[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.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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):*
---------------------------------------------------------------------------
    \*\ 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.

                                 
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