
itself explicit GAF text describing functioning is in bold print. After
the bold print are ``e.g.''s. This is I believe where the misreading of
the GAF comes on. ``E.g.'' means according to Webster's exempli gratia
(Latin for ``for example''). Therefore, the ``e.g.''s are examples. A
set of examples based on PTSD could be substituted for the examples
included in the DSM. The integrity of the GAF would be maintained and
the integrity of the various rating systems throughout the Federal
Government based on the GAF would also be maintained.
I believe inadvertently the IOM readers read ``e.g.'' as ``i.e.''
which means id. es (Latin for ``that is''). If the GAF had indeed used
``i.e.'' then their criticism would have been correct. If the Committee
is interested I could create a GAF scale using examples from the
behaviors and functioning observed in patients with mild to severe
PTSD.
In conclusion, the error in appreciating how the GAF was
constructed and the use of examples not required behaviors in the GAF
example accounts for the error in the IOM report.
I hope these responses adequately address the questions raised by
the Committee. Thank you again for the opportunity to speak about this
important issue and please let me know if I can be of any help in the
future.
Sincerely,
Sidney Weissman, M.D.
Member, Committee on Mental Healthcare for
Veterans and Military Personnel and their Families
Committee on Veterans' Affairs
Subcommittee on Disability Assistance and Memorial Affairs
Washington, DC.
February 29, 2008
Mr. Ronald Abrams
Joint Executive Director
National Veterans Legal Services Program
1600 K Street NW, Suite 500
Washington, DC 20006
Dear Mr. Abrams:
In reference to our Subcommittee hearing on The VA Schedule for
Rating Disabilities on February 26, 2008, I would appreciate it if you
could answer the enclosed hearing questions by the close of business on
April 2, 2008.
In an effort to reduce printing costs, the Committee on Veterans'
Affairs, in cooperation with the Joint Committee on Printing, is
implementing some formatting changes for materials for all Full
Committee and Subcommittee hearings. Therefore, it would be appreciated
if you could provide your answers consecutively on letter size paper,
single-spaced. In addition, please restate the question in its entirety
before the answer.
Due to the delay in receiving mail, please provide your response to
Ms. Orfa Torres by fax at (202) 225-2034. If you have any questions,
please call (202) 225-3608.
Sincerely,
JOHN J. HALL
Chairman
__________
National Veterans Legal Services Program
Washington, DC.
March 24, 2008
Honorable John J. Hall
Committee on Veterans' Affairs
335 Cannon House Office Building
Washington, DC 20515
Re: Subcommittee Hearing on VA Schedule for Rating Disabilities
Mr. Chairman:
Please find included in this submission answers to questions sent
February 29, 2008 regarding the Subcommittee Hearing on VA Schedule for
Rating Disabilities.
Sincerely,
Ronald B. Abrams
Joint Executive Director
__________
NVLSP Response To The Questions Of Hon. John J. Hall, Chairman
Subcommittee On Disability Assistance And Memorial Affairs
Question 1: You mentioned a very important point that I think
highlights the stigma we are fighting against mental illness--the
physically disabled can be 100 percent and still pursue employment, but
those with mental disabilities cannot. Should this be a parity issue?
Why not allow veterans with mental illnesses to work, if they can, and
still be 100 percent service connected?
Response: NVLSP recommends that the VA's General Rating Formula for
Mental Disorders be amended to accurately reflect a mental disorder's
impact on the average veteran's quality of life and earning capacity.
Congressman Hall's example aptly illustrates an underlying paradox:
veterans suffering from a mental disorder cannot be rated 100 percent
disabled if they are engaged in substantial gainful employment, despite
the severity of their mental condition. In stark contrast, a gainfully
employed veteran with any other service-connected disability (such as a
severe heart or lung condition) is eligible to receive a 100 percent
disability rating in addition to his or her full-time salary. This
policy is obviously inequitable and penalizes the extraordinary
individual who, although suffering from severe symptoms due to a mental
disorder, is able to find a job that gives purpose and meaning to the
veteran's life. NVLSP does not mean to suggest that there is no
relationship between the evaluation of mental illness and the average
veteran's ability to hold steady employment. The connection, however,
should not be absolute.
Moreover, this policy is inconsistent with current law and with
multiple VA regulations. Chapter 38 U.S.C. 1155 mandates that VA
ratings ``be based, as far as practicable, upon the average impairments
of earning capacity resulting from such injuries in civil occupations''
(emphasis added). Also see 38 C.F.R. 3.321 which mimics the language
of 38 U.S.C. 1155. The standard is repeated in 38 C.F.R. 4.1 and
4.15 which state in part, ``[t]he percentage ratings represent as far
as can practicably be determined the average impairment. . . .''
Finally, 38 C.F.R. 3.340(a)(1) reinforces this average person
standard in the context of a total disability rating, ``[t]otal
disability will be considered to exist when there is present any
impairment of mind or body which is sufficient to render it impossible
for the average person to follow a substantially gainful occupation''
(emphasis added). Notice that in all five instances above, no
distinction is made between mental and physical impairments, they are
both to be assessed under an objective average person standard.
The VA's physical disability rating schedule is largely aligned
with this standard. For all service connected disabilities but mental
disorders, the severity of the veteran's symptomatology determines the
percentage of disability the VA assigns. See 38 C.F.R. 4.71a.
However, the VA's General Rating Formula for Mental Disorders at 38
C.F.R. 4.130 (2008) utilizes a contrary standard, one that is
markedly unfavorable to veterans suffering with mental illness. For
example, in order for a veteran to receive a 100 percent rating, that
veteran, not the average veteran, must suffer from ``total occupational
and social impairment.'' This abandons the ``average person'' standard
mandated by law and espoused in VA regulations. Further it acts as a
major disincentive for mentally ill veterans to try an overcome their
disability.
By ignoring the average impairment standard, 4.130 not only
unfairly penalizes veterans suffering from service connected mental
conditions, but the regulation also fails to adequately incorporate the
impact of mental disabilities on a veteran's lifestyle. In the opinion
of NVLSP, the inability of a veteran to maintain effective
relationships with all or some family, friends, and co-workers should
support a 50 percent or 70 percent evaluation without a tie-in to
vocational difficulty.
NVLSP believes that a good first step would be to closely align the
rating schedule with the Global Assessment of Functioning (GAF) scale.
VA psychiatrists and other VA mental health examiners already employ
the GAF scale when making mental health assessments and this alignment
would streamline the rating process. For example, the rating schedule
could be amended so that every individual assessed as a 45 on the 100-
point GAF scale would receive the same percentage evaluation regardless
of their individual ability to overcome their mental disorder.(Of
course, VA adjudicators would not be required to accept GAF scores that
are not consistent with the symptoms indentified by the examiner. In
such instances, they could order a new VA mental health evaluation.)
Thus, the rating schedule for mental disorders would be aligned with
the average person standard mandated by 38 U.S.C. 1155, 38 C.F.R.
4.1, 38 C.F.R. 3.340(a)(1) and 38 C.F.R. 4.15.
Question 2: You stated that symptoms for TBI may wax and wane,
therefore it is important to consider the history of the symptoms,
isn't that true for mental disorders as well? Shouldn't every veteran
have a well documented military history assessment?
Response: Symptoms noted during service are important in
establishing service connection and in setting the initial evaluation.
However, in the context of a current mental evaluation, the relevance
of in-service noted symptoms diminishes the farther removed the
individual is from service. It should be mentioned that in-service
symptoms can be established through evidence not contained in service
medical records. At times competent lay evidence is enough to establish
that the veteran suffered certain symptoms while in service. 38 C.F.R.
3.159(a)(2). See also, Garlejo v. Derwinski, 2 Vet. App. 619; 1992
and Dizoglio v. Brown, 9 Vet. App. 163; 1996.
Question 3: What do you think we should do about the level of
evidence required to grant claims? Would you change that, and if so,
how?
Response: NVLSP strongly suggests that the ``benefit of the doubt''
(38 U.S.C.
5107, 38 C.F.R. 3.102) standard remain intact.
Question 4: The causation standard was suggested by the IOM after a
lengthy analysis. They found that the way VA sets presumptions has been
``complex, perplex, varied, inconsistent, diverse, and opaque.'' This
does not sound like the ``benefit of the doubt'' going to the veteran.
It sounds more like it is based on the ``luck of the draw'' and
veterans' don't know what to expect. Wouldn't a scientific standard be
better at establishing benefit of the doubt?
The answer is no. NVLSP strongly disagrees with the IOM suggestion
that Congress or the VA utilize a causation standard to set service
connection presumptions. As we discuss below, adoption of a causation
standard for service connection presumptions would require the VA to
deny benefits to literally tens of thousands of deserving disabled
veterans who presently qualify for compensation under the statutory and
regulatory presumptions established over the last four decades. In that
40 year span Congress and the VA have used a consistent, scientific
standard to set presumptions of service connection and this standard
wisely benefits veterans.
It should be clear at the outset that a causation standard is a
very high standard that requires a great deal of definitive scientific
evidence. A causation standard may be appropriate in the adversarial
process when a trier of fact must weigh expert scientific opinions
against one another in deciding a private civil lawsuit. But as a
policy matter such a standard is completely inappropriate to decide
whether veterans, who served our country in time of war, should receive
disability compensation from the government. Too often these are
situations where the scientific evidence is not developed enough to
definitively answer whether an event experienced by thousands of
veterans during military service caused a later developing disease from
which thousands of these veterans suffer.
Over the last four decades the VA and Congressional response to the
scientific shortcomings described above have been consistent and
appropriate. The VA or Congress has established presumptions of service
connection where the scientific epidemiologic evidence shows that there
is a statistically significant association between a common event
experienced by veterans in time of war and the subsequent development
of a particular disease. They have refused to adopt a stricter
standard. Several examples follow:
In the late 1970s, Congress mandated that the VA conduct a
scientific epidemiologic study to gauge the relationship between
veterans with leg or feet amputations and any subsequent increase in
the rate of cardiovascular disease. The study concluded that this
disabled group of veterans experienced a statistically significant
increased risk of cardiovascular disease, but that a strict cause-and-
effect relationship had not been established. Nevertheless based on the
National Academy of Sciences report, the VA promulgated what is now 38
C.F.R. 3.310(c) entitling veterans with ``a service-connected
amputation of one lower extremity at or above the knee or service-
connected amputations of both lower extremities at or above the
ankles'' to service connected disability compensation for any
subsequently developed cardiovascular disease. See Nehmer v. VA, 712 F.
Supp. 1404, 1419 (N.D. Cal. 1989).
Another example involves exposure to Agent Orange. In 1984,
Congress enacted Pub. L. No. 98-542, which required the VA to empanel
an advisory group of scientists to advise it on the adverse health
effects of Agent Orange exposure and to promulgate regulations
establishing presumptions of service connection for those diseases that
are scientifically related to such exposure. The VA instructed the
scientists to use a strict cause and effect relationship between
exposure and disease. Not surprisingly, the scientists found that Agent
Orange caused only chloracne, a skin condition.
A class of Vietnam veterans challenged these rules, and in 1989, a
Federal court invalidated the rules precisely because the VA had
required a strict cause and effect relationship. The Court found that
Congress and the VA had historically used a lower epidemiologic
scientific standard focused on whether there was a statistically
significant association between the event or exposure and the
subsequent development of a particular disease. The Court found that
Congress had intended the VA to use this more lenient standard when
deciding what diseases should be presumptively service connected to
Agent Orange exposure. See Nehmer, 712 F.Supp. at 1419-23 (N.D. Cal.
1989). When the VA procrastinated in adopting regulations to replace
those invalidated by the Court in Nehmer, Congress enacted the Agent
Orange Act 1991 requiring the VA to use a ``positive association''
standard similar to the one discussed in Nehmer. This was an explicit
rejection of the causation standard and it remains the standard the VA
uses today. Since the Agent Orange Act 1991, the VA has promulgated
regulations providing presumptive service connection for many types of
cancer due to Agent Orange exposure without requiring proof of
causation. It would be tragically wrong to diverge from this
longstanding tradition.
Question 5: Would you change the Rating Schedule to include a loss
of quality of life scale or do you feel that it is already included in
the compensation package or by awarding Special Monthly Compensation?
Would you say that there already examples of quality of life loss, such
as with procreative organs that are already included in the Rating
Schedule?
Response: The current rating schedule is based primarily upon the
average impairment in earning capacity. The extra benefits paid under
the special monthly compensation codes (see 38 U.S.C. 1114, and 38
C.F.R. 3.350) do take into account some quality of life issues, but
they are insufficient to compensate veterans for the diminished quality
of life caused by many disabilities. NVLSP suggests that the VA study
the rating schedule and adjust upward the evaluations for certain
conditions such as amputations, the residuals of severe gunshot wounds,
mental disabilities, and cognitive disorders, in order to take into
account quality of life issues.
For example, if a veteran becomes impotent due to the impact of a
service connected disability such as diabetes or hypertension and loses
the ability to procreate--under current law he would generally receive
a noncompensable evaluation (0&) plus $91 per month under special
monthly compensation code ``K''. Loss of use of a creative organ
secondary to impotence may be established in evaluating residuals of
multiple sclerosis, diabetes mellitus, or other diseases where loss of
erectile power is shown. A zero percent rating under DC 7522 will
establish entitlement.
Thus, while the VA may award a compensable evaluation for penis
deformity and testis atrophy under diagnostic codes 7522 and 7523,
there is no provision in Part 4 that mandates a compensable evaluation
for loss of erectile function sans deformity. In essence we are telling
a veteran that his inability to have children or have a full
relationship with his spouse is worth only $91 per month. That,
frankly, is insulting.
Committee on Veterans' Affairs
Subcommittee on Disability Assistance and Memorial Affairs
Washington, DC.
February 29, 2008
Mr. Dean Stoline
Assistant Director
National Legislative Commission
The American Legion
1608 K Street, NW
Washington, DC 20006
Dear Mr. Stoline:
In reference to our Subcommittee hearing on The VA Schedule for
Rating Disabilities on February 26, 2008, I would appreciate it if you
could answer the enclosed hearing questions by the close of business on
April 2, 2008.
In an effort to reduce printing costs, the Committee on Veterans'
Affairs, in cooperation with the Joint Committee on Printing, is
implementing some formatting changes for materials for all Full
Committee and Subcommittee hearings. Therefore, it would be appreciated
if you could provide your answers consecutively on letter size paper,
single-spaced. In addition, please restate the question in its entirety
before the answer.
Due to the delay in receiving mail, please provide your response to
Ms. Orfa Torres by fax at (202) 225-2034. If you have any questions,
please call (202) 225-3608.
Sincerely,
JOHN J. HALL
Chairman
__________
American Legion
Washington, DC.
March 20, 2008
Hon. John J. Hall, Chairman
Subcommittee on Disability Assistance and Memorial Affairs
Committee on Veterans' Affairs
U. S. House of Representatives
335 Cannon House Office Building
Washington, DC 20515
Dear Chairman Hall:
In reference to your letter of request dated February 29, 2008, to
answer a hearing question regarding our concern for reevaluations of
service-connected veterans that arose from our testimony in your
Subcommittee hearing on The VA Schedule for Rating Disabilities on
February 26, 2008, please find the attached answer in the format you
requested.
If you have any further questions please contact me. My contact
information is above. Thank you again for holding this important
hearing for America's veterans.
Sincerely,
Dean Stoline, Assistant Director
National Legislative Commission
Attachment
__________
Questions of the Honorable John J. Hall, Chairman
Question 1: In your statement you expressed concern over re-
evaluation of service-connected veterans. I understand that it could be
stressful, but isn't falling through the cracks more stressful and
wouldn't it be better to make sure veterans are getting all that they
deserve?
Response: The concern noted in our written statement pertains
specifically to the recommendation of the Veterans' Disability Benefits
Commission (VDBC) regarding the Department of Veterans Affairs
establishing a holistic approach, with respect to post-traumatic stress
disorder (PTSD), that, in part, calls for ``reevaluation'' every 2-3
years. (Recommendation 5-30; Chapter 5, Section III.3).
We are fully supportive of periodic reviews of the treatment
process to gauge its effectiveness and to determine whether or not the
veteran's PTSD medical condition has improved. It is, however, our
opinion that this process should be separate and distinct from any re-
evaluation done for the purpose of determining the severity of the
condition for compensation rating purposes. Veterans should not
perceive these periodic reevaluations of their condition and treatment
process as an attempt to reduce their compensation benefits. Such a
perception could cause undue stress and undermine the treatment process
of the veteran.
Even the Institute of Medicine (IOM) PTSD compensation Committee
concluded that across-the-board periodic reexaminations for veterans
with service-connected PTSD are not appropriate. We also agree with the
IOM's observation that symptomatology can improve (justifying
reexaminations in such circumstances) and that a reexamination policy
should be structured in a way that ``limits disincentives for receiving
treatment or rehabilitative services.'' We, therefore, encourage study
and review of possible unintended consequences regarding the PTSD re-
evaluation portion of the VDBC's recommendation.
Committee on Veterans' Affairs
Subcommittee on Disability Assistance and Memorial Affairs
Washington, DC.
February 29, 2008
Mr. Bradley Mayes
Director, Compensation and Pension Service
Veterans Benefits Administration
U.S. Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, DC 20420
Dear Mr. Mayes:
In reference to our Subcommittee hearing on The VA Schedule for
Rating Disabilities on February 26, 2008, I would appreciate it if you
could answer the enclosed hearing questions by the close of business on
April 2, 2008.
In an effort to reduce printing costs, the Committee on Veterans'
Affairs, in cooperation with the Joint Committee on Printing, is
implementing some formatting changes for materials for all Full
Committee and Subcommittee hearings. Therefore, it would be appreciated
if you could provide your answers consecutively on letter size paper,
single-spaced. In addition, please restate the question in its entirety
before the answer.
Due to the delay in receiving mail, please provide your response to
Ms. Orfa Torres by fax at (202) 225-2034. If you have any questions,
please call (202) 225-3608.
Sincerely,
JOHN J. HALL
Chairman
__________
The Honorable John J. Hall, Chairman
Question 1: Doctors and other health providers are already trained
in the tools, such as the AMA guides that Drs. Hyman and Weissman
described in their testimony, so wouldn't it make more sense to use
these tools rather than train people in an entirely new system?
Response: No, we do not believe so. The Department of Veterans
Affairs (VA) is authorized, by statute, to compensate veterans for the
average reductions in earnings capacity in civilian occupations due to
injury or disease incurred in or aggravated by active military service.
The Veterans' Disability Benefits Commission asked the Institute of
Medicine (IOM) to look at disability compensation for veterans. In its
report, A 21st Century System for Evaluating Veterans for Disability
Benefits, the IOM looked at the American Medical Association (AMA)
Guides, among other disability evaluation systems, and found that the
Guides do not measure work-related disability, only degree of physical
impairment, are designed for use by physicians, and do not determine
percentage of impairment from mental disorders. The IOM instead
recommended that VA update and improve its Schedule for Rating
Disabilities, codified at 38 CFR Part IV, rather than adopt an
impairment schedule developed for other purposes.
On Wednesday March 5, 2008, VA received a briefing on the AMA
guides from Dr. Robert Rondinelli, Medical Editor of the 6th edition of
the Guides. One of the issues that Dr. Rondinelli highlighted was the
following AMA disclaimer: ``The AMA Guides are not intended to be used
for direct estimates of work disability; impairment percentages derived
according to the Guides' criteria do not directly measure work
disability, therefore, it is inappropriate to use the Guides' criteria
or ratings to make direct estimates of work disability.''
Based on Dr. Rondinelli's presentation, the application of the
Guides appears significantly more complex than VA's existing system.
The number of clinicians trained and competent in the application of
the Guides is limited. We believe that adoption of the guides may
significantly lengthen the time to obtain an examination. It is
possible, using the Guides, to evaluate a condition in intervals of one
percent. While this may be appropriate in workers compensation claims,
we do not believe such fine distinctions reasonably reflect loss of
earning capacity.
The CNA Corp., in a study for the Veterans' Disability Benefits
Commission, found that the VA rating schedule with respect to lost
earnings capacity of male service-disabled veterans at the average age
of entry into the VA compensation system (50 to 55 years of age)
appears to achieve congressional intent. CNA's analysis also found that
the schedule is less effective in other respects, such as when dealing
with earnings loss for veterans with mental disorders, under
compensating at every level. Edition 6 of the AMA Guides does not allow
for a disability evaluation for any mental disorder higher than 50
percent. It would appear that adoption of the Guides would aggravate
CNA's findings regarding earnings-loss replacement for veterans with
mental illnesses.
Question 2: During the hearing, you were not able to tell us if VHA
already evaluates veterans for their quality of life. Isn't that what
the SF-36 scale is designed to indicate?
Response: The Veterans Health Administration (VHA) doesn't use the
standard form (SF)-36 on every veteran. VHA uses functional status tool
like the SF-12v or the SF-36 as needed for the assessment of the
patient. The SF-12v is a multipurpose short survey form. Survey
questions are used to evaluate physical and mental functioning and
overall health-related quality of life. Survey questions in the SF-12v
form are selected from the SF-36. The SF-36 was developed outside of VA
and is available to anyone for their population studies.
Question 3: Please explain why, according to the VDBC report, so
many veterans with PTSD were rated with IU instead of 100 percent
schedule rating.
Response: The rating schedule requires that a veteran must be
experiencing ``total occupational and social impairment'' in order to
receive a 100 percent schedular evaluation, such as evidence of gross
impairment in thought processes or communication; persistent delusions
or hallucinations; grossly inappropriate behavior; persistent danger of
hurting self or others; intermittent ability to perform activities of
daily living (including maintenance of minimal personal hygiene);
disorientation to time or place; memory loss for names of close
relatives, own occupation, or own name. In post traumatic stress
disorder (PTSD) cases, a situation may arise where the evidence shows
occupation and social impairment with deficiencies in most areas, such
as work, school, family relations, judgment, thinking or mood. In these
cases, a 70 percent schedular evaluation is awarded and VA regulations
provide that, once the veteran has reached a 70 percent schedular
evaluation and the available evidence shows unemployability, the
veteran is eligible for compensation at the 100-percent rate based on
the inability to obtain or maintain substantially gainful employment.
Question 4: What is VA's response to the recent IOM report on
Presumptive Disability Decisionmaking?
Response: We appreciate the efforts of the IOM Committee that
looked at the presumptive disability decisionmaking process. The IOM
Committee recommended that Congress create two new boards: the Advisory
Committee to recommend to the Secretary of Veterans Affairs exposures
and illnesses needing further consideration and the Science Review
Board, which would be independent from VA and evaluate evidence for
causation. Its recommendation represents a departure from the process
VA has used in the past to decide whether a presumption should be
created. It is also a departure from the Agent Orange Act 1991, for
example, which directs the Secretary to seek to enter into an agreement
with the National Academy of Sciences to review and summarize the
scientific evidence concerning the association between exposure to
herbicides used in support of military operations in the Republic of
Vietnam during the Vietnam era and each disease suspected to be
associated with such exposure and to determine, to the extent possible:
(1) Whether there is a statistical association between the suspect
diseases and herbicide exposure, taking into account the strength of
the scientific evidence and the appropriateness of the methods used to
detect the association; (2) the increased risk of disease among
individuals exposed to herbicides during service in the Republic of
Vietnam during the Vietnam era; and (3) whether there is a plausible
biological mechanism or other evidence of a causal relationship between
herbicide exposure and the suspect disease. Our careful review of the
report has not yet been completed. For this reason, VA has no formal
response at this time.
Committee on Veterans' Affairs
Subcommittee on Disability Assistance and Memorial Affairs
Washington, DC.
February 29, 2008
Major General Joseph Kelley, M.D., USAF (Ret.)
Deputy Assistant Secretary of Defense
For Clinical and Program Policy
U.S. Department of Defense
1000 Defense Pentagon
Washington, DC 20301-1000
Dear Dr. Kelley:
In reference to our Subcommittee hearing on The VA Schedule for
Rating Disabilities on February 26, 2008, I would appreciate it if you
could answer the enclosed hearing questions by the close of business on
April 2, 2008.
In an effort to reduce printing costs, the Committee on Veterans'
Affairs, in cooperation with the Joint Committee on Printing, is
implementing some formatting changes for materials for all Full
Committee and Subcommittee hearings. Therefore, it would be appreciated
if you could provide your answers consecutively on letter size paper,
single-spaced. In addition, please restate the question in its entirety
before the answer.
Due to the delay in receiving mail, please provide your response to
Ms. Orfa Torres by fax at (202) 225-2034. If you have any questions,
please call (202) 225-3608.
Sincerely,
JOHN J. HALL
Chairman
__________
Hearing Date: February 26, 2008
Committee: HVAC
Member: Congressman Hall
Witness: DASD (Clinical and Program Policy) Kelley
DoD Disability Advisory Committee
Question 1: You mentioned the DoD Disability Advisory Committee
during your testimony. When did that group start interacting with VBA
and do they ever discuss the Rating Schedule?
a. What would make the Rating Schedule a better tool from DoD's
standpoint?
Response: Beginning in September 2007, Department of Veterans
Affairs (VA) representatives were invited to the Disability Advisory
Committee (DAC). In December 2007, VA Membership was officially written
in the DAC charter. The rating schedule has been a topic of discussion
and a formal briefing from the VBA on how changes are made to the VA
Schedule for Rating Disabilities was given to the Members. A new
process was developed for Members to bring up issues formally at the
DAC. Continued close collaboration and establishment of joint working
groups, such as with the Department of Defense/VA collaboration on
traumatic brain injury, which lead to proposed updates to the Rating
Schedule, prove to be the most beneficial use of both the tool and the
expertise found in both Departments.
Question 2: During the hearing we discussed the Disability
Evaluation System pilot that is ongoing between DoD and VA. Can you
provide an update on the steps currently being taken to prepare for
this transition to a single system for evaluating disabilities?
Response: The Disability Evaluation System (DES) Pilot was
initiated to evaluate and significantly improve DES timeliness,
effectiveness, simplicity, and resource utilization by integrating the
Department of Defense (DoD) and the Department of Veterans Affairs (VA)
processes by eliminating duplication, and improving case management
practices. The DES Pilot includes a single, VA protocol-based medical
exam, to include a general review of systems and other specialty
medical examinations, for referred and claimed conditions. The Service
medical authorities use the VA medical examination to aid in evaluation
of members whose medical fitness for continued military service is
questionable. The VA will use the medical examination to determine
physical disability ratings. The exam will also serve as the separation
physical should separation from the military service occur.
Military Department Physical Disability Evaluation Boards (PEBs)
will determine servicemember fitness for continued military service.
servicemembers who participate in the DES Pilot receive a single-
sourced disability rating for use by the DoD and VA. The DES Pilot is
testing enhanced case management methods for seamless transition of our
wounded, ill, or injured to the care of the VA and prompt award of
disability benefits by the VA after the member's separation from
military service. The DES Pilot includes cases referred to the DES
without regard to whether servicemember wounds, illnesses, or injuries
were incurred in war. The DES Pilot does not include Reserve Component
Non-duty related and Temporary Disability Retired List reevaluations.
Close collaboration between DoD and VA is occurring with weekly
updates and special meetings for any issues. VA is providing Veterans
Administration Schedule for Rating Disabilities training in April 2008
for DoD DES representatives, to ensure a thorough understanding of the
VA rating process. Systems monitoring these members are being evaluated
for upgrades and integration.