[Senate Hearing 110-212]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 110-212
 
                  HEARING TO RECEIVE TESTIMONY ON THE 
                  DEPARTMENTS OF DEFENSE AND VETERANS 
AFFAIRS DISABILITY RATING SYSTEMS AND THE TRANSITION OF SERVICEMEMBERS 
                                 FROM 
                   THE DEPARTMENT OF DEFENSE TO THE 
                     DEPARTMENT OF VETERANS AFFAIRS

=======================================================================

                             JOINT HEARING

                               BEFORE THE

                    COMMITTEE ON ARMED SERVICES AND
                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                       ONE HUNDRED TENTH CONGRESS

                             FIRST SESSION

                               __________

                             APRIL 12, 2007

                               __________

       Printed for the use of the Committee on Veterans' Affairs


 Available via the World Wide Web: http://www.access.gpo.gov/congress/
                                 senate

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                     COMMITTEE ON VETERANS' AFFAIRS

                   Daniel K. Akaka, Hawaii, Chairman
John D. Rockefeller IV, West         Larry E. Craig, Idaho, Ranking 
    Virginia                             Member
Patty Murray, Washington             Arlen Specter, Pennsylvania
Barack Obama, Illinois               Richard M. Burr, North Carolina
Bernard Sanders, (I) Vermont         Johnny Isakson, Georgia
Sherrod Brown, Ohio                  Lindsey O. Graham, South Carolina
Jim Webb, Virginia                   Kay Bailey Hutchison, Texas
Jon Tester, Montana                  John Ensign, Nevada
                    William E. Brew, Staff Director
                 Lupe Wissel, Republican Staff Director
                              ----------                              

                      COMMITTEE ON ARMED SERVICES

                     Carl Levin, Michigan, Chairman
Edward M. Kennedy, Massachusetts     John McCain, Arizona, Ranking 
Robert C. Byrd, West Virginia            Member
Joseph I. Lieberman, Connecticut     John W. Warner, Virginia
Jack Reed, Rhode Island              James M. Inhofe, Oklahoma
Daniel K. Akaka, Hawaii              Jeff Sessions, Alabama
Bill Nelson, Florida                 Susan M. Collins, Maine
E. Benjamin Nelson, Nebraska         John Ensign, Nevada
Evan Bayh, Indiana                   Saxby Chambliss, Georgia
Hillary Rodham Clinton, New York     Lindsey O. Graham, South Carolina
Mark L. Pryor, Arkansas              Elizabeth Dole, North Carolina
Jim Webb, Virginia                   John Cornyn, Texas
Claire McCaskill, Missouri           John Thune, South Dakota
                                     Mel Martinez, Florida
                   Richard D. DeBobes, Staff Director
              Michael V. Kostiw, Republican Staff Director


                            C O N T E N T S

                              ----------                              

                             April 12, 2007
                                SENATORS

                                                                   Page
Levin, Hon. Carl, Chairman, Committee on Armed Services, U.S. 
  Senator from Michigan..........................................     1
    Prepared statement...........................................     4
McCain, Hon. John, Ranking Member, Committee on Armed Services, 
  U.S. Senator from Arizona......................................     6
Akaka, Hon. Daniel K., Chairman, Committee on Veterans' Affairs, 
  U.S. Senator from Hawaii.......................................     7
Craig, Hon. Larry E,, Ranking Member, Committee Veterans' 
  Affairs, 
  U.S. Senator from Idaho........................................     8
    Prepared statement...........................................     9
Warner, Hon. John, U.S. Senator from Virginia....................   129
Inhofe, Hon. James M., U.S. Senator from Oklahoma................   132
Lieberman, Hon. Joseph I., U.S. Senator from Connecticut.........   134
Collins, Hon. Susan M., U.S. Senator from Maine..................   136
Webb, Hon. Jim, U.S. Senator from Virginia.......................   138
Clinton, Hon. Hillary Rodham, U.S. Senator from New York.........   140
Specter, Hon. Arlen, U.S. Senator from Pennsylvania..............   142
McCaskill, Hon. Claire, U.S. Senator from Missouri...............   144
Cornyn, Hon. John, U.S. Senator from Texas.......................   146
Isakson, Hon. Johnny, U.S. Senator from Georgia..................   148
Murray, Hon. Patty, U.S. Senator from Washington.................   151
Martinez, Hon. Mel, U.S. Senator from Florida....................   154
Bayh, Hon. Evan, U.S. Senator from Indiana.......................   156
Sessions, Hon. Jeff, U.S. Senator from Alabama...................   159
Rockefeller, Hon. John D., IV, U.S. Senator from West Virginia...   161
Thune, Hon. John, U.S. Senator from South Dakota.................   167

                               WITNESSES

England, Hon. Gordon R., Deputy Secretary, Department of Defense; 
  accompanied by Hon. David S.C. Chu, Under Secretary for 
  Personnel and Readiness, Department of Defense.................    10
    Prepared statement...........................................    12
    Hon. Gordon R. England's response to written questions 
      submitted by:
      Hon. Carl Levin............................................    15
      Hon. Larry E. Craig........................................    17
      Hon. John McCain...........................................    18
      Hon. John D. Rockefeller IV................................    22
      Hon. Evan Bayh.............................................    30
      Hon. Barack Obama..........................................    32
      Hon. John W. Warner........................................    33
      Hon. Saxby Chambliss.......................................    33
      Hon. Mark L. Pryor.........................................    36
    Hon. David S.C. Chu's response to written questions submitted 
      by:
      Hon. John McCain...........................................    36
      Hon. Patty Murray..........................................    40
      Hon. Evan Bayh.............................................    40
      Hon. Hillary Rodham Clinton................................    41
      Hon. Johnny Isakson........................................    46
      Hon. Saxby Chambliss.......................................    46
Cooper, Hon. Daniel L., Under Secretary for Benefits, Department 
  of Veterans Affairs; accompanied by Gerald Cross, M.D., Acting 
  Principal Deputy Under Secretary for Health, Department of 
  Veterans Affairs...............................................    50
    Prepared statement...........................................    52
    Hon. Daniel L. Cooper's response to written questions 
      submitted by:
      Hon. Daniel K. Akaka.......................................    56
      Hon. Larry E. Craig........................................    56
      Hon. John McCain...........................................    57
      Hon. John D. Rockefeller IV................................    62
      Hon. Hillary Rodham Clinton................................    69
      Hon. Barack Obama..........................................    71
      Hon. Mark L. Pryor.........................................    73
      Hon. Johnny Isakson........................................    74
      Hon. Saxby Chambliss.......................................    74
    Dr. Gerald Cross' response to written questions submitted by:
      Hon. Daniel K. Akaka.......................................    75
      Hon. John McCain...........................................    76
      Hon. Saxby Chambliss.......................................    82
Geren, Hon. Preston M. ``Pete'', III, Acting Secretary of the 
  Army, Department of Defense....................................    83
    Prepared statement...........................................    86
    Response to written question submitted by:
      Hon. Daniel K. Akaka.......................................    89
      Hon. Larry E. Craig........................................    90
      Hon. John McCain...........................................    91
      Hon. Barack Obama..........................................    93
      Hon. Johnny Isakson........................................    94
      Hon. Saxby Chambliss.......................................    94
Scott, Lieutenant General James Terry (Ret.), Chairman, Veterans' 
  Disability Benefits Commission.................................    96
    Prepared statement...........................................    99
    Response to written questions submitted by:
      Hon. Daniel K. Akaka.......................................   122
      Hon. Larry E. Craig........................................   123
      Hon. John McCain...........................................   123
      Hon. Mark L. Pryor.........................................   124
      Hon. Saxby Chambliss.......................................   125

                                APPENDIX

Lawrence, Brian, Assistant National Legislative Director, 
  Disabled American Veterans; prepared statement.................   171
S. 1065, legislation introduced by Senator Hillary Rodham Clinton 
  and 
  Senator Susan M. Collins.......................................   173
S. 1113, legislation introduced by Senator Evan Bayh and Senator 
  Hillary Rodham Clinton.........................................   187
Insult to Injury New Data Reveal an Alarming Trend: Vets' 
  Disabilities Are Being Downgraded, U.S. News Report article....   193


                    HEARING TO RECEIVE TESTIMONY ON 
                    THE DEPARTMENTS OF DEFENSE AND 
                  VETERANS AFFAIRS DISABILITY RATING 
  SYSTEMS AND THE TRANSITION OF SERVICEMEMBERS FROM THE DEPARTMENT OF 
             DEFENSE TO THE DEPARTMENT OF VETERANS AFFAIRS

                              ----------                              


                        THURSDAY, APRIL 12, 2007

                               U.S. Senate,
                    Committee on Armed Services and
                            Committee on Veterans' Affairs,
                                                    Washington, DC.
    The Committees met, pursuant to notice, at 9:30 a.m., in 
Room 216, Hart Senate Office Building, Hon. Carl Levin, 
Chairman of the Committee on Armed Services, presiding.
    Present: Senators Levin, Akaka, Lieberman, Reed, Nelson of 
Florida, Nelson of Nebraska, Bayh, Clinton, Webb, McCaskill, 
Rockefeller, Murray, Obama, Brown, Tester, Sanders, McCain, 
Craig, Warner, Inhofe, Sessions, Collins, Ensign, Chambliss, 
Dole, Cornyn, Thune, Martinez, Specter, and Burr.

        OPENING STATEMENT OF HON. CARL LEVIN, CHAIRMAN, 
    COMMITTEE ON ARMED SERVICES, U.S. SENATOR FROM MICHIGAN

    Chairman Levin. Good morning, everybody. The Armed Services 
and Veterans' Affairs Committees meet together this morning to 
consider the complex and inconsistent disability rating systems 
of the Department of Defense (DOD) and the Department of 
Veterans Affairs (VA) and the problems relative to transition 
of servicemembers from the military to the VA.
    Our Nation has a moral obligation to provide quality health 
care to the men and women who put on our Nation's uniform and 
are injured and wounded fighting for our Nation in our wars. 
This obligation extends from the point of injury through 
evacuation from the battlefield, to medical facilities operated 
by the military services and the VA. Our responsibility ends 
only when the wounds are healed. Where the wounds will never 
heal, our obligation extends throughout the lifetime of the 
veteran. I am sad to say that we as a Nation are not meeting 
this obligation.
    We have called this unusual joint hearing of the Veterans' 
Affairs and Armed Services Committees because there are gaps 
and inconsistencies between the VA and DOD systems that need to 
be addressed jointly and because our Committees have a shared 
responsibility to authorize funding for the DOD and the VA and 
to oversee their efforts to provide proper care and treatment 
of servicemembers wounded in military service.
    At present, when a servicemember is transitioned from the 
military to the VA, they face hurdles and roadblocks that no 
veteran should have to face. Disability ratings by the military 
services are inconsistent with disability ratings by the VA. 
Ratings for similar disabilities vary widely between the 
military services. And for some disabilities, the ratings do 
not accurately reflect the impact of the disability on the 
member's ability to function in an information-age society.
    These programs are not only complex and difficult to 
navigate. Servicemembers often feel like they have to fight for 
a rating that accurately reflects their disability. In other 
words, the service they belong to, and put on the uniform of, 
acts as their adversary in their eyes. We simply have to do 
better than that. The cracks between the military and VA 
delivery systems must be filled. The transition must be 
smoothed out. The differences must be removed. The adversarial 
aspects must also be removed.
    The military's disability rating is extremely important to 
the lives of our wounded warriors and their families. Those 
with disabilities rated at 30 percent or higher are medically 
retired, entitling them and their families to health care for 
life through the military's TRICARE health care program, a 
military pension, and access to commissary and post exchange 
benefits. Those whose disabilities are rated less than 30 
percent are given a medical separation with severance pay. 
Although these servicemembers whose disabilities are rated at 
less than 30 percent are eligible to receive health care 
through the VA, their families are not. The VA disability 
rating is equally as important because the amount of VA 
disability compensation is based on the VA disability rating.
    It takes too long to get a disability rating from the VA. 
Veterans report that they have to wait months and months to get 
a VA disability rating before they can start receiving 
compensation for their disabilities. Currently, the VA has a 
backlog of approximately 400,000 cases and it takes an average, 
they say, of 177 days to rate a claim. When I visited the VA 
hospital in Ann Arbor, Michigan, veterans told me that there 
are several thousand claims that have been pending for an 
average of a year. A few years ago, it was bad enough when the 
wait was 6 months.
    Another problem reported by our servicemembers is the lack 
of a smooth or seamless transition from the military to the VA. 
Many say that their military medical records are often not 
available to VA doctors. One veteran said that there is too 
much red tape, so much red tape that it can take up to 22 
documents with 8 different commands to exit the military 
medical system and enter the VA program. This exists even 
though there are numerous programs that are supposed to help 
the veterans as they leave active duty, such as the Transition 
Assistance Program and the Benefits Delivery at Discharge 
program. Despite those programs, the gaps and the chasms 
remain.
    This is not a new issue. In 2003, the President's Task 
Force to Improve Health Care Delivery for our Nation's Veterans 
made a series of recommendations to ease the transition from 
servicemember to veteran status, most of which recommendations 
have not been implemented. For example, that Task Force 4 years 
ago recommended that the VA and the DOD implement by Fiscal 
Year 2005 a mandatory single separation physical as a 
prerequisite of promptly completing the military's separation 
process, expand the one-stop shopping process to include at a 
minimum a standard discharge exam, full outreach, claimant 
counseling, and when appropriate, referral for a VA 
compensation and pension examination and follow-up claims 
adjudication and rating. By Fiscal Year 2004, they recommended 
that we initiate a process of routine sharing of each 
servicemember's assignment history, exposures to occupational 
hazards, location and injuries information.
    The disability rating issues and transition challenges are 
currently under review by at least five different entities. I 
am not going to enumerate them all, but they are all listed in 
my statement. A preliminary report of the Secretary of 
Defense's Independent Review Group, which proposed an 
acceleration of the closure of Walter Reed, describes in 
today's paper the current system for assessing soldiers' 
disabilities as ``extremely cumbersome, inconsistent and 
confusing,'' and it calls for a complete overhaul of the 
process.
    The findings and the recommendations of all of the groups 
may be useful as we seek solutions to the problems confronting 
our wounded servicemembers, but previous reports have been 
ignored and we can't wait until all of these studies and 
reviews are completed before we act.
    The House of Representatives has already acted and passed 
the Wounded Warrior Assistance Act of 2007, which would impose 
a number of new requirements on DOD to improve medical care and 
other services for servicemembers and would require the DOD and 
VA to establish a single medical information system.
    Several bills have been introduced in the Senate, including 
the Restoring Disability Benefits for Injured and Wounded 
Warrior Act of 2007, introduced by Senator Clinton; a Dignity 
for Wounded Warriors Act of 2007, which was introduced by 
Senators Obama, McCaskill, and others; the Effective Care for 
the Armed Forces and Veterans Act of 2007, by Senator Biden; 
and those are just some of the bills that have been introduced 
and those bills have been referred to the Senate Armed Services 
Committee, where we will address those bills soon.
    The American people are deeply angry about the shortfalls 
in care for our wounded veterans. The war in Iraq has divided 
our Nation, but the cause of supporting our troops and our 
veterans unites us, unites us all as Americans and as Members 
of this Congress. We will do everything that we can do, not as 
Democrats or Republicans, but as grateful Americans, to care 
for those who have served our Nation with such honor and 
distinction. That is an obligation which all Americans accept 
and insist be met to the fullest.
    [The prepared statement of Chairman Levin follows:]

           Prepared Statement of Hon. Carl Levin, Chairman, 
        Committee on Armed Services, U.S. Senator from Michigan

    The Armed Services and Veterans' Affairs Committees meet together 
this morning to consider the complex and inconsistent disability rating 
systems of the Department of Defense and the Department of Veterans 
Affairs and the problems relative to transition of servicemembers from 
the military to the VA.
    Our Nation has a moral obligation to provide quality health care to 
the men and women who put on our Nation's uniform and are injured and 
wounded fighting our Nation's wars. This obligation extends from the 
point of injury, through evacuation from the battlefield, to medical 
facilities operated by the military services and the VA. Our 
responsibility ends only when the wounds are healed. Where the wounds 
will never heal, our obligation extends throughout the lifetime of the 
veteran. I am sad to say that we as a Nation are not meeting this 
obligation.
    I welcome our witnesses here today: Deputy Secretary of Defense 
Gordon England; Under Secretary of Defense for Personnel and Readiness, 
Dr. David Chu; VA Under Secretary for Benefits, Daniel Cooper; Acting 
Secretary of the Army, Pete Geren; Acting Principal Deputy Under 
Secretary for Health for VA, Dr. Gerald Cross; and Chairman of the 
Veterans' Disability Benefits Commission Lieutenant General James 
Scott.
    We have called this unusual joint hearing of the Veterans Affairs 
and Armed Services Committees because there are gaps and 
inconsistencies between the VA and DOD systems that need to be 
addressed jointly, and because our Committees have a shared 
responsibility to authorize funding for the Department of Defense and 
the Department of Veterans Affairs and to oversee their efforts to 
provide proper care and treatment of servicemembers wounded in military 
service.
    At present, as servicemembers transition from the military to the 
VA, they face hurdles and roadblocks that no veteran should face.
    Disability ratings by the military services are inconsistent with 
disability ratings by the VA; ratings for similar disabilities vary 
widely between the military services; and for some disabilities, the 
ratings do not accurately reflect the impact of the disability on the 
member's ability to function in an information age society. These 
programs are not only complex and difficult to navigate, servicemembers 
often feel like they have to fight for a rating that accurately 
reflects their disability, i.e, the service they belong to, and put on 
the uniform of, acts as their adversary. We simply have to do better 
than that. The cracks between the military and VA delivery systems must 
be filled. The transition must be smoothed out. The differences must be 
removed. The adversarial aspects must also be removed.
    The military's disability rating is extremely important to the 
lives of our wounded warriors and their families. Those with 
disabilities rated at 30 percent or higher are medically retired, 
entitling them and their families to healthcare for life through the 
military's TRICARE health care program, a military pension, and access 
to commissary and post exchange benefits. Those whose disabilities are 
rated less than 30 percent are given a medical separation with 
severance pay. Although these servicemembers whose disabilities are 
rated at less than 30 percent are eligible to receive health care 
through the VA, their families are not. The VA disability rating is 
equally as important because the amount of VA disability compensation 
is based on the VA disability rating.
    I recently talked to a soldier at Walter Reed who had been injured 
by an IED blast while on his second tour of duty in Iraq. He 
understands that he is no longer physically fit for military duty 
because of the seriousness of his injuries. He receives care for his 
injuries in an outpatient status. He also is suffering from memory loss 
and believes that the Army's rating system will not take that problem 
into account. He told me that he is ``scared to death'' that the 
physical disability evaluation system will rate his disability at less 
than 30 percent and will ``put me out on the street'' without the 
ability to take care of his family, including his children. How can we, 
as a Nation, ask our young men and women to serve, and when they are 
wounded while serving, put them in a position where they are ``scared 
to death'' that we will not take proper care of them and their 
families? Surely we must change such a system.
    It also takes too long to get a disability rating from the VA. 
Veterans report that they have to wait months and months to get a VA 
disability rating before they can start receiving compensation for 
their disabilities. Currently, the VA has a backlog of approximately 
400,000 cases and it takes an average of 177 days to rate a claim. When 
I visited the VA hospital in Ann Arbor, Michigan, veterans told me that 
there are several thousand claims that have been pending for an average 
of a year--a few years ago it was bad enough--when the wait was 6 
months.
    Another problem reported by our servicemembers is the lack of a 
smooth or seamless transition from the military to the VA. Many say 
that their military medical records are often not available to VA 
doctors. One veteran said that there is so much red tape that it can 
take up to 22 documents with 8 different commands to exit the military 
medical system and enter the VA program. This exists even though there 
are numerous programs that are supposed to help the Veterans as they 
leave active duty, such as the Transition Assistance Program and the 
Benefits Delivery at Discharge Program. Despite these programs, the 
gaps and chasms remain.
    This is not a new issue. In 2003, the President's Task Force to 
Improve Health Care For Our Nations Veterans made a series of 
recommendations to ease the transition from servicemember to veteran 
status, most of which recommendations have not been implemented. For 
example, this Task Force recommended that VA and DOD:

     Implement by Fiscal Year 2005 a mandatory single 
separation physical as a prerequisite of promptly completing the 
military separation process;
     Expand the ``one-stop shopping'' process to include, at a 
minimum, a standard discharge exam, full outreach, claimant counseling, 
and when appropriate, referral for a VA Compensation and Pension 
examination and follow-up claims adjudication and rating. Upon a 
servicemember's separation, DOD should transmit an electronic DD 214 to 
VA; and
     By Fiscal Year 2004, initiate a process for routine 
sharing of each servicemember's assignment history, exposures to 
occupational hazards, location, and injuries information.

    The disability rating issues and the transition challenges are 
currently under review by at least 5 different entities. The Army 
Inspector General recently completed an inspection of the Army Physical 
Disability Evaluation System, identifying numerous shortfalls in the 
Army system. The Secretary of Defense has established an Independent 
Review Group to identify shortcomings and opportunities to improve 
rehabilitative care, administrative processes and the quality of life 
of outpatients at Walter Reed and Bethesda hospitals. The report of 
this independent review group is due on April 16th. The President 
established a bipartisan Presidential Commission on Care for America's 
Returning Wounded Warriors. This Commission is to provide independent 
advice and recommendations on care provided to wounded servicemen and 
women from the time they leave the battlefield through their return to 
civilian life. The Commission's report is due on June 30th, with an 
option for an extension to July 31st. The President also created an 
inter-agency cabinet level Task Force on Returning Global War on Terror 
Heroes to identify and examine Federal services provided to 
servicemembers who served in Afghanistan and Iraq, to identify gaps in 
the services, and to ensure cooperation between Federal agencies. The 
final report of this task force is due on June 30th. Finally, the 
Veterans' Disability Benefits Commission has been looking at these 
issues for some time. This Commission's report is due on October 1st. 
I'm confident that General Scott will give us some insight into this 
Commission's observations thus far. A preliminary report of the 
Secretary of Defense's Independent Review Group which proposed an 
acceleration of the closure of Walter Reed, describes the current 
system for assessing soldiers' disabilities ``extremely cumbersome, 
inconsistent, and confusing,'' calling for a complete overhaul of the 
process. The findings and recommendations of all of these groups may be 
useful as we seek solutions to the problems confronting our wounded 
servicemembers, but previous reports have been ignored. We shouldn't 
wait until they are all completed before we act.
    The House has already acted and passed the Wounded Warrior 
Assistance Act of 2007, which would impose a number of new requirements 
on the Department of Defense to improve medical care and other services 
for servicemembers and would require the Department of Defense and 
Veterans' Administration to establish a single medical information 
system. Several bills have also been introduced in the Senate, 
including the Restoring Disability Benefits for Injured and Wounded 
Warrior Act of 2007 introduced by Senator Clinton; the Dignity for 
Wounded Warriors Act of 2007 introduced by Senators Obama, McCaskill 
and others; and the Effective Care for the Armed Forces and Veterans 
Act of 2007 introduced by Senator Biden. All of these bills have been 
referred to the Senate Armed Services Committee where we will address 
these bills soon.
    The American people are deeply angry about the shortfalls in care 
for our wounded veterans. The war in Iraq has divided our Nation, but 
the cause of supporting our troops and our veterans unites us all as 
Americans and as Members of Congress. We will do everything we possibly 
can do, not as Democrats or Republicans but as grateful Americans, to 
care for those who have served our Nation with such honor and 
distinction. That is an obligation which all Americans accept and 
insist be met to the fullest.

    Chairman Levin. Senator McCain?

        STATEMENT OF HON. JOHN McCAIN, RANKING MEMBER, 
        COMMITTEE ON ARMED SERVICES, U.S. SENATOR FROM 
                            ARIZONA

    Senator McCain. Thank you very much, Senator Levin. I want 
to thank you and Senator Akaka for conducting this hearing. It 
is an important next step in determining how our Armed Services 
and Veterans' Affairs Committees will respond to the needs of 
the wounded and injured servicemembers and I join you in 
welcoming the witnesses today.
    At our last hearing on the situation at Walter Reed, I 
described the conditions there as appalling. Perhaps even more 
appalling was the failure to appreciate the bureaucratic manner 
in which outpatients were being treated after they had received 
superb medical care and they and their families were attempting 
to transition to civilian life.
    It took that situation and holding accountable those who 
were in charge to bring us to a point where we can all agree 
that change is needed. Information that was reported this 
morning on the recommendations of the Independent Review Group 
appointed by Secretary Gates confirms the need for significant 
and far-reaching change. There appears to be consensus, for 
example, that the current decentralized disability evaluation 
systems for the Army, Navy, Air Force, and Marines have 
received very little oversight from DOD and have produced 
questionable outcomes for many severely wounded soldiers.
    I and others have drafted legislation that would address 
some of the problems that have already been identified. For 
example, it would provide independent review on request from 
any servicemember who has received less than a 30 percent 
rating, in response to accusations that junior enlisted have 
been systematically low-balled in the disability ratings they 
have been offered and been denied the benefits of a medical 
retirement. It would also authorize the most severely injured 
to retain their medical health benefits for up to 5 years in 
order to complete their care.
    These and many other good ideas need to be included, and 
Mr. Chairman, I am confident that they will be included in this 
year's Defense Authorization Act. Bureaucracies at both 
agencies, the Department of Defense and the Department of 
Veterans Affairs, have caused many of our wounded to wait 
months for disability evaluations, benefits, or pay. Why is it 
that health care information still cannot be easily shared 
between the military and the Department of Veterans Affairs? 
Why do the disability evaluation and claims processes take so 
long? Is there an adequate safety net for victims of Traumatic 
Brain Injury and Post Traumatic Stress Disorder whose injuries 
and care needs cannot easily conform to standardized time lines 
and criteria?
    I recognize, Mr. Chairman, that while several commissions 
and review boards are at work, important changes have already 
begun in DOD and the VA. I hope we will receive assurances from 
Secretary England and our other witnesses that the housing and 
leadership problems not only at Walter Reed but throughout the 
military and VA systems have been corrected.
    I challenge our witnesses to inform the Committees about 
other meaningful reforms to the military and veterans' systems 
that build on the strength of each and ensure that procedures 
for disability evaluation and transition assist and do not 
frustrate the recovery of wounded servicemen and women. The 
heroism and sacrifice of these brave men and women deserve no 
less.
    President Kennedy, in speaking about our treatment of 
veterans, expressed what I consider to be our responsibility to 
our injured and wounded troops. He said, ``As we express our 
gratitude, we must never forget that the highest appreciation 
is not to utter words but to live by them.'' Obviously, Mr. 
Chairman, we must live up to that responsibility.
    I thank you, Mr. Chairman, and I thank Senator Akaka and 
Senator Craig.
    Chairman Levin. Thank you very much, Senator McCain.
    Senator Akaka, who has very aggressively joined in this 
mutual effort, this joining together in a very unprecedented 
way of these two Committees to address an issue which can only 
be addressed by these two Committees, working together here in 
the Senate and by our comparable Committees working together in 
the House. Senator Akaka?

     OPENING STATEMENT OF HON. DANIEL K. AKAKA, CHAIRMAN, 
    COMMITTEE ON VETERANS' AFFAIRS, U.S. SENATOR FROM HAWAII

    Chairman Akaka. Thank you very much, Mr. Chairman. I am 
really delighted to join you, the Armed Services Committee 
Chairman, and Senator McCain, the Ranking Member, and the 
Senate Veterans' Affairs Committee Ranking Member, Senator 
Craig, and all of our colleagues, Members of both Committees, 
in this really unprecedented joint hearing. Also, I want to 
welcome our guests and our witnesses who are here today and 
look forward to working with you for the good of our country.
    It is my hope that through this hearing and our follow-up 
work, we will be able to identify solutions to the problems 
that first gained public attention in connection with the 
stories about Walter Reed Army Medical Center. Unfortunately, 
many of the problems that surfaced at Walter Reed, particularly 
concerns about how DOD works with those servicemembers who will 
be leaving the service due to injuries or illness, are not 
limited to Walter Reed but exist throughout the military 
services.
    I am concerned that the government is not doing an adequate 
job in providing a smooth transition between DOD and VA. As 
Chairman of the Veterans' Affairs Committee and a Member of the 
Armed Services Committee, I am able to look at these issues 
from two different perspectives. However, in the end, it is 
clear that the problems facing DOD and VA are not separate. 
While there are two organizations, both of them deal with the 
same set of servicemembers.
    It is vital that we address both DOD and VA 
responsibilities and concerns to ensure that servicemembers 
receive the benefits and services available to them. I know we 
all agree that we have an obligation to provide our wounded and 
ill servicemembers with optimal care from both DOD and VA. That 
obligation also must ensure the transition between the two 
departments is as smooth as possible.
    We have to realize that VA not only has a relationship with 
DOD, but an independent relationship with each of the military 
services. In this regard, we should not just be looking at DOD, 
but at each of the military services individually. Hopefully, 
our oversight will result in identifying best practices from 
the services that can be exported and implemented DOD-wide.
    I intend for this hearing to identify workable solutions to 
the many problems that confront DOD, the military services, and 
VA. I look forward to hearing the testimony of the Departments. 
These are some of the most important issues of our time. We 
have a unique opportunity at this joint hearing to focus upon 
identifying solutions to problems that impact our 
servicemembers and veterans. We owe them no less.
    Thank you, Mr. Chairman.
    Chairman Levin. Thank you very much, Senator Akaka.
    Senator Craig?

STATEMENT OF HON. LARRY E. CRAIG, RANKING MEMBER, COMMITTEE ON 
           VETERANS' AFFAIRS, U.S. SENATOR FROM IDAHO

    Senator Craig. Chairman Levin, thank you very much, 
Chairman Akaka, Senator McCain, for bringing together these two 
Committees of jurisdiction on this very important issue. To all 
of you who have assembled to give testimony, we appreciate an 
opportunity to visit with you and better understand a situation 
that is not new and has been addressed over a long period of 
time with relatively few solutions.
    To say the least, it has been disheartening over the past 
few months to learn of severely injured servicemembers and 
their families who have experienced delays, frustrations, and 
disappointments while trying to get decisions about their 
military disability benefits. For the men and women who have 
given so much in service to this Nation, I think we can all 
agree that we must ensure they are swiftly and properly 
compensated for their service-related disabilities.
    When I first became Chairman of the Veterans' Affairs 
Committee a few years ago, one of the first hearings we held 
was with survivors, spouses, predominantly women, who gave us 
testimony of the years it took sometimes to thread their way 
through the bureaucracy of the systems to get what was legally 
and rightfully theirs. And if they were not extremely 
sophisticated in their pursuit of those benefits that were 
rightfully theirs, oftentimes they did not receive them, or 
they would find out later or 3 or 5 years from the time they 
had lost their loved one that they were still owed and 
deserving of certain benefits.
    To have two separate disability systems between the 
Department of Defense and the Department of Veterans Affairs 
seems to me to only multiply the bureaucracy by two. 
Unfortunately, that issue and others that we are going to 
discuss today, as I earlier mentioned, are not new. Five 
decades ago, a commission chaired by General Omar Bradley--yes, 
let me repeat that, General Omar Bradley--found that the 
military disability program overlaps the system of disability 
compensation administered by the VA and recommended eliminating 
duplication of administrative functions. The Bradley Commission 
also found that there were great variances in rating 
assignments by DOD and VA and that the rating criteria needed 
to be revised to reflect up-to-date medical, economic, and 
social thinking with respect to ratings and compensation 
disability. That is exactly what we need today. After fifty 
years and ten Administrations, there are still concerns about 
variances between rating assignments in VA and DOD and how they 
are assigned.
    In that regard, I am perplexed as to why the Army only 
rates conditions that would independently render a soldier 
unfit, even if the soldier has multiple disabilities caused by 
the same event. For a soldier who has a number of wounds caused 
by an IED blast, shouldn't we look at how those wounds in 
concert affect his or her fitness and rate the overall 
disability level accordingly? Otherwise, the policy seems akin 
to totaling a car and only being compensated by the insurance 
company for the tires that were flattened in the accident.
    Well, Mr. Chairman, there is a good deal more I could say. 
Let me ask unanimous consent that the balance of my statement 
be a part of the record and again thank all three of you for 
recognizing the importance of bringing these two Committees 
together that have dual jurisdiction in a variety of areas 
oftentimes that overlap. Most importantly, it is time, I think, 
we look at whether we continue the bureaucracy and the system 
we have or if we get modern, like the modern military and the 
young men and women who serve in it.
    Thank you, Mr. Chairman.
    [The prepared statement of Senator Craig follows:]

      Prepared Statement of Hon. Larry E. Craig, Ranking Member, 
        Committee on Veterans' Affairs, U.S. Senator from Idaho

    Good morning, and welcome to this joint hearing of the Senate Armed 
Services and Veterans' Affairs Committees. And thank you to Chairman 
Levin and Chairman Akaka for calling this very important hearing.
    To say the least, it has been disheartening over the past few 
months to learn of severely injured servicemembers and their families 
who have experienced delays, frustrations, and disappointments while 
trying to get decisions about their military disability benefits. For 
the men and women who have given so much in service to their Nation, I 
think we can all agree that we must ensure they are swiftly and 
properly compensated for their service-related disabilities.
    But many of us are probably wondering whether we need two separate 
disability systems to do that--one run by the Department of Defense and 
the other by the Department of Veterans Affairs--or whether that much 
bureaucracy only adds to the frustrations.
    Unfortunately, that issue--and others that we will discuss today--
are not new. In fact, five decades ago, a commission chaired by General 
Omar Bradley found that ``the military program overlaps the system of 
disability compensation administered by [VA]'' and recommended 
``eliminating duplication of administrative functions.''
    The Bradley Commission also found that there were ``great 
variances'' in ratings assigned by DOD and VA and that the rating 
criteria needed to be revised to ``reflect up-to-date medical, 
economic, and social thinking with respect to rating and compensation 
of disability.''
    Yet today--after 50 years and 10 different Administrations--there 
are still concerns about variances between ratings assigned by VA and 
DOD; about rating criteria that are not sufficiently up to date; and 
about overlapping functions being performed by DOD and VA. Also, 
serious concerns have been raised about whether DOD is providing 
adequate disability ratings to wounded servicemembers.
    In that regard, I am perplexed as to why the Army only rates 
conditions that would independently render a soldier unfit, even if the 
soldier has multiple disabilities caused by the same event. For a 
soldier who has a number of wounds caused by an IED blast, shouldn't we 
look at how those wounds--in concert--affect his or her fitness and 
rate the overall disability level accordingly? Otherwise, the policy 
seems akin to totaling a car and only being compensated by the 
insurance company for the tires that went flat!
    In my view, long-term solutions must start with a serious 
assessment of what purpose each system is intended to serve and whether 
either system--as currently structured--is capable of providing timely, 
accurate and consistent decisions.
    Later this year, the Veterans' Disability Benefits Commission--
chaired by General Scott--will provide Congress with a comprehensive 
assessment of veterans' disability benefits. And I hope that will 
provide the foundation for the types of fundamental changes that may be 
needed to ensure lasting improvement in how we compensate injured 
servicemembers.
    But, in the meantime, I think it is clear that we need to take 
immediate steps to make these systems work better for our Nation's 
heroes. For starters, there needs to be a more efficient system for 
transferring records both between DOD and VA and within different 
facilities at each department. In this age of technology, it seems 
inexcusable that injured servicemembers are asked to fill out the same 
forms over and over again or to endure long waits while records from 
different facilities are located and transferred.
    I know our witnesses will have other suggestions for how to improve 
these systems--both in the short-term and the long-term--and I look 
forward to hearing their recommendations.
    Whether we pursue those options or others, I sincerely hope that we 
can all work together to streamline the systems and omit overlapping 
levels of bureaucracy that serve only to lengthen the process and 
frustrate our Nation's wounded warriors.
    Thank you again Chairman Levin and Chairman Akaka for calling this 
hearing, and thank you to all of our witnesses for being here today.

    Chairman Levin. Thank you. Your statement, of course, will 
be made part of the record. I want to also thank you and 
Senator McCain for all you have done to make this joint hearing 
possible.
    Let me first note that there will be a vote at 10:30. It is 
our intent to work right through that vote, so some of us could 
leave, vote early, and come back, and so forth. We will, after 
the statements from our witnesses, proceed on an early bird 
basis, alternating between Democrats and Republicans, with only 
a 4-minute round, I am afraid, given the number of Senators, at 
least for the first round and then we will see how far that 
goes.
    So now let me thank our witnesses for being here. We very 
much appreciate your all coming and I think we are going to 
start with you, Secretary England.

          STATEMENT OF HON. GORDON R. ENGLAND, DEPUTY 
  SECRETARY, DEPARTMENT OF DEFENSE; ACCOMPANIED BY HON. DAVID 
    S.C. CHU, UNDER SECRETARY FOR PERSONNEL AND READINESS, 
                     DEPARTMENT OF DEFENSE

    Mr. England. Chairman Levin, thank you very much, Senator 
McCain and Members of the Senate Armed Services Committee, and 
Chairman Akaka and Senator Craig and Members of the Senate 
Veterans' Affairs Committee. I do thank you for the opportunity 
to be here today. This is indeed, as you have commented, a 
vitally important topic, not just for our men and women in 
uniform, but, frankly, for all the citizens of this great 
Nation. And we do have some experts here today that hopefully 
can add some light on this discussion.
    Let me first assure you that the very top priority of the 
Department of Defense is taking care of our men and women in 
uniform and their families and, in particular, those who have 
made the greatest sacrifices for our Nation. The Administration 
and the Department are absolutely committed to fixing problems 
and resolving outstanding issues and we are ready to bring 
forward to the Congress proposed legislation if and as required 
to fix problems identified.
    In the meantime, the Department is indeed being proactive. 
Where problems are identified and can be fixed, we are doing 
so. I can tell you Secretary Gates is personally and actively 
engaged in meeting regularly with OSD and service leaders on 
this topic.
    Our goal is an uninterrupted, seamless continuum of care 
and support for servicemembers who are wounded or injured as a 
result of their service. The population of the greatest concern 
which requires the most urgent action includes those warriors 
with war-related injuries or conditions, who account for about 
11 percent of the total workload of the Department's Disability 
Evaluation System.
    Unfortunately, despite good faith efforts by the services 
and by our agencies, by a lot of really very, very good people, 
and despite many significant accomplishments, it is evident 
that some of our valued servicemen and women, and particularly 
those with war injuries, are not receiving the benefits they 
deserve, and some of them and their families are also caught up 
in unacceptable bureaucratic delays and frustrations.
    Now, given, frankly, what is in place today, it is not a 
single system and those delays and frustrations are, therefore, 
not really surprising, because DOD itself is a system of 
internal systems under a broad umbrella. Then the Department of 
Veterans Affairs is another system, and then the DOD and the VA 
are linked by the all important transition system.
    Now, for an individual servicemember looking in from the 
outside, the division of roles and responsibilities is far less 
important than a completely transparent process to provide 
timely adjudication and appropriate results, and that should be 
the end objective of our efforts. That is, we should look at 
this from the servicemember's view looking in and they should 
see a completely transparent system.
    Now, this time of taking stock, I believe, is a good 
opportunity to consider the overall joint DOD-VA health care 
and disability apparatus, so I have two suggestions. The first 
is that we immediately concentrate on the wounded. Currently, 
with the transition from DOD to the Department of Veterans 
Affairs, the ratings process is a one-size-fits-all process. 
That is, the same basic procedures are followed inside the 
Department and during the transition to the VA for all 
individuals, so the 11 percent of cases that are those wounded 
or severely wounded are funneled through exactly the same 
system as the other 89 percent, the career members 
transitioning to retirement. Now, many of the wounded have 
combat injuries that are readily understood, so these should be 
the most straightforward in terms of disposition. The system 
should be able to process these individuals very expeditiously, 
and so my first recommendation is we should work on this 
particular immediate issue.
    Secondly, we have a lot of studies, reviews, commissions, 
and panels underway and they will all be reading out before the 
end of the year. Using results of those efforts, in my 
judgment, it is time to step back and take a more holistic look 
at the system instead of just applying fixes to the system, and 
that was basically the complete overhaul that Senator McCain 
commented earlier for the commission that Secretary Gates put 
together. We do need an integrated systemic solution with the 
right mechanisms in place, a solution that makes sense from the 
soldier's perspective. So if we were designing the system today 
from scratch, what would that system look like, and then what 
administrative and possibly legislative steps would we need to 
take to get there?
    Lastly, our people eventually go into other systems of the 
Federal Government and it may be useful to look at the military 
disability system in the context of the entire national system 
for disability determination and compensation. Today, our 
Nation has diverse approaches. In the public sector, the 
problems have much in common. We have Social Security 
Disability payments, Department of Labor Workers' Compensation, 
Department of Veterans Affairs, Department of Defense's 
disability evaluation system. They are all carried out in 
different ways against different standards to achieve different 
ends and the complexity and the variance and outcomes often 
confuse benefit recipients. So even when we solve this problem, 
I believe our people eventually get into an even more complex 
system, so it may be time to cast a wider net and look at this 
whole area of disability.
    I do want to comment, in conclusion, that Secretary Gates 
has clearly stated that the Department of Defense will work 
with the commissions, the panels, the study groups we have in 
place, the Congress, and all the partner agencies to clearly 
identify problems and fix them, so you have our full absolute 
support and cooperation. And I do thank the Members of the 
Committees here for your care and concern for our heroes. This 
is an extraordinarily important topic, I know, to all of you 
and to all of us in the Department of Defense, because at the 
end of the day, this is about the brave men and women in 
uniform who serve our Nation. So I thank you. I also thank you 
for the opportunity to be here today.
    [The prepared statement of Mr. England follows:]

             Prepared Statement of Hon. Gordon R. England, 
                Deputy Secretary, Department of Defense

    Chairman Levin, Senator McCain, Members of the Senate Armed Service 
Committee, Chairman Akaka, Senator Craig, Members of the Senate 
Veterans' Affairs Committee, thank you for your strong support for the 
brave men and women in uniform of the Department of Defense, and their 
families, who so courageously serve the Nation. And thank you for the 
opportunity to meet with you this morning to discuss two practical 
issues that directly and profoundly affect their well-being: disability 
ratings, and the transition of responsibility for servicemembers from 
the Department of Defense to the Department of Veterans Affairs. These 
are important issues that merit thoughtful consideration. Dialogue and 
discussion are helpful and appreciated.
    It is a pleasure to appear with colleagues from the Department of 
Veterans Affairs--Under Secretary Dan Cooper and Dr. Gerald Cross--and 
with LTG (ret.) Terry Scott, Chairman of the Veterans' Disability 
Benefits Commission, since the complex challenges under discussion 
require efforts from multiple agencies. With me this morning from the 
Department of Defense are Acting Secretary of the Army Pete Geren, and 
Under Secretary of Defense for Personnel and Readiness Dr. David Chu.
    Let me assure you that the top priority of the Department of 
Defense is taking care of our men and women in uniform and their 
families, and in particular those who have made the greatest sacrifices 
for the Nation. The Administration and the Department are absolutely 
committed to fixing problems and resolving outstanding issues, and are 
ready to bring forward to the Congress proposed legislation, if and as 
required to fix the problems.
    The goal is an uninterrupted, seamless continuum of care and 
support, for servicemembers who are wounded or injured as a result of 
their service. The population of greatest concern--which requires the 
most urgent attention--includes those warriors with war-related 
injuries or conditions, who account for about 11 percent of the total 
workload of the Department's Disability Evaluation System.
    Unfortunately, despite good faith efforts by the Services and by 
our agencies, and despite many significant accomplishments, it is 
evident that some of our valued servicemen and women, particularly 
those with war injuries, are not receiving the level of care they 
deserve. Some of them and their families are caught up in unacceptable 
bureaucratic delays and frustrations.
    To address these issues, a number of efforts have already been 
initiated. On March 1, 2007, Secretary Gates appointed an independent 
panel--the Independent Review Group (IRG), co-chaired by the Honorable 
Togo West, Jr., and the Honorable Jack Marsh--to take a broad look at 
rehabilitative care, administrative processes, and quality of life, at 
Walter Reed Army Medical Center and Bethesda National Navy Medical 
Center. The Group's report is expected very soon.
    The President also appointed an independent panel--the Commission 
on Care for America's Returning Wounded Warriors, co-chaired by Senator 
Bob Dole and Secretary Donna Shalala--to take a comprehensive look at 
the full lifecycle of treatment for wounded veterans returning from the 
battlefield. And the President directed the Department of Veterans 
Affairs to establish an Interagency Task Force on Returning Global War 
on Terror Heroes, in which the Department participates.
    The results of these efforts will add to the ongoing work by the 
Veterans' Disability Benefits Commission, chaired by LTG (ret.) Terry 
Scott, and chartered by the National Defense Authorization Act of 2004 
to study veterans' benefits, which is due to report out later this 
year.
    As Secretary Gates has clearly stated, the Department will work 
with the Commissions, the Congress, and partner agencies to clearly 
identify the problems and fix them.
    Meanwhile, the Department has taken a proactive approach. For 
example, a major internal review of care for our wounded servicemembers 
was launched immediately after the issues at Walter Reed came to light.
    As Acting Secretary of the Army Pete Geren can better attest, the 
Army is evaluating the installation's infrastructure, upgrading 
information technology, improving clothing and food services, and 
creating the Warrior Transition Brigade, to provide wounded Soldiers 
with a full chain of command.
    Where problems are evident and can be fixed immediately, the 
Department is doing so. The Department requested an adjustment to the 
Fiscal Year 2007 Emergency Supplemental request, to provide $50 million 
to create a Medical Support Fund to implement any findings or 
recommendations in which the Department can take action before Fiscal 
Year 2008.
    This time of taking stock is a good opportunity to consider the 
overall joint DOD/DVA disability and health care system. In fact, what 
is in place today is not a single ``system,'' but rather several: (1) 
DOD, itself a system of internal Service systems under a broad 
umbrella; (2) DVA; and (3) the all-important transition process that 
links the two departments. For an individual servicemember looking in 
from the outside, the division of roles and responsibilities is far 
less important than a completely transparent process that provides 
timely adjudication and appropriate results. This should be the end 
objective of our efforts.
    Within the Department, the Disability Evaluation System is run 
primarily by the Secretaries of the Military Departments. Since the 
``fitness to serve'' standard must and does vary by Service, military 
specialty, and grade, there is variance among the approaches. In a 
system that processes 20,000 cases annually, there are also real, and 
likely unwarranted, variances in execution.
    In the transition from the Department of Defense to the DVA, our 
agencies do benefit from a strong basis for partnership. DOD and DVA 
share the mission of taking care of those who serve, and making sure 
cooperation is as seamless as possible. Our agencies have put in place 
a responsive organizational structure--the VA/DOD Joint Executive 
Council, co-chaired by DVA Deputy Secretary Gordon Mansfield and Under 
Secretary of Defense David Chu, which provides guidance and establishes 
policy for the full spectrum of collaborative initiatives. To provide 
broad vision for ongoing collaboration, DOD and the VA developed a 
Joint Strategic Plan, which will be updated over time. Secretary 
Nicholson and I do meet and confer, when issues need to be addressed at 
our level. However, there are still challenges in meeting our shared 
goal of seamless transition between DOD and the VA.
    However, seams between our agencies remain.
    A fundamental challenge is that the Department of Defense and the 
Department of Veterans Affairs use two different disability ratings 
systems, which both produce end products expressed in terms of 
``percentages''--but the percentages refer to different things. DOD's 
Military Departments rate fitness, at a fixed point in time, for 
continued military service, while the DVA rates civilian employability, 
based on any changes in health status that can be linked to time in 
service--and the DVA's ratings may change over time, if the medical 
condition changes. This imperfect integration produces undue confusion 
for servicemembers and their families.
    Another problem with the transition from DOD to the DVA is that the 
disability ratings process is ``one size fits all''--the same basic 
procedures are followed inside the Department and during the transition 
to the DVA, for all individuals. The 11 percent of cases that are those 
wounded or severely wounded in war are funneled through exactly the 
same system as the other 89 percent, the career Servicemembers 
transitioning to retirement.
    Many of the wounded have combat injuries that are readily 
understood. These should be the most straightforward cases in terms of 
disposition. The system should be able to process these individuals 
very expeditiously.
    Other wounded warriors have conditions--particularly those 
resulting from new forms of warfare--that present new challenges to the 
medical profession, and stretch the abilities of the current system. 
For example, one of the most difficult conditions a Servicemember can 
struggle through is Traumatic Brain Injury (TBI), and much more needs 
to be done to leverage national capabilities, both civilian and 
military, to apply the most advanced technology and medicine to this 
condition. And while the Department is working to improve its ability 
to identify and treat mental health issues, including Post Traumatic 
Stress Disorder, this is another war-related challenge that needs 
further attention.
    Another serious challenge is that DOD and DVA still operate largely 
on the basis of two different sets of information, based on two 
different vocabularies, without a single, accessible electronic 
database of information. While this is being addressed, a full solution 
is still several years away.
    In the transition from DOD to the DVA, even when the system 
``works,'' it still fails in the eyes of too many servicemembers, due 
to bureaucracy and delays, and the anxiety, confusion and frustration 
they cause, even for those who pass ``successfully'' through the 
system. Because the process is complex and lengthy, and its results 
have such profound effects on servicemembers, it is understandably 
viewed by some as ``adversarial.'' The system needs to be timely, and 
at the same time deliberate enough to produce fair, accurate and 
consistent results. Despite its complexities, it must be clear and 
transparent to its customers.
    There is no single silver-bullet solution, but it might make sense 
to consider the following:

     As a first step, focus on and seek innovative solutions 
for the wounded and severely wounded cases, and then turn to the 
general population of servicemembers.
     Move beyond stovepiped data-storage systems to create a 
central database of information to expedite full electronic information 
exchange.
     Make existing benefits more accessible through common 
terminologies and a fully integrated process.

    Lastly, it may be useful to re-evaluate the entire national system 
for disability determination and compensation. The Nation has diverse 
approaches in the public sector to problems that have much in common. 
Social Security's disability payments, the Department of Labor, 
Workmen's Compensation, the Department of Veterans Affairs' and the 
Department of Defense's Disability Evaluation Systems are carried out 
in different ways, against different standards, to achieve different 
ends. The complexity and variance in outcomes and numerous program 
offsets and tax exempt statuses often confuse benefit recipients. The 
purposes of the various programs also vary widely. These diverse 
approaches regarding compensation for disabled workers suggest the need 
for a new paradigm for the Nation.
    The Department remains committed to working in closest partnership 
with the Department of Veterans Affairs, with the Commissions and Task 
Forces, and with the Congress, as we go forward.
    I do thank the Members for your care and concern for our heroes--
the brave men and women in uniform who serve the Nation.
                                 ______
                                 
      Response to Written Questions Submitted by Hon. Carl Levin 
    to Hon. Gordon England, Deputy Secretary, Department of Defense

    Question 1. What does DOD think of suggestion that the fitness for 
duty determination be made by the DOD and then there be one 
comprehensive physical examination by the VA that determines the 
rating?
    Response. The Department of Defense (DOD) supports the suggestion 
of keeping the fitness determination in the Department of Defense. We 
also support a collaborative DOD and the Department of Veterans Affairs 
(DVA) single agency determination of disability ratings. A future 
system should also integrate the efforts of DOD and DVA, where 
reasonable, by eliminating redundancies. A DOD determination of fit/
unfit allows decisions critical to maintaining a fit and ready force to 
reside appropriately in the Department. Deferring the disability 
determination to a collaborative body of DOD and DVA authorities more 
expert in utilization of the disability schedules would eliminate much 
of the tension associated with the adversarial burden of proof board 
process by placing the determination of permanent or temporary 
retirement, concurrent receipt, and disability percentage to the single 
entity that is most skilled at disability determinations. We believe 
that a demonstration authority is needed to adequately evaluate this 
concept. In this demonstration project, DOD and DVA would jointly 
define the framework and focus initially on those with a combat-related 
condition(s). DOD and DVA would report successes and findings of the 
demonstration to Congress on a regular basis. A major issue would be 
funding of retirements and disability ratings.
    Note: It is assumed that the question on ``one comprehensive 
physical examination . . . '' is in reference to one disability 
determination and not to the medical examinations required to diagnosis 
severity of conditions accomplished by the DOD and DVA.

    Question 2. What is the DOD timeline for electronic transfer of 
medical records?
    Response. Department of Defense (DOD) and the Department of 
Veterans Affairs (VA) share health information today. Beginning with 
our electronic sharing in 2001, the Departments continue to pursue 
incremental enhancements to information management and technology 
initiatives to significantly improve the secure sharing of appropriate 
health information. Under the VA/DOD Joint Strategic Plan, these health 
information technology data sharing initiatives are prioritized by DOD 
and VA leadership.

            CURRENTLY SHARED ELECTRONIC MEDICAL RECORD DATA

     Inpatient and outpatient laboratory and radiology results, 
allergy data, outpatient pharmacy data, and demographic data are 
viewable by DOD and VA providers on shared patients through 
Bidirectional Health Information Exchange (BHIE) from 15 DOD medical 
centers, 18 hospitals, and over 190 clinics and all VA facilities.
     Electronic digital radiographic images are being 
electronically transmitted from Walter Reed Army Medical Center (WRAMC) 
and National Naval Medical Center (NNMC) Bethesda to the Tampa and 
Richmond VA Polytrauma Centers for inpatients being transferred there 
for care.
     Electronic transmission of scanned medical records on 
severely injured patients transferred as inpatients from WRAMC to the 
Tampa VA Polytrauma Center.
     Pre- and Post-Deployment Health Assessments and Post 
Deployment Health Re-assessments for separated Servicemembers and 
demobilized Reserve and National Guard members who have deployed.
     When Servicemembers end their terms in service, DOD 
transmits to VA laboratory results, radiology results, outpatient 
pharmacy data, allergy information, consult reports, admission, 
disposition and transfer information, elements of the standard 
ambulatory data record, and demographic data.
     Discharge Summaries from 5 of the 13 DOD medical centers 
and hospitals using the Clinical Information System (CIS) to document 
inpatient care.

                 ENHANCEMENT PLANS FOR FISCAL YEAR 2007

     Expanding the electronic digital radiographic images 
transfer capability to Brooke Army Medical Center (BAMC) and from 
WRAMC, NNMC, and BAMC to all four VA Polytrauma Centers.
     Expanding the electronic transmission of scanned medical 
records on severely injured patients from WRAMC, NNMC, and BAMC to all 
4 VA Polytrauma Centers.
     Making available discharge summaries, operative reports, 
inpatient consults, and histories and physicals for viewing by all DOD 
and VA providers from inpatient data at all 13 DOD medical centers and 
hospitals using CIS.
     Expanding availability of inpatient and outpatient 
laboratory and radiology results, allergy data, outpatient pharmacy 
data, and demographic data viewable by DOD and VA providers on shared 
patients through BHIE to all DOD and VA facilities.
     Making available theater outpatient encounters, laboratory 
and radiology results, and pharmacy data for VA providers to view 
through BHIE.
     Beginning collaboration efforts on a DOD and VA joint 
solution for documentation of inpatient care.

                 ENHANCEMENT PLANS FOR FISCAL YEAR 2008

     Making available encounters/clinical notes, procedures, 
and problem lists to DOD and VA providers through BHIE.
     Making available vital sign data, family history, social 
history, other history, and questionnaires/forms to DOD and VA 
providers through BHIE.
     Making available theater inpatient encounters, to include 
clinical notes, discharge summaries and operative reports; laboratory 
and radiology results; and pharmacy data to all DOD and VA providers 
via BHIE through a specific interface to the Theater Medical Data 
Store, designated the BHIE-Theater.
     Expanding CIS deployment to Landstuhl Regional Medical 
Center, Germany. Once CIS is installed at Landstuhl, the discharge 
summaries, operative reports, inpatient consults and histories and 
physicals will be available to VA on shared patients.

    Question 3. There was a GAO report in March 2006 which criticized 
the Department and the Services for failing to systematically determine 
the consistency of disability decisionmaking. The Department has issued 
timeliness goals for processing disability cases, but there's no 
collection of information to determine compliance. The consistency and 
timeliness of decisions depend in part on the training that disability 
staff receives. However, the GAO found that the DOD is not exercising 
oversight over training for staff in the disability system. Are you 
familiar with that GAO report? I think the question is, are you 
familiar with the report and what are you doing about the findings?
    Response. The Department has been working hard on remedying the 
problems identified in the GAO report. The GAO report conclusions 
stemmed partially from dated Department issuances and lack of an active 
Disability Advisory Council (DAC)--a consortium of advisors from the 
Military Departments, Department of Defense (DOD) agencies, and the 
Department of Veterans Affairs. In response:

     The Department has revitalized the DAC so that it plays an 
active and strengthened role in managing Department disability policy.
     The DAC is working to update the set of DOD issuances that 
promulgate disability policies and is charged with strengthening 
oversight processes and making recommendations on program effectiveness 
measures, future policy, and changes to title 10.
     A Directive-Type Memorandum (DTM), which is an interim 
policy, is in coordination that will implement policy consistent with 
the Department's overall efforts to address the recommendations of the 
GAO report and those directed by Section 597 of the Fiscal Year (FY) 
2007 National Defense Authorization Act, which establishes procedural 
requirements for Physical Evaluation Boards (PEBs), including conveying 
PEB findings in an orderly and itemized fashion, assigning and training 
of PEB Liaison Officers and PEB staff, and establishing PEB operating 
procedures and timeliness goals. Section 597 also directs a 
comprehensive review of compliance every 3 years. The guidance in the 
DTM creates annual and quarterly reporting and verification mechanisms, 
clarifies timeliness goals, establishes sampling of disposition 
determinations and other performance measures, and formally elevates 
program awareness and issues to senior leadership levels.
     Additionally, the interim policies, incorporating these 
and other additions will, in due course, be formally coordinated and 
published. The current DOD Directive 1332.18, ``Separation or 
Retirement for Physical Disability,'' and DOD Instruction 1332.38, 
``Physical Disability Evaluation,'' will be combined into one issuance. 
Until such time, the Department will issue regular directive-type 
memoranda every couple of months, which will allow consideration of 
findings and recommendations from the various commissions, task forces, 
and study groups. This process of continuous process improvement will 
help develop solutions to resolve many statutory and systemic issues 
associated with the Disability Evaluation System and the transition of 
those separated to the care of the Department of Veterans Affairs.
     The entire disability process and oversight by the Office 
of the Secretary of Defense have been strengthened by the utilization 
of outside assistance to assist in analyzing data and recording process 
for use in policy formulation, promulgation, and management. We are 
pursuing permanent manpower dedicated to disability management 
oversight.
                                 ______
                                 
      Response to Written Question Submitted by Hon. Larry Craig 
    to Hon. Gordon England, Deputy Secretary, Department of Defense

    Question 1. What is the status of the Department of Defense (DOD) 
report regarding the implementation of a uniform policy of casualty 
assistance for survivors, pursuant to section 562 of Public Law 109-
163? How exactly have the problems identified in the Government 
Accountability Office report filed pursuant to that same law been 
remedied?
    Response. The report to Congress on Improvement of Casualty 
Assistance Programs was forwarded on April 20, 2007. The GAO made two 
recommendations. First, that the Department develop an oversight 
framework that includes measurable DOD-wide objectives for casualty 
assistance programs as well as DOD-wide outcome measures to evaluate 
aspects of its program, such as survivors' satisfaction with assistance 
they received from casualty assistance officers, and clearly link 
program performance with these objectives requiring the Services to 
report on these outcome measures so that DOD can use the reports to 
monitor the casualty assistance program's performance and make fact-
based decisions about program operations and resources. Second, that 
the Department incorporate standards, such as a comprehensive checklist 
of duties for casualty assistance officers, when revising its casualty 
assistance policy.
    The DOD's Instruction has been revised, incorporating the policy 
elements required by section 562, and is in the final stages of formal 
coordination. The Military Services, including the United States Coast 
Guard, are revising their policies and procedures, as necessary, to 
ensure a uniform application of services across the Military 
Departments.
    Two standardized evaluation mechanisms are being developed to 
measure the effectiveness of the Department's casualty assistance 
program as well as measure the quality of the assistance provided.

    Question 2. There is a wide array of benefits and services provided 
by both the Department of Veterans Affairs (VA) and DOD, yet there are 
discrepancies between benefits available for those on active duty 
versus those who are medically retired and in veteran status. This 
discrepancy may lead to confusion among family members who do not 
understand why legal distinctions exist for benefits meant to help 
those wounded in combat, irrespective of their status. The Wounded 
Warrior Project has recommended legislation to authorize a blanket 
overlap of DOD and VA benefits for a period of two years following the 
medical retirement of an injured servicemember or for the length of 
time a servicemember is held on Temporary Disability Retirement List 
(TDRL), whichever is greater. What are your views on this idea?
    Response. Such a step would only create more confusion, would upend 
the principle precluding compensation for the same purpose, and is 
opposed by the Department.
    Changes in compensation should be structured to resolve specific 
problems. In this case, the problem is that the veteran may need more 
financial support during the transition to civilian employment. The VA 
could possibly rate the Servicemember as individually unemployable (100 
percent) until the member is gainfully employed, providing an economic 
bridge. DOD and VA should be provided the opportunity to study this 
concept.

    Question 3. There exists a VA Office of Seamless Transition (OST) 
with a mission to facilitate the transition of servicemembers from 
active duty to civilian lives by coordinating VA benefits and services 
with those provided by DOD. Yet the OST reports only to the Under 
Secretary of Health. Within DOD, the Military OneSource Center is 
designed to augment and support transition services, yet problems with 
coordination with the support services provided by the military 
services persist. Is there a need for an organizational restructuring 
within VA so that the transition office has authority over ALL VA 
benefits and services and reports directly to the Deputy Secretary of 
VA? To increase interagency transition coordination, should DOD 
establish a mirror transition office that reports directly to the Under 
Secretary for Personnel and Readiness?
    Response. We defer to the Secretary of VA on VA organizational 
issues. The several DOD offices that deal with various policies, 
benefits, programs, and information for transitioning Servicemembers, 
including the National Guard and Reserves, come under the Under 
Secretary of Defense for Personnel and Readiness. The Department 
believes this facilitates coordination while drawing on the expertise 
of functional specialists.

    Question 4. If we were to start from scratch and design a new 
system of compensation for those who are severely injured in service, 
what should that system look like?
    Response. The existing compensation system for severely injured 
members under the Department's responsibility before separation 
continues all pays and allowances normally payable to the 
Servicemember. Additionally, the Department augments this normal 
compensation with certain travel benefits and traumatic injury 
insurance payments that contribute to the supporting family expenses 
while the member is undergoing active duty hospitalization, 
recuperation, and medical evaluation for potential continuation of 
active service.
    The very term ``compensation'' might be challenged, with its 
connections post-discharge to a 1940s-world of conscripts that linked 
physical issues with the ability to perform manual tasks on an assembly 
line. Instead, we might focus on the national responsibility to enable 
the former Servicemember to pursue a satisfying career and lifestyle. 
That implies investment vice compensation, and emphasizes outcomes vice 
annuity calculations.

    Question 5. What do you think should be the purpose of a modern 
compensation program and how should we regularly determine whether the 
program, as designed, is meeting its intended purpose?
    Response. A modern compensation program should focus on career and 
lifestyle outcomes, vice income replacement per se. This would 
emphasize investment in the individual (education, accommodations, 
placement, coaching, etc.), instead of awarding a stipend, which may 
prove inadequate in any event.
                                 ______
                                 
      Response to Written Questions Submitted by Hon. John McCain 
    to Hon. Gordon England, Deputy Secretary, Department of Defense

                     QUALITY AND ACCURACY ASSURANCE

    Question 1. One requirement I see as essential is that the Office 
of the Secretary of Defense (OSD) establish a dedicated review process 
independent of the Services that will critically examine the 
performance of the Services' Physical Evaluation Boards (PEBs) and 
provide timely appellate review for individual members who perceive 
they have been unfairly treated. While changes surely are coming, it is 
no longer acceptable that the Department of Veterans Affairs (VA), in 
effect, be the safety net for poor DOD decision making. How are you 
going to ensure that the performance of the Services' PEBs is evaluated 
critically in the future?
    Response. The Service Secretaries are charged with operating their 
respective disability evaluation systems consistent with Service roles 
and missions--this does not constitute poor decisionmaking. To improve 
oversight, the Department recently issued instructions on addressing 
the performance of PEBs. On May 3, 2007, the Department published 
interim oversight guidance in a directive-type memorandum entitled, 
``Policy Guidance for the Disability Evaluation System and 
Establishment of Recurring Directive-Type Memorandum.'' The guidance in 
this memorandum formally establishes the Disability Advisory Council, 
creates annual and quarterly PEB reporting and verification mechanisms, 
clarifies timeliness goals and other performance measures, formally 
elevates program awareness to senior leadership levels, and issues 
policy to comport with Section 597 of the John Warner National Defense 
Authorization Act for Fiscal Year 2007 (Public Law 109-364), which is 
codified at 10 United States Code Sec.  1222.

    Question 2. Would you support establishment of an OSD-level review 
panel that would examine cases in which members with severe injuries 
received low ratings from the PEB and that would be empowered to change 
those ratings?
    Response. I would consider it as an option, but we are looking at 
wholesale redesign of the complex and arcane Disability Evaluation 
System (DES), which dates back to constructs from 1949. The Department 
of Defense (DOD) needs empowerment to revolutionize DES, rather than a 
new set of compliance standards that only serve to reinforce the 
present, much-criticized system. A demonstration authority would 
empower the Department of Veterans Affairs (VA) and DOD to operate a 
combined activity that transcends present law, and allow for rapid 
proof of new concepts and a quick response to the needs of the 
disabled. In the interim, DOD, in compliance with the April 19, 2007 
report from the President's Task Force on Returning Global War on 
Terror Heroes, is working with VA toward developing an approach within 
current policies for VA and DOD collaboration on the DES.

               DOD AND VA JOINT INPATIENT MEDICAL RECORD

    Question 3. In January of this year, DOD and VA announced that the 
two departments would develop a joint inpatient medical record. But in 
his February report to Congress, the former Assistant Secretary of 
Defense for Health announced that the two departments were merely 
embarking on ``a six-month assessment'' of a strategy for achieving 
this important transition milestone. How many more years must we wait 
for complete medical records that can be easily shared between DOD and 
VA?
    Response. DOD is fully committed to working with VA to implement a 
joint inpatient electronic health record (EHR) system. Mr. Mansfield, 
Deputy Secretary for Veterans Affairs, and Dr. Chu, Under Secretary of 
Defense for Personnel and Readiness, identified the joint acquisition/
development of a new common inpatient EHR system as one of their top 
priorities for DOD and VA sharing.
    The full scope of the Armed Forces Health Longitudinal Technology 
Application (AHLTA), the DOD EHR, will support both outpatient and 
inpatient care. Support for outpatient care was the first priority for 
AHLTA. The inpatient component for AHLTA is targeted for a future 
version. The VA is undertaking a modernization of VistA, their EHR, 
which encompasses both outpatient and inpatient. While current VA and 
DOD health information sharing is significant, the information shared 
is primarily outpatient data with limited inpatient data. Given that 
DOD and VA are both in the process of developing and/or acquiring an 
inpatient EHR component, it was to our mutual advantage to explore the 
potential for working jointly.
    The joint DOD-VA inpatient EHR project includes a 6-month 
assessment of clinical processes and functional requirements that must 
be met by a joint DOD-VA inpatient EHR. There is clearly much 
commonality in the delivery of inpatient health care for DOD and VA, 
but there are also unique mission requirements that must be addressed. 
In addition, many existing information systems must provide data to or 
obtain data from the inpatient EHR. Therefore, it is critical that a 
solid assessment of requirements, business processes, and the existing 
technical environment be conducted in order to take the appropriate 
next steps to select the best approach to a joint inpatient EHR. 
Business process analysis and requirements definition is required under 
United States Code, title 40 (formally known as the Clinger-Cohen Act), 
prior to system acquisition and is consistent with best industry 
business practices for a project of this size and complexity.

    Question 4. Is there a plan to achieve a real goal, not just a 
study?
    Response. The Department of Defense (DOD) is fully committed to 
working with the Department of Veterans Affairs (VA) to implement a 
joint inpatient electronic health record (EHR) system. Mr. Mansfield, 
Deputy Secretary for Veterans Affairs, and Dr. Chu, Under Secretary of 
Defense for Personnel and Readiness, identified the joint acquisition/
development of a new common inpatient EHR system as one of their top 
priorities for DOD and VA sharing.
    The full scope of the Armed Forces Health Longitudinal Technology 
Application (AHLTA), the DOD EHR, will support both outpatient and 
inpatient care. Support for outpatient care was the first priority for 
AHLTA. The inpatient component for AHLTA is targeted for a future 
version. The VA is undertaking a modernization of VistA, their EHR, 
which encompasses both outpatient and inpatient. While current VA and 
DOD health information sharing is significant, the information shared 
is primarily outpatient data with limited inpatient data. Given that 
DOD and VA are both in the process of developing and/or acquiring an 
inpatient EHR component, it was to our mutual advantage to explore the 
potential for working jointly.
    The joint DOD-VA inpatient EHR project includes a six-month 
assessment of clinical processes and functional requirements that must 
be met by a joint DOD-VA inpatient EHR. There is clearly much 
commonality in the delivery of inpatient healthcare for DOD and VA, but 
there are also unique mission requirements that must be addressed. In 
addition, many existing information systems must provide data to or 
obtain data from the inpatient EHR. Therefore, it is critical that a 
solid assessment of requirements, business processes, and the existing 
technical environment be conducted in order to take the appropriate 
next steps to select the best approach to a joint inpatient EHR. 
Business process analysis and requirements definition is required under 
United States Code, title 40 (formally known as the Clinger-Cohen Act), 
prior to system acquisition and is also consistent with best industry 
business practices for a project of this size and complexity.
    The plan, including milestones for achieving a joint inpatient EHR, 
will be developed after the analysis of alternatives and agreement on 
the approach.

    Question 5. Are resources included in the President's budget 
request, or are we just buying time until the next commission comes to 
a similar conclusion: that DOD and the VA need to be able to share 
medical information electronically in order to facilitate the 
transition of patients from one system to the other?
    Response. The Joint Electronic Health Record Interoperability 
(JEHRI) program is funded across the Future Years Defense Program. The 
JEHRI program is the roadmap for the way the VA and DOD will share 
electronic health information to achieve health data interoperability 
and support the seamless transition from active duty status to veteran 
status.
    With regard to the DOD and VA joint inpatient medical record, as 
each department was planning a new inpatient electronic record 
acquisition or modernization, DOD and VA have initiated this joint 
assessment project. We anticipate a contract award to a study support 
contractor in May 2007. A 6-month study will produce an initial 
recommendation for a joint acquisition/development strategy. The DOD 
and VA will then evaluate alternatives for funding which will be 
incorporated into future President's Budget requests.

                PROJECTION OF FUTURE HEALTH CARE NEEDS 
                         BY AMERICA'S VETERANS

    Question 6. A column by Harvard researcher Linda Bilmes asserts 
that ``the seeds of the Walter Reed Army Medical Center scandal were 
sown in . . . a failure to foresee the sheer number and severity of 
casualties.'' Do you agree with that statement?
    Response. Not exactly. It is true that the volume of Medical 
Evaluation Board (MEB) cases for the Army significantly increased from 
6,560 cases in FY 2002 to approximately 11,000 cases in each of the 
last two FYs (2005 and 2006). In addition, the number of Physical 
Evaluation Board (PEB) cases rose from just over 9,000 cases in 
calendar year (CY) 2001 to a peak of over 15,000 cases in CY 2005. The 
increased volume resulted in the Army augmenting the Medical Treatment 
Facility staffs conducting the MEB process. The Army also doubled the 
number of adjudicators in their existing PEBs and established a mobile 
PEB to accommodate the increased volume. The severity of the cases is 
well known and is a result of improvements in treatment that allowed 
Servicemembers to survive injuries that previously would not have been 
possible. In approximately 70 percent of all cases, the Military 
Departments are meeting the processing MEB and PEB timeline goals.

    Question 7. What joint planning or analytical process exists today 
between DOD and the VA that did not exist in the past which will ensure 
a more complete understanding of the near- and long-term needs of our 
returning servicemembers?
    Response. The DOD and VA developed the VA/DOD Joint Strategic Plan 
(JSP) in 2003. The JSP contains a number of specific targets and 
actions under each performance goal. The Fiscal Year (FY) 2007-2009 JSP 
was approved and signed by the co-chairs of Joint Executive Council 
(JEC) in January 2007. Each goal, objective, and strategy was reviewed 
to reflect the current climate of DOD/VA joint collaboration. Roles and 
responsibilities of the entities under the JEC structure were 
clarified, specific performance metrics were developed, and VA/DOD JSP 
goals and objectives were linked to departmental strategic plans. JSP 
objectives and measures are tracked monthly by the Health Executive 
Council and Benefits Executive Council work groups and reported to the 
JEC. It is reviewed and updated annually. JSP progress is reported in 
the annual report to the Secretaries and Congress.
    The guiding principles of the JSP are:

     Collaboration--to achieve shared goals through mutual 
support of both our common and unique mission requirements.
     Stewardship--to provide the best value for our 
beneficiaries and the taxpayer.
     Leadership--to establish clear policies and guidelines for 
VA/DOD partnership, promote active decision-making, and ensure 
accountability for results.
    JSP Mission--To improve the quality, efficiency, and effectiveness 
of the delivery of benefits and services to veterans, Servicemembers, 
military retirees, and their families through an enhanced VA and DOD 
partnership.
    JSP Vision--A world-class partnership that delivers seamless, cost-
effective, quality services for beneficiaries and value to our nation.

    The strategic goals of the JSP are:

     Goal 1: Leadership Commitment and Accountability--Promote 
accountability, commitment, performance measurement, and enhanced 
internal and external communication through a joint leadership 
framework.
     Goal 2: High Quality Health Care--Improve the access, 
quality, effectiveness, and efficiency of health care for beneficiaries 
through collaborative activities.
     Goal 3: Seamless Coordination of Benefits--Improve 
understanding of, and access to, services and benefits that uniformed 
Servicemembers and veterans are eligible for through each stage of 
their life, with a special focus on ensuring a smooth transition from 
active duty to veteran status.
     Goal 4: Integrated Information Sharing--Ensure that 
appropriate beneficiary and medical data is visible, accessible, and 
understandable through secure and interoperable information management 
systems.
     Goal 5: Efficiency of Operations--Improve management of 
capital assets, procurement, logistics, financial transactions, and 
human resources.
     Goal 6: Joint Contingency/Readiness Capabilities--Ensure 
the active participation of both agencies in Federal and local incident 
and consequence response through joint contingency planning, training, 
and conduct of related exercises.
       mandatory separation physicals for military servicemembers
    Question 8. The President's Task Force to Improve Health Care 
Delivery for Our Nation's Veterans recommended in May 2003 that the DOD 
and VA should implement a mandatory single separation physical to 
accelerate determinations of benefits and increase access to care for 
those veterans eligible for VA benefits. What is the status of DOD's 
implementation of this important one-stop shopping concept to ease 
transition for military servicemembers?
    Response. The VA and DOD signed a Memorandum of Agreement (MOA) on 
November 17, 2004, establishing a cooperative separation process/
examination. This initiative was established to provide transition 
assistance and continuity of care to Servicemembers who are separating 
from active duty. Under this MOA, Servicemembers can begin the claims 
process with VA up to 180 days prior to separation through VA's 
Benefits Delivery at Discharge (BDD) program. The MOA also stipulates 
that only one examination is to be conducted which meets the needs of 
the VA and the military using VA's examination protocols. This MOA 
builds upon the prior successes of the BDD program over the past 
several years. VA has implemented the BDD program at 140 BDD sites in 
the United States plus two overseas sites. 130 of the 140 are VA/DOD 
sites and all of these targeted sites have signed Memoranda of 
Understanding between DOD and VA related to the BDD. Not all 
Servicemembers receive a physical examination when receiving transition 
assistance at a BDD site, and not all Servicemembers' physical 
examinations or transition assistance are received at a BDD site. The 
BDD program is expanding to the Navy in San Diego, California. BDD can 
commence 180 days before discharge, and is briefed to Servicemembers 
within the transition assistance program. The examinations must take 
place no more than 6 months before discharge in order to ensure that 
the exam is timely and has currency relative to the date of discharge. 
This has extra importance if the claim ever goes to appeal. In Fiscal 
Year 2006, approximately 40,000 BDD claims were completed, averaging 68 
days of completion time. DOD has created a stretch goal of reaching 100 
percent BDD use for Servicemembers receiving their separation/
retirement physical at one of the 140 BDD sites.

    Question 9. What is the impediment or objection to full 
implementation of this policy by the two departments?
    Response. Department of Defense (DOD) memorandum, dated October 14, 
2005, Subject: ``Policy Guidance for Separation Physicals Exams,'' 
states ``Compliance with this statutory requirement is a priority and 
will require a concerted effort by Military Treatment Facilities (MTFs) 
and commands and commanders at all levels.''
    DOD works closely with the Department of Veterans Affairs (VA) on a 
daily basis to expand awareness and use of the coordinated separation 
process that meets the needs of the VA disability compensation 
evaluation and the DOD separation retirement assessment. Currently, 
Memoranda of Understanding between local MTFs, Veterans Health 
Administration medical centers, and Veterans Benefits Administration 
regional offices are in place at 130 sites across the country. Under 
the auspices of these memoranda, VA representatives begin assisting 
Servicemembers in filing disability claims as early as 6 months before 
discharge. Not all Servicemembers receive a physical examination when 
receiving transition assistance at a Benefits Delivery at Discharge 
(BDD) site, and not all Servicemembers' physical examinations or 
transition assistance are received at a BDD site. DOD has created a 
stretch goal of 100 percent of Servicemembers departing due to routine 
separation or retirement at one of the 140 BDD sites receive a 
separation/retirement physical.
    VA is participating in the reinvigorated DOD Disability Advisory 
Council. A key objective of this collaboration is to develop a process 
in which VA is a part as early in the DOD disability evaluation process 
as possible. This objective is consistent with the suggestions and 
recommendations for improvement contained in the Global War on Terror 
Heroes Task Force Report to the President and the Final Report of the 
Independent Review Group, submitted to the Secretary of Defense.

                 PRIVACY RULES AND THE SHARING OF DOD 
                       AND VA MEDICAL INFORMATION

    Question 10. Congress enacted the Health Insurance Portability and 
Accountability Act (HIPAA) of 1996 (Public Law 104-191) to prevent the 
disclosure of certain personal medical information, but permits DOD and 
VA to share information on individuals being treated in both systems. 
Yet HIPAA is often cited as a barrier to easy sharing of health data 
between DOD and VA. In 2003 a Presidential task force recommended that 
the two departments be declared a single health care system for the 
purposes of implementing HIPAA--in order to smooth transition of 
servicemembers from DOD to the VA, and to accelerate the development of 
shared health care information technology. What did the two departments 
do, if anything, in response to this recommendation?
    Question 11. Why is HIPAA still cited as a barrier to information 
sharing?
    Response. Certainly, the Department of Defense (DOD) and the 
Department of Veterans Affairs (VA) must ensure that they comply with 
the requirements of the Department of Health and Human Services (HHS) 
HIPAA privacy final rule whenever they use or disclose the protected 
health information of patients. For this reason, whenever new 
information sharing initiatives are proposed, how compliance with the 
HHS HIPAA Privacy Final Rule will be achieved is among the matters 
discussed and documented. DOD has not cited the HHS HIPAA privacy final 
rule as a barrier to sharing that protected health information with the 
VA when it makes sense to do so. The DOD and VA, by making maximum use 
of the authority provided in the HHS HIPAA privacy final rule to share 
protected health information for purposes of treatment at time of 
separation and between covered government entities providing public 
benefits, are currently sharing protected health information at 
unprecedented levels and continue to implement new initiatives in this 
regard.
                                 ______
                                 
Response to Written Questions Submitted by Hon. John D. Rockefeller IV 
    to Hon. Gordon England, Deputy Secretary, Department of Defense

    Question 1. Given the recent GAO report's finding that policies and 
guidance for military disability determinations differ between 
services, Secretary Gordon England, do you consider this a problem? 
What have you done to address this disparity? And what is the 
difference between military retirement and temporary military 
retirement? How long can temporary retirement and those benefits last? 
What is the median time for temporary retirement benefits? Why hasn't 
disability decision making process been examined for its consistency 
across DOD and within individual services? Who should review the 
consistency of this process? How does it compare with VA's process?
    Response. We are addressing perceived disparities among the 
Military Departments. Training on application of the rating schedule, 
centralized rating decisions, and continuous review of disposition data 
will all improve consistency. We are working to improve in all these 
areas.
    I should note, however, that the GAO's detailed statistical 
analysis concluded that for a given condition, ratings were consistent 
between active and Reserve members. That may indicate there is more 
consistency than is perceived.
    According to title l0, United States Code, chapter 61, 
Servicemembers are placed on the Temporary Disability Retirement List 
(TDRL) when they would be qualified for permanent disability 
retirement, but for the fact that the Servicemember's disability is not 
determined to be of a permanent nature and stable. Servicemembers are 
reevaluated every 18 months to ascertain permanency and stability of 
the disqualifying medical condition; members may be retained on the 
TDRL for 5 years, after which time the conditions are automatically 
considered permanent and stable and the Secretary must make final 
disposition of the case. Department analysis reflects that 
approximately 55 percent of the Servicemembers separated with severance 
from the TDRL served less than 4 years. Temporary retirement provides 
the Servicemember the benefits of normal retirement with the exception 
that the monthly retirement pay can be no less than 50 percent of the 
high three base pay average and no more than 75 percent.
    To deal with the several issues you raise, the Department formally 
established the Disability Advisory Council, created annual and 
quarterly Physical Evaluation Board reporting and verification 
mechanisms, clarified timeliness goals and other performance measures, 
and formally elevated program awareness to senior leadership levels.

    Question 2. The Health Executive Council established a VA/DOD 
Mental Health Working Group (MHWB) to focus on increasing the 
collaboration between VA and DOD on mental health services to both VA 
and DOD beneficiaries. An assessment of opportunities for greater 
collaboration on mental health issues were in education, administration 
and transition of care. What has been done with these recommendations? 
Can you walk me through the process and provide a time frame from 
recommendations to implementation?
    Response. The VA/DOD MHWB has collaborated on a number of 
initiatives in the areas of education, administration, and seamless 
transition. In education, the work group supported a training event 
utilizing the VA's Electronic Education System (EES). The topic evolved 
from the knowledge that Reserve component Servicemembers are being 
followed for significant mental health conditions in the VA. Many of 
these members are subject to deploying again. On March 29, 2006, DOD 
and VA mental health providers explored the ethical dimensions of 
sharing mental health records across departments. This generated high 
interest and utilized the full capacity of the EES. The new role of the 
VA taking care of Servicemembers who would return to active duty was 
explored.
    The work group is also collaborating to disseminate evidence-based 
psychotherapeutic techniques across the VA and DOD. Subject matter 
experts will conduct train-the-trainer seminars for both VA and DOD 
mental health providers. Three mental health providers will receive 
additional specialized training from the Air Force, Navy, and Marine 
Corps. Six Army mental health providers will be the trainers of other 
providers in these techniques. Implementation of this shared program 
will begin the last quarter of Fiscal Year (FY) 2007 and carry over 
into FY 2008. This is in addition to other training programs available 
to providers in other venues and those sponsored by Service branches.
    Administratively, the VA/DOD MHWB explored a number of areas of 
mutual concern. VA clinicians did not have clear direction from DOD on 
what mental health diagnoses/treatment regimens were identified as 
deployment-limiting conditions. DOD published policy guidance for 
deployment-limiting psychiatric conditions and medications internally 
and posted this information on its Internet site on November 7, 2006. 
VA/DOD MHWB collaboration facilitated coordination of this policy and 
additional internal guidance to ensure that VA clinicians who may be 
treating National Guard or Reserve members can utilize this DOD 
guidance to ensure the best care for the subject individuals in the 
face of their military career concerns.
    In addition, there was not a clear understanding about the degree 
to which DOD Servicemember information was available in the Bilateral 
Health Information Exchange (BHIE) system. DOD Pre- and Post-deployment 
Health Assessment and Reassessment (PPDHA) data for over 680,000 
Servicemembers have been sent to the VA with ongoing input of 
subsequent PPDHAs, and Post-deployment Health Reassessments. Work group 
communication resulted in the VA publishing an internal information 
note (``Hey VA Have You Heard'') to advise VA clinicians of the 
information available in the BHIE and how to access it as needed for 
treatment of Operation Iraqi Freedom/Operation Enduring Freedom 
veterans. It is anticipated that, in October 2007, medical and mental 
health electronic encounter notes will be visible throughout both 
departments via the BHIE.
    Also administratively, it was unclear on web sites whether VA 
clinical practice guidelines for various mental health conditions also 
applied to DOD. As these clinical practice guidelines are co-developed 
by both departments, sites were modified to clearly indicate they are 
shared VA-DOD clinical practice guidelines, reinforcing common 
practices.
    Regarding seamless transition issues, the VA/DOD MHWB is committed 
to improve methods and strategies to ensure appropriate care for 
Reserve component members who are released from active duty with an 
ongoing health care requirement or need to maintain continuity of care 
across the VA and DOD health care systems. Areas of concern include 
leveraging community care resources to ensure a comprehensive safety 
net for behavioral health care and improving strategies to include 
methods to identify, track, and provide access for treatment for 
behavioral health issues. This requires active VA collaboration with 
existing Guard and Reserve, and State and regional coalitions to 
address the mental health and readjustment needs of Operation Iraqi 
Freedom and Operation Enduring Freedom veterans. The work group 
recommended a target of 90 percent or greater of existing Guard and 
Reserve or regional coalitions to include both Veterans Health 
Administration mental health and Vet Center staff as members by 
September 30, 2007.
    Currently, members of the VA/DOD MHWB are identifying Reserve 
component best post-deployment practices with the intent to disseminate 
such information and make policy recommendations based upon findings.

    Question 3. At an earlier hearing this year, VA testified that 
disability claims for PTSD more than double since 2000, from 130,000 to 
nearly 270,000 VA claims. Such claims are hard to process, and even 
harder to ensure consistency. What efforts are underway to help Guard 
and Reserves get screened for PTSD, and get the care and benefits they 
deserve during their 2-year window of eligibility? And I believe that 
this should be extended to at least 5 years. Is DOD and/or VA studying 
how delays in care and disability benefits affects soldiers who are 
struggling with mental health issues, particularly PTSD? How can such 
stress be minimized?
    Response. Currently, there are multiple efforts to ensure that PTSD 
is recognized and identified early before it becomes a chronic health 
condition. All Servicemembers receive global health assessments at 
least three times post-deployment. All assessment procedures include a 
review of possible PTSD and other deployment-related mental health 
condition and concerns. Servicemembers participate in the Post-
deployment Health Assessment immediately at the end of deployment, the 
Post-deployment Health Reassessment at three to six months after they 
return home, and the Periodic Health Assessment annually, which 
includes the Reserve Components as specified in DOD Policy in DOD 
Instruction 6025.19, paragraph 6.1, as part of their Individual Medical 
Readiness requirement.
    In addition, there are repeated education and outreach efforts to 
increase awareness of the signs and symptoms associated with PTSD and 
the sources of care available. This public education campaign is 
assisting veterans who are now recognizing their mental health symptoms 
and seeking both treatment and disability, when appropriate. One of 
DOD's efforts is the Mental Health Self Assessment Program, which is a 
voluntary and anonymous method for Servicemembers, veterans, and their 
family members to learn more about signs and symptoms associated with 
PTSD and where to go for counseling or treatment. This program is 
available 24 hours a day on the Internet and by telephone, in addition 
to health fairs held throughout the year to provide in-person screening 
and assessment. For Servicemembers and families who may need counseling 
on readjustment after deployment or need further assistance in locating 
sources of care, Military OneSource provides 24-hour access to a 
counselor. In addition, each veteran who enters the VA health care 
system completes a PTSD screening questionnaire to determine if there 
are signs and symptoms that have not been otherwise identified. The 
Managed Care Support Contractors are also enhancing mental health 
support. As an example, in a recent press release, TRIWEST announced 
they have set up a Behavioral Health Center for Service Members' 
Families.
    DOD and VA are studying mental health issues both jointly and 
separately. The Mental Health Task Force (MHTF) report sets forth 
recommendations to continue the longitudinal Millenium Cohort Study 
that addresses these issues, and notes the need for greater 
collaboration between DOD and VA on future longitudinal studies. The 
report also recommended more emphasis and priority on family issues. 
The DOD/VA Joint Executive Council Workgroup on Mental Health serves as 
a forum to address these issues. DOD is convening a Psychological 
Health Summit to incorporate the MHTF recommendations.
    We are not aware of any studies on the impact of delays in care or 
disability determination. DOD and VA are working to minimize stress on 
Servicemembers by minimizing delays while maximizing psychotherapy and 
medical treatments in a supportive psychosocial environment.

    Question 4. How are DOD and VA treating our National Guards and 
Reserves as well as their families? What special outreach is underway? 
And isn't it odd the less Guards and Reservists are seeking service 
than active duty? One would intuitively think that active duty soldiers 
have more training and support? Could it be that Guard and Reservists 
just unaware of the options and benefits?
    Response. DOD and the National Guard and Reserve family programs 
prepare, support, and sustain families when their military members are 
activated and/or deployed. Support is facilitated through education, 
outreach services, and partnerships by leveraging resources, training, 
and constantly capitalizing on new capabilities, concepts, and 
technological advances.
    The National Guard has a strong joint service family support 
network, organized in each State and territory by the National Guard 
State Family Program Director, and reinforced by a Wing Family Program 
Coordinator at each Air National Guard Wing. While limited full-time 
support staff at headquarters and some other locations around the 
country lead the day-to-day activities for providing family readiness 
support to commanders, Servicemembers and families, volunteers, and the 
Family Readiness Network are the heart of this program, and the unit 
level Family Readiness Group volunteers provide vitality to the 
program.
    Approximately 330 Family Assistance Centers (FACs) are regionally 
based and are the primary entry point for all services and assistance 
that any military family member, regardless of Service or component may 
need during the deployment process. This process includes the 
preparation (pre-deployment), sustainment (actual deployment), and 
reunion phases (reintegration). The primary services provided by the 
FACs are information, referral, outreach, and follow-up to ensure a 
satisfactory result.
    Joint Force Headquarters Commands (JFHCs) within each State, 
territory, and the District of Columbia are responsible for 
coordinating family assistance for all military dependents, regardless 
of Service and component, within the State and in the geographically 
dispersed areas beyond the support capability of military facilities. 
To coordinate family assistance, each JFHC is authorized one State 
Family Support Director.
    Military OneSource (www.militaryonesource.com) is a key resource 
available to National Guard and Reserve members and their families. 
OneSource supplements existing family programs with a 24-hour, 7 days a 
week, toll-free information and confidential referral telephone and 
Internet/web-based service. It is available at no cost to Guard and 
Reserve members and their families, regardless of their activation 
status. OneSource provides information ranging from everyday practical 
advice to deployments/reintegration issues and will provide referrals 
to professional civilian counselors for assistance.
    Military Family Life Consultants (MFLCs) are another resource 
available to National Guard and Reserve families. The goal of the MFLC 
is to prevent family distress by providing education and information on 
family dynamics, parent education, available support services, and the 
effects of stress and positive coping mechanisms.
    A Regional Joint Family Support Model is being designed per 
direction in the Fiscal Year 2007 National Defense Authorization Act. 
Critical components of the model involve building coalitions and 
connecting Federal, State, and local resources and nonprofit 
organizations to support Guard and Reserve families. Best practices 
learned from more than 22 inter-Service Family Assistance Committees 
and the Joint Service Family Support Network will guide the planning 
process. Minnesota will serve as a model.
    The VA Office of Seamless Transition has implemented a robust 
outreach program for all separating Servicemembers/veterans. These 
interactions with new veterans include the offering of Transition 
Assistance Program (TAP) and TAP for Disabled Veterans briefings at the 
demobilization stations, and, when they return home, National Guard and 
Reserve units request VA participation at family day events, Post-
deployment Health Reassessments (PDHRAs), Freedom Salute, and family 
reunions. These new veterans are Guard/Reserve members who now return 
to Reserve status and live in rural areas of the State. VA also 
partnered with the National Guard for their hiring/VA training for 
Transition Assistance Advisors (TAA) to be the point of contact for 
returning veterans in the State and to enhance access to VA services 
and community organizations in rural areas. VA has collaborated with 
National Guard and DOD family programs. These partnerships have granted 
VA access to Soldiers/Sailors/Marines/Airmen and Coast Guard veterans 
as well as family members to educate them on VA services and benefits 
that are available to them in rural areas. Due to this partnership, 
TAAs are energizing the formation of State VA/National Guard coalitions 
to ensure any returning veteran in need will have access to VA and/or 
community resources. VA is also participating in PDHRA events at the 
unit level with VA eligibility staff, Vet Center staff, and TAAs who 
discuss VA health care services and benefits that they are eligible to 
receive. To track effectiveness of outreach activities to this 
population, rates for utilization of Veterans Health Administration 
services are monitored quarterly to identify those on active duty, 
National Guard, and all other Reserves who use VA health care. Outreach 
staff members continue to brief the senior leadership in the Guard/
Reserve and family program directors on VA services and benefits by 
providing monthly conference calls to the TAAs, national conferences, 
booth displays, and close ties with family programs.

VA/DOD JOINT EXECUTIVE COUNCIL FY 2006 ANNUAL REPORT PUBLISHED FEBRUARY 
                                  2007

    Question 5. The Joint Executive Council (JEC) was established by 
Congress and has been meeting for 4 years. However, it has taken 4 
years to produce broad recommendations and the group proposed 
additional working groups to examine the issues further. In July 2006, 
the JEC approved a proposal to establish a VA/DOD Joint Coordination 
Transition Working Group that will be focused on achieving an even 
greater integrated approach to coordinated transition for injured and 
ill servicemembers and their families. Why did the JEC feel a group 
needed to be developed in order to achieve this approach? Who has been 
chosen/assigned to this working group? Have they met yet? If so, what 
have they developed so far? Why has it taken so long to acknowledge 
this problem needed another group to address transition issues for 
injured and ill servicemembers? The JEC has been meeting for 4 years 
and was established by Congress. However, it has taken 4 years to 
produce broad recommendations and proposed additional working groups to 
examine the issue further. I would request a breakdown of each council, 
working group, members of each, and dates of meetings. This information 
would be helpful in determining their level of commitment to the joint 
project(s).
    Response. First, I should note that the Joint Executive Council was 
originally established by the two cabinet departments, and later 
sanctioned by the Congress in statute.
    The VA created an Office of Seamless Transition in the VA central 
office in January 2005. Its mission is to improve coordination between 
the Veterans Health Administration, the Veterans Benefits 
Administration, and the DOD, and to ensure appropriate VA policies and 
procedures are in place to enhance seamless transition of health care 
and disability services. This VA office began interacting with 
individual Military Treatment Facilities to place VA social workers and 
benefits counselors to assist severely injured Servicemembers and their 
families during the transition to the VA.
    The VA/DOD JEC approved the establishment of a VA/DOD Coordinated 
Transition Working Group. The JEC decided this working group would be 
an excellent solution to integrate the various DOD and VA support 
services, which are needed by all Servicemembers who are transitioning 
their medical care and benefits from DOD to VA.
    Attached, please find information on the DOD/VA Executive Councils 
as well as the Fiscal Year 2006 JEC Annual Report to Congress that 
describes the collaborative efforts of DOD and VA.

[GRAPHIC] [TIFF OMITTED] T5997.040


JEC Charter
     Oversee development and implementation of VA/DOD Joint 
Strategic Plan (JSP)
     Oversee Health and Benefits Executive Councils
     Identify opportunities (policy, operations, and capital 
planning) to enhance mutually beneficial coordination
     Submit Annual Report to Secretaries on progress to-date on 
JSP
JEC Membership
DOD
     Under Secretary of Defense (Personnel and Readiness)--Co-
Chair
     Principal Deputy Under Secretary of Defense (Personnel and 
Readiness)
     Assistant Secretary of Defense (Health Affairs)
     Principal Deputy Assistant Secretary of Defense (Health 
Affairs)
     Deputy Chief Information Officer
     Assistant Secretary of the Air Force (Manpower and Reserve 
Affairs)
     Assistant Secretary of the Army (Manpower and Reserve 
Affairs)
     Assistant Secretary of the Navy (Manpower and Reserve 
Affairs)
     Deputy Director of Contract Policy and Administration
VA
     Deputy Secretary, Veterans Affairs--Co-Chair
     Under Secretary for Health
     Under Secretary for Benefits
     Assistant Secretary for Policy, Planning and Preparedness
     Assistant Secretary for Management
     Assistant Secretary for Information and Technology
     Counselor to the Secretary of Veterans Affairs
JEC Committees, Steering Groups and Workgroups
Joint Strategic Planning Committee
     To improve the quality, efficiency and effectiveness of 
the delivery of benefits and services to veterans, servicemembers, 
military retirees and their families through an enhanced VA and DOD 
partnership
Construction Planning Committee
     Provide an integrated approach to the oversight and 
coordination of joint capital asset planning and investment to ensure 
maximum benefit
Joint Health Care Facility Operations Steering Group
     Provide direct oversight of all HEC approved joint 
facility initiatives, including submission to the HEC of recommended 
courses of action to reach early issue resolution and problem solutions
Coordinated Transition Workgroup
     Foster an integrated approach and common understanding of 
coordinated transition as it pertains to injured and/or ill 
servicemembers and their families who are eligible for VA benefits and 
services
Communications Workgroup
     Oversee and implement the joint communications efforts 
outlined in the VA/DOD JSP
     Improve information flow between the two departments and 
ensure coordinated messages and statistics are communicated
     Maintain and comply with the approved joint communications 
plan
BEC Charter
     Examine ways to expand and improve information sharing
     Refine process of records retrieval and identify 
procedures to improve benefits claims process
     Streamline the transition process from active duty to 
veterans status including the standardization of the cooperative 
physical examination protocol, interoperability and data sharing
BEC Membership
DOD
     Principal Deputy Under Secretary of Defense (Military 
Community and Family Policy)
     Deputy Under Secretary of Defense (Military Personnel 
Policy)
     Deputy Under Secretary of Defense (Civilian Personnel 
Policy)
     Deputy Under Secretary of Defense (Program Integration)
     Assistant Secretary of Defense (Health Affairs)
     Assistant Secretary of Defense (Reserve Affairs)
VA
     Under Secretary for Benefits (USB)
     Associate Deputy Under Secretary for Policy and Program 
Management (VBA)
     Deputy Chief Information Officer for Benefits (VBA)
BEC Workgroups
Benefits and Services
     Enhance collaborative efforts to educate active duty, 
Reserve, and National Guard personnel on VA and DOD benefits programs, 
eligibility criteria and application processes
Cooperative Physical Exam
     Review laws, policies, and procedures pertaining to 
separation in order to develop a DOD/VA cooperative physical assessment 
protocol
Information Sharing/Information Technology
     Develop interoperable date repositories that will form the 
backbone for all sharing electronic military personnel information; 
interoperable software applications; and the adoption and 
identification of common data, architecture, communications, security 
and software standards
Medical Records
     Address Health Treatment Record (HTR) issues and 
facilitate resolution and review the paper HTR business process within 
the Departments as required
HEC Charter
     Oversee development and implementation of VA/DOD JSP
     Oversee Workgroups
     Identify opportunities (policy, operations, and capital 
planning) to enhance mutually beneficial coordination
     Submit Annual Report to JEC on progress to-date on JSP
HEC Membership
DOD
     Assistant Secretary of Defense (Health Affairs)--Co-Chair
     Principal Deputy Assistant Secretary of Defense (Health 
Affairs)
     Surgeon General of the Army
     Surgeon General of the Navy
     Surgeon General of the Air Force
     Deputy Assistant Secretary of Defense (Health Budgets and 
Financial Policy)
     Deputy Assistant Secretary of Defense (Force Health 
Protection and Readiness)
     Deputy Assistant Secretary of Defense (Clinical and 
Program Policy)
     Chief Operating Officer, TRICARE Management Activity
     Chief Information Officer, Military Health System
VA
     Under Secretary for Health
     Deputy Under Secretary for Health
     Deputy Under Secretary for Operations and Management
     Chief of Staff, VHA
     Chief, DOD Coordination Officer
     Chief Financial Officer
     Chief Information Officer
     Chief Patient Care Services Officer
     Chief Public Health and Environmental Hazards Officer
HEC Workgroups
Acquisition and Medical Materiel Management Workgroup
     Combine medical supply requirements to leverage volume and 
negotiate better pricing
     Eliminate duplication of contracting and contract 
administration effort
     Allow customers to select products and pricing
     Identify new business practices
Case Management Workgroup
     Define and utilize a clinical case management model to 
address the transition issues of our servicemembers and veterans
     Support the delivery of comprehensive healthcare 
regardless of the care delivery setting
Continuing Education Workgroup
     Enhance the open and ongoing dialogue between the 
departments on continuing education and training infrastructure and 
operations issues
     Identify opportunities for joint educational contracts and 
co-development of training programs of mutual interest and benefit
     Design and develop a strategy to facilitate sharing of 
education and training opportunities particularly those that take 
advantage of distributed learning architectures
Contingency Planning Workgroup
     Enhance collaborative efforts in support of the VA/DOD 
Contingency Plan and the National Disaster Medical System
     Review and update the VA/DOD Contingency Memorandum of 
Understanding and Plan to reflect current and future DOD requirements
Deployment Health Workgroup
     Establish an open dialogue between Departments on issues 
of deployment health
     Collaborate on review of VA's Congressionally mandated 
report on Gulf War illnesses, and other related reports
     Identify and foster opportunities for sharing information 
and research between VA, DOD, and Health and Human Services
Evidence-Based Practice Workgroup
     Identify CPGs requiring clarification/modification to 
remove barriers and enhance sharing
     Develop recommendations for streamlining CPGs for 
specified clinical areas
     Develop tools to facilitate implementation of CPGs
     Monitor and evaluate published CPGs to identify strengths 
and resolve problems
Financial Management Workgroup
     Inter-departmental communication on resource management 
issues
     Review reimbursement policies and identify policies 
requiring modification/clarification
     Develop recommendations for improving financial processes 
and practices (create incentives)
     Resolve billing and reimbursement problems
     Joint incentive fund implementation guidelines
Graduate Medical Education (GME) Workgroup
     Review current state of GME between both departments
     Develop joint pilot program for GME
     Develop agreement for departments to implement and finance 
program
Information Management/Information Technology Workgroup
     Oversee the development and implementation of VA/DOD 
health IM/IT initiatives
Joint Facility Utilization and Resource Sharing Workgroup
     Identify areas for improved resource utilization
     Oversight of joint assessment study and demonstration 
projects
Mental Health Workgroup
     Increase collaboration between VA and DOD on the provision 
of mental health services to both VA and DOD beneficiaries
Patient Safety
     Improve continuity of care/patient safety
     Identify and implement best practices in patient safety
Pharmacy
     Joint evaluation of high dollar/volume pharmaceuticals
     Increase uniformity and improve clinical and economical 
outcomes of drug therapies
     Eliminate redundancies in class reviews, contracting 
prescribing guidelines, and utilization management
              dod military severely injured center (msic)
    Question 6. Prior to the Walter Reed incident, the Army requested 
the MSIC to remove its caseworkers from monitoring Army soldiers. Has 
this decision by the Army been reversed, and if not how has the MSIC 
role with the Army been recreated?
    Response. The Department of Defense (DOD) established the MSIC in 
December 2004 to augment support provided by the Military Services to 
severely injured Servicemembers and their families. Counselor-advocates 
were assigned to military installations and Department of Veterans 
Affairs medical facilities to provide non-medical support as needed.
    As part of a routine program assessment, staff from the Military 
Community and Family Policy office consulted with each of the Military 
Services to evaluate the support provided by the counselor-advocates. 
Leadership from the Army Wounded Warrior Program indicated a readiness 
and desire to accept total responsibility for delivery of services. As 
a result, on January 16, 2007, cases supported by the counselor-
advocates at Fort Campbell, Kentucky; Fort Carson, Colorado; Fort Drum, 
New York; Fort Hood, Texas; Fort Lewis, Washington; Fort Riley, Kansas; 
and Fort Stewart, Georgia, were transferred to soldier family life 
consultants with the Army Wounded Warrior program. The Army has 
increased the number of soldier family life consultants to 46 staff to 
support this mission.
    Counselor-advocates have continued to support Sailors and Marines 
receiving care at Brooke Army Medical Center, Texas; Camp Lejeune, 
North Carolina; Camp Pendleton, California; Palo Alto, California; San 
Diego, California; Tripler Army Medical Center, Hawaii; and Redstone 
Arsenal, Alabama.
                                 ______
                                 
       Respone to Written Questions Submitted by Hon. Evan Bayh 
    to Hon. Gordon England, Deputy Secretary, Department of Defense

    Question 1. My understanding is that active duty personnel, who 
suffer from TBI, have access to private facilities that contain the 
latest cognitive therapies but that care is not available to retirees 
in the VA system. Is that true? If so, why?
    Response. Rehabilitation therapy is covered under the TRICARE 
program. It is therapy to improve, restore, or maintain function, or to 
minimize or prevent deterioration of a function, of a patient when 
prescribed by a physician. The rehabilitation therapy must be medically 
necessary and appropriate care rendered by an authorized provider, 
necessary to the establishment of a safe and effective maintenance 
program, and must not be custodial, or otherwise excluded from 
coverage.
    Under the TRICARE Basic Program, the law requires all medical 
services to be medically necessary, that is, appropriate medical care 
which is in keeping with generally accepted norms for medical practice 
in the United States. Covered rehabilitation services for TBI patients 
may include physical, speech, occupational, and behavioral services. 
Under the TRICARE Basic Program, cognitive rehabilitation defined as 
``services that are prescribed specifically and uniquely to teach 
compensatory methods to accomplish tasks which rely upon cognitive 
processes'' are considered unproven and are not covered when separately 
billed as distinct and defined services. Coverage of ``a systematic, 
goal-oriented rehabilitation treatment program designed to improve 
cognitive functions and functional abilities to increase levels of self 
management and independence following neurologic damage to the central 
nervous system'' is excluded. Community and work integration training, 
and vocational rehabilitation are also excluded.
    Cognitive rehabilitation strategies can be integrated into these 
components of a rehabilitation program and may be covered when 
cognitive rehabilitation is not billed as a distinct and separate 
service. Beneficiaries, including active duty Servicemembers, may 
receive rehabilitation services in direct or purchased care facilities. 
Active duty Servicemembers may also receive TBI rehabilitation in 
specialized Veterans Affairs treatment centers.
    Some forms of Traumatic Brain Injury (TBI) rehabilitation 
(including cognitive rehabilitation) excluded from coverage under the 
TRICARE Basic benefit may be extended to active duty Servicemembers 
under the Supplemental Health Care Program (SHCP). Under the SHCP, 
active duty Servicemembers may receive care that is excluded under the 
TRICARE benefit if those services are potentially contributory to 
keeping or making the active duty patient fit to remain on active duty.
    The Department of Defense recognizes that change in coverage during 
transition from active duty to retired status can create disruptions of 
care for combat-wounded Servicemembers and is exploring the feasibility 
of testing strategies for mitigating this disruption using 
demonstration authority. The Department of Defense has commissioned a 
formal Technical Assessment of the current scientific evidence 
supporting cognitive rehabilitation intervention for TBI. This 
evaluation will be completed in August 2007. The Department will 
reevaluate its coverage policy for cognitive rehabilitation under the 
basic TRICARE benefit at that time.

              MEDICAL COVERAGE FOR TRAUMATIC BRAIN INJURY

    Question 2. As you mentioned during the hearing, Active Duty 
servicemembers who have incurred Traumatic Brain Injury (TBI) are able 
to access private rehabilitation facilities at the expense of the 
Department of Defense (DOD). Contrary to your testimony, however, once 
retired, I understand that TRICARE no longer covers such therapy. In 
fact, I have heard several personal stories from servicemembers and 
their families indicating that they were medically retired before 
learning of the apparent discrepancy in benefits, and, therefore, were 
precluded from accessing private facilities. Conversely, I have also 
heard from families of TBI patients fighting to stay on Active Duty for 
fear of losing their TRICARE eligibility for cognitive therapy in a 
private facility. Are medically retired servicemembers with TBI 
eligible to receive cognitive therapy in a private rehabilitation 
facility under TRICARE? If so, how are they informed of such an option, 
and why have the families with whom I have spoken asked for and been 
denied private care? If not, do you agree that such a discrepancy 
should be addressed to ensure that these severely injured warriors have 
options available to them?
    Response. Rehabilitation therapy covered under the TRICARE basic 
program is available to both active duty Servicemembers and retirees, 
and includes physician-prescribed therapy to improve, restore, or 
maintain function, or to minimize or prevent deterioration of patient 
function. Rehabilitation therapy under the TRICARE basic program must 
be medically necessary and appropriate care keeping with accepted norms 
for medical practice in the United States, rendered by an authorized 
provider, necessary to the establishment of a safe and effective 
maintenance program, and must not be custodial, or otherwise excluded 
from coverage.
    Covered rehabilitation services for TBI patients may include 
physical, speech, occupational, and behavioral services. Cognitive 
rehabilitation strategies may be integrated into these components of a 
rehabilitation program and may be covered under the TRICARE basic 
program when cognitive rehabilitation is not billed as a distinct and 
separate service. Beneficiaries, including active duty Servicemembers, 
may receive rehabilitation services in direct or purchased care 
facilities. Active duty Servicemembers and veterans may also receive 
TBI rehabilitation in specialized Department of Veterans Affairs' 
treatment centers.
    Under the TRICARE basic program, cognitive rehabilitation, defined 
as ``services that are prescribed specifically and uniquely to teach 
compensatory methods to accomplish tasks which rely upon cognitive 
processes,'' are considered unproven, therefore, not appropriate care 
keeping with accepted norms for medical practice in the United States 
and are not covered when separately billed as distinct and defined 
services. Post-acute, community reentry programs, work integration 
training, and vocational rehabilitation are also excluded. TBI 
rehabilitation excluded from coverage under the TRICARE basic benefit 
for retirees and dependents may be extended to active duty 
Servicemembers under the supplemental health care program (SHCP), if 
those services may potentially keep or make the active duty patient fit 
to remain on active duty.
    Coverage of cognitive rehabilitation by major health insurers is 
mixed. For example, Cigna, Aetna, and UniCare cover cognitive 
rehabilitation for TBI, when it is determined to be medically 
necessary. Cigna excludes coverage of cognitive rehabilitation for mild 
TBI. Regence and Blue Cross/Blue Shield consider cognitive 
rehabilitation to be investigational and do not provide coverage for 
it. There is no Medicare national coverage determination for cognitive 
rehabilitation for TBI. In determining whether a medical treatment has 
moved from unproven to proven, TRICARE reviews reliable evidence, as 
defined in 32 Code of Federal Regulations (CFR), Part 199. Research 
study of cognitive rehabilitation in neurological conditions, including 
TBI, is limited by differences between patients, and by variation in 
the type, frequency, duration, and focus of cognitive rehabilitation 
interventions. The TRICARE determination that cognitive rehabilitation 
for TBI is unproven is supported by a 2002 technical assessment 
performed by Blue Cross/Blue Shield (updated in 2006), and by a 2004 
technical assessment by Hayes, Inc. (also updated in 2006).
    Medical evidence is dynamic and evolving, however. We know that, in 
the future, some care considered unproven today will achieve the 
required evidence threshold and become covered under the TRICARE basic 
program. Care that is likely to become proven is periodically 
reevaluated to ensure that TRICARE coverage is current and consistent 
with the latest evidence. DOD therefore commissioned a formal technical 
assessment of the current scientific evidence supporting cognitive 
rehabilitation intervention for TBI. This evaluation will be completed 
in August 2007. DOD will reevaluate its coverage policy for cognitive 
rehabilitation under the TRICARE basic program at that time.
    DOD recognizes that, as a determination is made that an active duty 
patient will not be able to return to active duty service, and the 
transition is made from active duty to retired status, changes in 
coverage may result in discontinuity in care for combat-wounded 
Servicemembers. DOD is exploring the feasibility of testing strategies 
for mitigating potential disruption in care using demonstration 
authority.
                                 ______
                                 
     Response to Written Questions Submitted by Hon. Barack Obama 
    to Hon. Gordon England, Deputy Secretary, Department of Defense

    Question 1. Secretary Gates announced yesterday that tours would be 
extended from 1 year to 15 months for our active duty soldiers. Leading 
up to this decision, could you describe what additional steps the DOD 
took to plan for the impact of these extended tours on servicemembers 
and their families at home?
    Response. The Department recognizes that extended deployments place 
a heavy burden on Servicemembers and their families. In response, the 
Department established the Military and Family Life Consultant (MFLC) 
program to provide non-medical, short-term counseling to active duty 
Servicemembers and their families and to the National Guard and Reserve 
component Servicemembers and their families. The program augments 
existing military and civilian support services by providing as needed, 
short-term, situational, problem-solving counseling services when and 
where they are needed. The MFLC program assists individuals and 
families in dealing with the stress of deployment, family separations, 
reunions, and reintegration due to deployments, parent-child 
communications, anger management, school/academic issues, and more.

    Question 2. Is the DOD tracking who is serving in this war, and the 
potential impact on different groups of servicemembers? For example: 
how many single mothers are currently deployed in Iraq and Afghanistan? 
Do you have a sense of how many American children have one or more 
parents deployed?
    Response. Yes, we do track Servicemembers serving in the Global War 
on Terror (GWOT). Regarding the specific questions, on March 31, 2007, 
2,978 single mothers were currently deployed for GWOT and 205,629 
children had one or more parents currently deployed.

    Question 3. Last year's Defense Authorization Act required that 
servicemembers be screened for Traumatic Brain Injury and that all 
servicemembers receive postdeployment mental health screenings with 
clear criteria for follow-up referrals. Are these screenings occurring 
yet, and are they being conducted face-to-face?
    Response. The Department of Defense (DOD) implemented Post-
deployment Health Assessments (PDHAs) in the late 1990s. These 
assessments occur at the end of each operational deployment. The 
process consists of the Servicemember answering a series of questions 
on DD Form 2796 and then completing a face-to-face interview with a 
health care provider. The provider then clarifies all of the 
Servicemember's concerns, whether physical, mental, or environmental. 
To address health problems or concerns that emerge after returning 
home, the DOD implemented the Post-deployment Health Reassessment 
(PDHRA) program in 2005. This process is very similar to that described 
for the PDHA and includes a self-reporting tool (DD Form 2900). 
However, because the PDHRA is accomplished three to six months after 
returning, it is not possible to provide a face-to-face encounter in 
all cases because many of the Reserve component Servicemembers live far 
from active duty military installations and some Servicemembers have 
separated from military service. To ensure everyone has an opportunity 
to voice concerns and receive additional evaluation as clinically 
indicated, the DOD established roving onsite teams and a national call 
center.
    The PDHA and PDHRA self-reporting questionnaires have always 
contained questions about several general symptoms that are often 
associated with TBI or post-concussive syndrome and validated screening 
scales for several common mental health conditions, including Post 
Traumatic Stress Disorder, depression, relationship problems, and the 
potential for self-harm or loss of control. The PDHRA questionnaire 
specifically asks if the Servicemember was exposed to a blast or 
explosion during deployment. On March 8, 2007, the Assistant Secretary 
of Defense for Health Affairs issued direction to modify the DD Form 
2796 and DD Form 2900 to include additional TBI-specific screening 
questions with an effective date of June 1, 2007. These new questions 
follow the methodology recently developed by the Department of Veterans 
Affairs (VA) and reflect the decision of the DOD-VA Health Executive 
and Joint Executive Councils to use the same approach to TBI screening.

    Question 4. How many servicemembers have been diagnosed with 
Traumatic Brain Injury since the start of the war? How is the DOD 
tracking this information?
    Response. Approximately 2,700 Servicemembers injured since the 
start of the war have been found to have a TBI. Individuals identified 
as having TBI are tracked in databases at the Defense Veterans Brain 
Injury Center and at the National Naval Medical Center.

    Question 5. You spoke about the need for an improved disability 
rating system. It's great that we fix things going forward, but what 
should we do to address the cases that may have received a low rating 
previously? What kind of fair process should we put in place to 
reassess those cases where it appears the Army low-balled the rating 
for a given servicemember?
    Response. As we move forward with an improved system, we will 
maintain data to compare previous disability decisions with those of 
the new system or pilot. If the data indicate a need to review past 
decisions, then we will. In addition, in any case where there is 
evidence of improper application of statute, policy, or the disability-
rating schedule, the case will be referred to the respective Military 
Department's Board for Correction of Military Records.
                                 ______
                                 
      Response to Written Question Submitted by Hon. John Warner 
    to Hon. Gordon England, Deputy Secretary, Department of Defense

    Question. Regarding closing WRAMC as soon as possible and 
constructing a larger Army hospital at Fort Belvoir. What steps are you 
taking to accelerate the funding profile to initiate an earlier start 
at these two institutions?
    Response. Thank you for your interest in this critical issue. The 
Department is evaluating options and costs to accelerate the Bethesda 
and Fort Belvoir Base Realignment and Closure construction projects. We 
will keep Congress informed of our progress and recommendations.
                                 ______
                                 
    Response to Written Questions Submitted by Hon. Saxby Chambliss 
    to Hon. Gordon England, Deputy Secretary, Department of Defense

                         RATIO OF CASE MANAGERS

    Question 1. I understand that the only DOD regulation related to 
the number of case managers required to manage personnel in a medical 
hold status is a 1 to 35 ratio of case managers to Guard/Reserve 
personnel in a medical holdover unit. By implication, there are no 
regulations for the ratio of case managers to personnel for Active Duty 
personnel in a medical hold status. Do you believe that the 1 to 35 
ratio for medical holdover personnel is adequate and do you think that 
DOD should establish a requirement standard for case managers for 
Active Duty personnel in medical hold?
    Response. The ratio for case management to personnel is not a ``one 
size fits all'' answer, including Servicemembers in the medical hold 
status. The Department of Defense (DOD) Medical Management Guide, dated 
January 2006, outlines a suggested caseload for case managers. The 
ratio is determined on several factors, including the experience of the 
case manager, Military Treatment Facility and community-based 
resources, and other variables. Currently, DOD supports the Case 
Management Society of America's recommendations that are based on 
acuity of the patient as illustrated in the following table:


----------------------------------------------------------------------------------------------------------------
                  Level                              Amount                               Type
----------------------------------------------------------------------------------------------------------------
Acute...................................  8-10 cases.................  Early injury/illness stages (case manager
                                                                        performs all coordination).
Mixed...................................  25-35 cases................  Acute and chronic cases (some requiring
                                                                        semi-annual or annual follow-up, some
                                                                        needed full-time case manager
                                                                        coordination).
Chronic.................................  35-50 cases................  Cases requiring 1-2 hours follow-up/
                                                                        month.
----------------------------------------------------------------------------------------------------------------


    Question 2. One focus of complaints related to DOD's rehabilitation 
process has been the role of case managers in the process. To what 
extent are there prescribed regulations related to the duties and 
responsibilities of DOD case managers of medical hold and holdover 
personnel?
    Response. DOD Instruction 6025.20, Medical Management Programs in 
the Direct Care System and Remote Areas, gives specific guidance on 
responsibilities for case management. Specific guidance regarding 
medical holdover personnel is addressed in Section II-17 of the DOD 
Medical Management Guide, dated January 2006. Coordination of care from 
the Military Health System to the Department of Veterans Affairs is 
also addressed in the Medical Management Guide.

    Question 3. Is there a required training program for case managers 
and regulations that govern their specific responsibilities on behalf 
of servicemembers or do those regulations vary from installation to 
installation and Service to Service?
    Response. There is a required training program for case managers, 
and the TRICARE Management Activity (TMA) provides medical management 
training which includes case management. The medical management 
training is typically held annually in each of TRICARE's three regions. 
Participants include Military Treatment Facility providers, case 
managers, utilization managers, and disease management managers.
    Additionally, Department of Defense Instruction 6025.20, Medical 
Management Programs in the Direct Care System and Remote Areas, gives 
specific guidance on responsibilities for not only case management, but 
also disease and utilization management. Additionally, there are Web-
based modules available for case management training through the TMA.
    The Assistant Secretary of Defense for Health Affairs is convening 
the Military Healthcare System Case Management Summit on 15-16 May. An 
action plan will be developed at the multi-agency, multi-disciplinary 
meeting that focuses on the way forward for addressing policy, 
training, and information sharing issues/challenges for injured, ill, 
and wounded warriors.

    Question 4. One of the responsibilities of case managers should be 
to better educate soldiers on the medical evaluation and disability 
process. Is that in fact one of their responsibilities?
    Response. The Department of Defense is bringing all of the involved 
members together for a Case Management Conference on May 15-16, 2007, 
to outline all requirements and assign responsibilities. The role of 
educating Servicemembers on the Physical Evaluation Board (PEB) process 
has traditionally been the role of the PEB Liaison Officer and not the 
case manager. We have to be careful we do not ``medicalize'' command 
and personnel responsibilities. While it is true that the case managers 
can assist with the education of Servicemembers on the medical 
evaluation and disability process, their major role will be to provide 
care coordination; ensuring that the Servicemember gets the right care 
at the right place and at the right time.

                           EVALUATION BOARDS

    Question 5. One complaint I have heard regarding the MEB/PEB 
process is that it was established in the 1970s, is outdated, and is 
extremely bureaucratic. For an Active Duty servicemember, the process 
requires between 22 and 27 pieces of paper, and even more for a Guard/
Reserve member. Some would argue that given the numerous opportunities 
for appeals during the process, that it is overly biased toward the 
servicemember, and maybe that is the way it should be. We want to give 
our servicemembers every opportunity to get well and, if they desire, 
continue their service in the military. I would appreciate your 
comments on the MEB/PEB process, and your thoughts regarding--if you 
had to do a ``lean event'' to streamline and remove the excess time and 
steps in the process--what would you change to make it more efficient 
and cause it to better serve our men and women in uniform?
    Response. The Disability Evaluation System (DES), which consists of 
the MEB and PEB processes, is complex, sometimes adversarial, and 
burdensome. Much of that is related to the statutory imperative for a 
fair and impartial system that affords due process protections (boards, 
legal representation, witnesses, an appellate process, etc.). The DES, 
as set forth in statute, allows the Department to provide additional 
guidance, but ultimately, the Secretaries of the Military Departments 
operate their DES consistent with their roles and missions, and apply 
ratings in accordance with how they interpret application of the 
Veterans Affairs (VA) Rating Schedule for Disabilities (VASRD).
    The complex and adversarial nature of the DES is partially a result 
of the magnitude of the benefits associated with the decisions on the 
rating. The disability rating determines whether the individual will 
separate with severance or with retirement benefits. For many, there is 
strong motivation to be declared fit to remain in uniform, despite 
injuries that would suggest otherwise.
    There are concerns that the VASRD has not kept current with the 
knowledge and service job environment, especially for brain injuries 
and pain as compared to other more physical injuries.
    We are looking at wholesale redesign of the complex and arcane DES, 
which dates back to constructs from 1949, but we need authority to 
waive current laws in fielding a new system. There is substantial 
precedent for this. It is highly effective and it points the way to 
legislative changes that could be enacted next year, as needed. DOD 
needs empowerment to revolutionize DES, rather than a new set of 
compliance standards that only serve to reinforce the present, failed 
system. A demonstration authority would empower VA and DOD to operate a 
combined activity for rating those judged unfit by DOD. It would also 
authorize the establishment of benefits under programs that transcend 
present law, and allow rapid proof of new concepts and quick response 
to the needs of the disabled. VA and DOD jointly would define the 
framework for conducting the demonstration. The Secretaries of VA and 
DOD would partner in making determinations with regard to waiving 
existing statutes and in managing congressional reporting.

                       MEDICAL HOLDOVER PERSONNEL

    Question 6. One key to effectively handling medical holdover 
personnel is by having active and engaged case managers. The Army has 
three medical holdover units in Georgia, at Fort Gordon, Fort Benning, 
and Fort Stewart. The Fort Benning medical holdover unit relies in part 
on contract case managers. I am not fundamentally opposed to 
contractors performing this function, but I do think it can put the 
mission at risk if the contract expires and new case managers cannot be 
recruited and hired in time to replace the old ones. Do you think there 
should be a regulation requiring a certain percentage of case managers 
to be DOD civilians or military personnel?
    Response. Military personnel do not provide all health care in the 
DOD Military Health System. Federal civilians and contract staff 
supplement the military medical professionals in virtually all 
settings. Similarly, case management is not conducted using only 
military providers. Contract personnel are required to accomplish an 
activity of such scope and volume. However, it would not be good 
practice to mandate specific percentages for the mix of case managers. 
Instead, the mix at any particular medical care facility should be 
determined by the workload, budget, and other operational factors for 
that location.

    Question 7. In the event that contractors are utilized, what are 
you doing to ensure the medical holdover mission is not compromised and 
that our soldiers receive the necessary advocacy when they are in a 
medical holdover unit?
    Response. Supervision of all Servicemembers and the personnel 
supporting them takes an active and engaged command. Each Military 
Service will stay actively engaged in the care of all of its 
Servicemembers to ensure there are no lapses.

                     SHORTAGE OF MEDICAL PERSONNEL

    Question 8. My staff traveled across the State of Georgia last week 
and visited three DOD hospitals, and one comment that surfaced at every 
installation related to the Army's inability to offer attractive enough 
incentives to hire the doctors and nurses they need to execute their 
mission, as well as an overly burdensome bureaucratic hiring and 
contracting process that prevents military bases from getting the 
military, civilian, and contract health care providers that they need 
when they need them. I think you will agree that this is a problem 
across DOD. In my mind, we ought to be able to do whatever we need to 
streamline this process and give you the authorities you need to get 
the personnel you need in this area because it is one of the most 
critical areas facing our military. What, in your opinion, needs to be 
done here and how can Congress help?
    Response. While conducting the most recent Quadrennial Defense 
Review (QDR), the DOD identified a requirement to transform the process 
by which the Military Services acquire contracted medical professionals 
to work in MTFs. The QDR Roadmap for Medical Transformation includes an 
initiative titled ``Contracting for Professional Services,'' that will 
enable the Military Health System (MHS) to more effectively and 
efficiently employ contract medical personnel by providing an 
acquisition process that is consistent throughout the system and makes 
health care more accessible to beneficiaries.
    DOD is establishing a Strategic Sourcing Council for the 
acquisition of medical professional services. The council will oversee 
a collaborative and structured process by the Military Services to 
critically analyze the MHS spending for contracted medical personnel in 
order to optimize performance, minimize price, increase achievement of 
socio-economic acquisition goals, improve vendor access to business 
opportunities, and otherwise increase the value of each dollar spent. 
This transformed acquisition process will be first applied to 
establishing a common, standing contracting vehicle that all of the 
Military Services can use to quickly fill medical professional staffing 
needs as they arise in the MTFs. Congress has already provided the 
statutory authority needed to accomplish this.
                                 ______
                                 
      Response to Written Questions Submitted by Hon. Mark Pryor 
    to Hon. Gordon England, Deputy Secretary, Department of Defense

    Question 1. When our soldiers deployed in combat fall victim to 
IEDs, it is many times the concussion impact, and not shrapnel that 
causes the most significant ``injury.'' These head traumas consequently 
require a lengthy and specialized rehabilitation to return a cognitive 
thought process and speech capability. What initiatives does the 
military's ``seamless transition'' address toward the significant lack 
of psychologists, psychiatrists, counselors and social workers 
available to treat these men and women?
    Response. As of January 2007, the Department of Defense (DOD) 
uniformed mental health clinical staffing levels were as follows: 
psychiatrists = 85 percent; clinical psychologists = 78 percent; social 
workers = 75 percent; psychiatric nurses = 129 percent; and psychiatric 
techs = 98 percent. These statistics do not include contracted services 
within our Medical Treatment Facilities, they do not reflect the role 
of the managed care support contractor network providers, nor do they 
include other counseling services through Military OneSource, family 
support, chaplain, and family advocacy systems.
    A variety of incentives are currently authorized (e.g., board 
certification pay, critical skills retention bonuses, educational loan 
repayment programs, incentive special pay, and multiyear specialty pay) 
to enhance recruitment and retention of mental health providers. These 
incentives have increased substantially in the last year. They will 
continue and likely expand. In addition, the DOD Mental Health Task 
Force has been exploring mental health staffing issues and will report 
to the Secretary by June 15, 2007. The report should provide some 
recommendations for improving mental health provider staffing issues.

    Question 2. The responsibility for assigning a disability rating 
originates from the services' Medical Evaluation Board (MEB) and 
Physical Exam Boards (PEB). On average the Department of Defense (DOD) 
and Veterans Affairs (VA) evaluation systems yield a significantly 
different distribution of disability ratings, with the VA rating at a 
statistically higher percentage and rate than that of the DOD. How do 
we address this disparity? What is the ``fitness to serve'' standard? 
Should we create a common, shared database between the DOD and VA?
    Response. The DOD Disability Evaluation System (DES) ratings cannot 
be compared directly to those from the VA. While both the DOD and the 
VA use the Veterans Administration Schedule for Rating Disabilities, 
the DOD ratings focus on conditions determined to be physically 
unfitting--compensating for a military career cut short. The VA may 
rate any service-connected impairment (not merely the condition 
rendering the member unfit for further service). In addition, the DOD's 
ratings are permanent upon final disposition, while VA ratings change 
(most often an increase) as conditions worsen with age.
    The ``fitness to serve'' standard, based on statutory direction, is 
what the Military Departments use to determine whether an injured or 
ill Servicemember can physically perform the duties of their office, 
grade, rank, or rating. Only the unfitting conditions are assigned 
disability ratings, as required by title 10, United States Code, 
chapter 61.
    The Department supports a common, shared database between DOD and 
VA for the purposes of health care and disability evaluation.
                                 ______
                                 
  Response to Written Question Submitted by Hon. John McCain to Hon. 
David S.C. Chu, Under Secretary for Personnel and Readiness, Department 
                               of Defense

                     UNIFORMITY AMONG THE SERVICES

    Question 1. There are many complaints about the operation of the 
disability evaluations systems, and one of those most consistently 
heard is that each of the Services has been permitted to interpret law 
and DOD regulations differently. The Army Inspector General (IG), for 
example, found that the Army had devised its own processing timelines 
despite DOD guidelines. Do you agree that each of the Services has gone 
its own way in interpreting controlling law and DOD regulations 
regarding the disability evaluation system?
    Response. As legislated in title 10, United States Code, chapter 
61, and set forth in DOD policy and Directives, the Secretaries of the 
Military Departments are charged to operate their respective Disability 
Evaluation Systems (DES) consistent with the roles and missions of 
their Military Department. The Department, however, can do a better job 
when interpreting the inconsistent DES statutes and the Veterans' 
Administration Schedule of Rating Disabilities. To this end, we 
recently published the first of many DES-related clarifying issuances 
and have reinvigorated the Department's Disability Advisory Council.
    Question 2. What does OSD intend to do now to provide oversight and 
to ensure uniformity in the manner in which the Services conduct 
disability evaluation?
    Response. The Department reinstituted and maintains an aggressive 
schedule of Disability Advisory Council (DAC) meetings. These meetings 
are conducted quarterly and have had intense agendas, which focus on 
oversight and revisions to policy and process to ensure the consistency 
and accuracy of the Disability Evaluation System (DES). A recently 
published charter for the DAC guides our efforts and authorizes the 
formation of work groups to address specific issues.
    The Department also issued a directive-type memorandum providing 
policy for the overall management of the DES. The guidance addressed 
the issues of the Government Accountability Office report and statutory 
changes from National Defense Authorization Act for Fiscal Year 2007. 
The directive-type memorandum, in addition to other policies, included 
a comprehensive review of compliance every three years and the 
establishment of reporting requirements. These will include sampling of 
decisions on disability ratings of medical conditions for Department-
wide analyses. The memorandum also established the DES Annual Report 
and the Quarterly DES Performance Measures Report to the Under 
Secretary of Defense for Personnel and Readiness.

                 DOD AND VA HEALTH INFORMATION SHARING

    Question 3. Shared health care information technology has been 
identified by congressional and Presidential task forces for nearly a 
decade as a key enabler of transition for servicemembers from DOD to 
the VA. In spite of years of joint committees and joint programs, we 
continue to hear that when wounded soldiers transition from DOD to VA 
for their health care, they carry with them a conglomeration of health 
records on paper--often incomplete. Why are VA and DOD hospitals faxing 
important laboratory and inpatient data?
    Response. The DOD and VA share a significant amount of health 
information today (itemized below). By the end of 2007, DOD will be 
sharing electronically with VA nearly every health record data element 
identified in our VA/DOD Joint Strategic Plan (JSP) for health 
information transfer. By 2008, we will be sharing the remaining 
electronic health record data elements identified in the VA/DOD JSP. 
However, a significant number of Servicemembers have their historical 
medical data on paper records that were generated prior to the full 
implementation of DOD's electronic outpatient medical record system, 
Armed Forces Health Longitudinal Technology Application.
Currently shared electronic medical record data
     Inpatient and outpatient laboratory and radiology results, 
allergy data, outpatient pharmacy data, and demographic data are 
viewable by DOD and VA providers on shared patients through 
Bidirectional Health Information Exchange (BHIE) from 15 DOD medical 
centers, 18 hospitals, and over 190 clinics and all VA facilities.
     Digital radiology images are electronically transmitted 
from Walter Reed Army Medical Center (WRAMC) and National Naval Medical 
Center (NNMC) Bethesda to the Tampa and Richmond VA Polytrauma Centers 
for inpatients being transferred there for care.
     Electronic transmission of scanned medical records on 
severely injured patients transferred as inpatients from WRAMC to the 
Tampa and Richmond VA Polytrauma Centers.
     Pre- and Post-deployment Health Assessments and Post-
deployment Health Reassessments for separated Servicemembers and 
demobilized Reserve and National Guard members who have deployed.
     When a Servicemember ends their term in service, DOD 
transmits to VA laboratory results, radiology results, outpatient 
pharmacy data, allergy information, consult reports, admission, 
disposition and transfer information, elements of the standard 
ambulatory data record and demographic data.
     Discharge summaries from 5 of the 13 DOD medical centers 
and hospitals using the Clinical Information System to document 
inpatient care are available to VA on shared patients.
Enhancement plans for 2007
     Expanding the electronic digital radiology image transfer 
capability to include images from WRAMC, NNMC, and Brooke Army Medical 
Center (BAMC) to all four VA Polytrauma Centers.
     Expanding the electronic transmission of scanned medical 
records on severely injured patients from WRAMC, NNMC, and BAMC to all 
four VA Polytrauma Centers.
     Making discharge summaries, operative reports, inpatient 
consults, and histories and physicals available for viewing by all DOD 
and VA providers from inpatient data at all 13 DOD medical centers and 
hospitals using CIS.
     Expanding BHIE to include all DOD facilities.
     Making encounters/clinical notes, procedures and problem 
lists available to DOD and VA providers through BHIE.
     Making theater outpatient encounters, inpatient and 
outpatient laboratory and radiology results, pharmacy data, inpatient 
encounters to include clinical notes, discharge summaries and operative 
reports available to all DOD and VA providers via BHIE.
     Beginning collaboration efforts on a DOD and VA joint 
solution for documentation of inpatient care.
Enhancement plans for 2008
     Making vital sign data, family history, social history, 
other history, and questionnaires/forms available to DOD and VA 
providers through BHIE.
     Making discharge summaries, operative reports, inpatient 
consults and histories, and physicals at Landstuhl Regional Medical 
Center, Germany available to VA on shared patients.

    Question 4. Why are medical records still being lost?
    Response. Past reliance on paper records accounts for an important 
part of the lost record problem. The Department of Defense (DOD) and 
Department of Veterans Affairs (VA) now share a significant amount of 
health information electronically (itemized below). By the end of 2007, 
DOD will be sharing electronically with VA nearly every health record 
data element identified in our VA/DOD Joint Strategic Plan (JSP) for 
health information transfer. By 2008, we will be sharing the remaining 
electronic health record data elements identified in the VA/DOD JSP. 
However, a significant number of Servicemembers have their historical 
medical data on paper records that were generated prior to the full 
implementation of DOD's electronic outpatient medical record system, 
Armed Forces Health Longitudinal Technology Application.
Currently shared electronic medical record data
     Inpatient and outpatient laboratory and radiology results, 
allergy data, outpatient pharmacy data, and demographic data are 
viewable by DOD and VA providers on shared patients through 
Bidirectional Health Information Exchange (BHIE) from 15 DOD medical 
centers, 18 hospitals, and over 190 clinics and all VA facilities.
     Digital radiology images are electronically transmitted 
from Walter Reed Army Medical Center (WRAMC) and National Naval Medical 
Center (NNMC) Bethesda to the Tampa and Richmond VA Polytrauma Centers 
for inpatients being transferred there for care.
     Electronic transmission of scanned medical records on 
severely injured patients transferred as inpatients from WRAMC to the 
Tampa and Richmond VA Polytrauma Centers.
     Pre- and Post-deployment Health Assessments and Post-
deployment Health Reassessments for separated Servicemembers and 
demobilized Reserve and National Guard members who have deployed.
     When a Servicemember ends their term in service, DOD 
transmits to VA laboratory results, radiology results, outpatient 
pharmacy data, allergy information, consult reports, admission, 
disposition and transfer information, elements of the standard 
ambulatory data record and demographic data.
     Discharge summaries from 5 of the 13 DOD medical centers 
and hospitals using the Clinical Information System to document 
inpatient care are available to VA on shared patients.
    Enhancement plans for 2007:
     Expanding the electronic digital radiology image transfer 
capability to include images from WRAMC, NNMC, and Brooke Army Medical 
Center (BAMC) to all four VA Polytrauma Centers.
     Expanding the electronic transmission of scanned medical 
records on severely injured patients from WRAMC, NNMC, and BAMC to all 
four VA Polytrauma Centers.
     Making discharge summaries, operative reports, inpatient 
consults, and histories and physicals available for viewing by all DOD 
and VA providers from inpatient data at all 13 DOD medical centers and 
hospitals using CIS.
     Expanding BHIE to include all DOD facilities.
     Making encounters/clinical notes, procedures and problem 
lists available to DOD and VA providers through BHIE.
     Making theater outpatient encounters, inpatient and 
outpatient laboratory and radiology results, pharmacy data, inpatient 
encounters to include clinical notes, discharge summaries and operative 
reports available to all DOD and VA providers via BHIE.
     Beginning collaboration efforts on a DOD and VA joint 
solution for documentation of inpatient care.
Enhancement plans for 2008
     Making vital sign data, family history, social history, 
other history, and questionnaires/forms available to DOD and VA 
providers through BHIE.
     Making discharge summaries, operative reports, inpatient 
consults and histories, and physicals at Landstuhl Regional Medical 
Center, Germany available to VA on shared patients.

    Question 5. Why are these still problems for our servicemembers?
    Response. They shouldn't be much longer. The Department of Defense 
(DOD) and Department of Veterans Affairs (VA) now share a significant 
amount of health information electronically (itemized below). By the 
end of 2007, DOD will be sharing electronically with VA nearly every 
health record data element identified in our VA/DOD Joint Strategic 
Plan (JSP) for health information transfer. By 2008, we will be sharing 
the remaining electronic health record data elements identified in the 
VA/DOD JSP. However, a significant number of Servicemembers have their 
historical medical data on paper records that were generated prior to 
the full implementation of DOD's electronic outpatient medical record 
system, Armed Forces Health Longitudinal Technology Application.
Currently shared electronic medical record data
     Inpatient and outpatient laboratory and radiology results, 
allergy data, outpatient pharmacy data, and demographic data are 
viewable by DOD and VA providers on shared patients through 
Bidirectional Health Information Exchange (BHIE) from 15 DOD medical 
centers, 18 hospitals, and over 190 clinics and all VA facilities.
     Digital radiology images are electronically transmitted 
from Walter Reed Army Medical Center (WRAMC) and National Naval Medical 
Center (NNMC) Bethesda to the Tampa and Richmond VA Polytrauma Centers 
for inpatients being transferred there for care.
     Electronic transmission of scanned medical records on 
severely injured patients transferred as inpatients from WRAMC to the 
Tampa and Richmond VA Polytrauma Centers.
     Pre- and Post-deployment Health Assessments and Post-
deployment Health Reassessments for separated Servicemembers and 
demobilized Reserve and National Guard members who have deployed.
     When a Servicemember ends their term in service, DOD 
transmits to VA laboratory results, radiology results, outpatient 
pharmacy data, allergy information, consult reports, admission, 
disposition and transfer information, elements of the standard 
ambulatory data record and demographic data.
     Discharge summaries from 5 of the 13 DOD medical centers 
and hospitals using the Clinical Information System to document 
inpatient care are available to VA on shared patients.
Enhancement plans for 2007
     Expanding the electronic digital radiology image transfer 
capability to include images from WRAMC, NNMC, and Brooke Army Medical 
Center (BAMC) to all four VA Polytrauma Centers.
     Expanding the electronic transmission of scanned medical 
records on severely injured patients from WRAMC, NNMC, and BAMC to all 
four VA Polytrauma Centers.
     Making discharge summaries, operative reports, inpatient 
consults, and histories and physicals available for viewing by all DOD 
and VA providers from inpatient data at all 13 DOD medical centers and 
hospitals using CIS.
Expanding BHIE to include all DOD facilities
     Making encounters/clinical notes, procedures and problem 
lists available to DOD and VA providers through BHIE.
     Making theater outpatient encounters, inpatient and 
outpatient laboratory and radiology results, pharmacy data, inpatient 
encounters to include clinical notes, discharge summaries and operative 
reports available to all DOD and VA providers via BHIE.
     Beginning collaboration efforts on a DOD and VA joint 
solution for documentation of inpatient care.
Enhancement plans for 2008
     Making vital sign data, family history, social history, 
other history, and questionnaires/forms available to DOD and VA 
providers through BHIE.
     Making discharge summaries, operative reports, inpatient 
consults and histories, and physicals at Landstuhl Regional Medical 
Center, Germany available to VA on shared patients.
                                 ______
                                 
      Response to Written Question Submitted by Hon. Patty Murray 
 to Hon. David S.C. Chu, Under Secretary for Personnel and Readiness, 
                         Department of Defense

    Question. I do want to make sure that those people who have already 
been discharged and are now finding that they have TBI, that they 
aren't lost. So I'd like to hear back from you as to your 
recommendation on that.
    Response. Servicemembers who served in Operations Iraqi Freedom or 
Enduring Freedom who, after leaving active service, find they have 
symptoms compatible with having suffered a Traumatic Brain Injury 
(TBI), may go to a Veterans Affairs medical facility where they will be 
screened for TBI. When a veteran screens positive for possible TBI, the 
findings are discussed with the patient by an appropriate clinical 
staff member and further evaluation is offered. Consults for further 
evaluation must be submitted, but only after discussion with and 
agreement by the patient.
                                 ______
                                 
       Response to Written Questions Submitted by Hon. Evan Bayh 
 to Hon. David S.C. Chu, Under Secretary for Personnel and Readiness, 
                         Department of Defense

              MEDICAL COVERAGE FOR TRAUMATIC BRAIN INJURY

    Question 1. As you mentioned during the hearing, Active Duty 
servicemembers who have incurred Traumatic Brain Injury (TBI) are able 
to access private rehabilitation facilities at the expense of the 
Department of Defense (DOD). Contrary to your testimony, however, once 
retired, I understand that TRICARE no longer covers such therapy. In 
fact, I have heard several personal stories from servicemembers and 
their families indicating that they were medically retired before 
learning of the apparent discrepancy in benefits, and, therefore, were 
precluded from accessing private facilities. Conversely, I have also 
heard from families of TBI patients fighting to stay on Active Duty for 
fear of losing their TRICARE eligibility for cognitive therapy in a 
private facility. Are medically retired servicemembers with TBI 
eligible to receive cognitive therapy in a private rehabilitation 
facility under TRICARE? If so, how are they informed of such an option, 
and why have the families with whom I have spoken asked for and been 
denied private care? If not, do you agree that such a discrepancy 
should be addressed to ensure that these severely injured warriors have 
options available to them?
    Response. Rehabilitation therapy covered under the TRICARE basic 
program is available to both active duty Servicemembers and retirees, 
and includes physician-prescribed therapy to improve, restore, or 
maintain function, or to minimize or prevent deterioration of patient 
function. Rehabilitation therapy under the TRICARE basic program must 
be medically necessary and appropriate care keeping with accepted norms 
for medical practice in the United States, rendered by an authorized 
provider, necessary to the establishment of a safe and effective 
maintenance program, and must not be custodial, or otherwise excluded 
from coverage.
    Covered rehabilitation services for TBI patients may include 
physical, speech, occupational, and behavioral services. Cognitive 
rehabilitation strategies may be integrated into these components of a 
rehabilitation program and may be covered under the TRICARE basic 
program when cognitive rehabilitation is not billed as a distinct and 
separate service. Beneficiaries, including active duty Servicemembers, 
may receive rehabilitation services in direct or purchased care 
facilities. Active duty Servicemembers and veterans may also receive 
TBI rehabilitation in specialized Department of Veterans Affairs' 
treatment centers.
    Under the TRICARE basic program, cognitive rehabilitation, defined 
as ``services that are prescribed specifically and uniquely to teach 
compensatory methods to accomplish tasks which rely upon cognitive 
processes,'' are considered unproven, therefore, not appropriate care 
keeping with accepted norms for medical practice in the United States 
and are not covered when separately billed as distinct and defined 
services. Post-acute, community reentry programs, work integration 
training, and vocational rehabilitation are also excluded. TBI 
rehabilitation excluded from coverage under the TRICARE basic benefit 
for retirees and dependents may be extended to active duty 
Servicemembers under the supplemental health care program (SHCP), if 
those services may potentially keep or make the active duty patient fit 
to remain on active duty.
    Coverage of cognitive rehabilitation by major health insurers is 
mixed. For example, Cigna, Aetna, and UniCare cover cognitive 
rehabilitation for TBI, when it is determined to be medically 
necessary. Cigna excludes coverage of cognitive rehabilitation for mild 
TBI. Regence and Blue Cross/Blue Shield consider cognitive 
rehabilitation to be investigational and do not provide coverage for 
it. There is no Medicare national coverage determination for cognitive 
rehabilitation for TBI. In determining whether a medical treatment has 
moved from unproven to proven, TRICARE reviews reliable evidence, as 
defined in 32 Code of Federal Regulations (CFR), Part 199. Research 
study of cognitive rehabilitation in neurological conditions, including 
TBI, is limited by differences between patients, and by variation in 
the type, frequency, duration, and focus of cognitive rehabilitation 
interventions. The TRICARE determination that cognitive rehabilitation 
for TBI is unproven is supported by a 2002 technical assessment 
performed by Blue Cross/Blue Shield (updated in 2006), and by a 2004 
technical assessment by Hayes, Inc. (also updated in 2006).
    Medical evidence is dynamic and evolving, however. We know that, in 
the future, some care considered unproven today will achieve the 
required evidence threshold and become covered under the TRICARE basic 
program. Care that is likely to become proven is periodically 
reevaluated to ensure that TRICARE coverage is current and consistent 
with the latest evidence. DOD therefore commissioned a formal technical 
assessment of the current scientific evidence supporting cognitive 
rehabilitation intervention for TBI. This evaluation will be completed 
in August 2007. DOD will reevaluate its coverage policy for cognitive 
rehabilitation under the TRICARE basic program at that time.
    DOD recognizes that, as a determination is made that an active duty 
patient will not be able to return to active duty service, and the 
transition is made from active duty to retired status, changes in 
coverage may result in discontinuity in care for combat-wounded 
Servicemembers. DOD is exploring the feasibility of testing strategies 
for mitigating potential disruption in care using demonstration 
authority.
                                 ______
                                 
Response to Written Questions Submitted by Hon. Hillary Rodham Clinton 
 to Hon. David S.C. Chu, Under Secretary for Personnel and Readiness, 
                         Department of Defense

                  MILITARY DISABILITY BENEFITS SYSTEM

    Question 1. In March 2006, the Government Accountability Office 
released GAO Report #06-362: Military Disability System: Improved 
Oversight Needed to Ensure Consistent and Timely Outcomes for Reserve 
and Active Duty Servicemembers. According to the report the Department 
of Defense regulations and policies allows each service to set up their 
own processes for certain aspects of the disability evaluation system. 
As a result, each service implements its system somewhat differently. 
Additional issues identified by the report include: Failure to monitor 
compliance of disability benefits evaluation system policies and 
guidance; Lack of oversight of the disability benefits evaluation 
system by the Disability Advisory Council; Ineffective protocols for 
processing disability benefit claims; Faulty disability benefits data 
entry system with high error rates exist; Lack of effective U.S. Army 
data processor training programs; Lack of oversight for disability 
system staff training; A need exists to improve the access and 
availability of each service's Physical Evaluation Board Liaison 
Officers; A need exists to improve service awareness and use of Line of 
Duty determinations for Active Duty and Reserve servicemembers; A need 
exists to improve the quality of care and services provided to 
reservists that are in a medical holdover status and receiving medical 
treatment away from their homes and families; and A need to improve 
each service's quality assurance mechanisms in an effort to ensure that 
disability determinations are consistent.
    Will this report be used as a basis to improve the Department of 
Defense Disability System? What compliance checks are in place to 
address this year old report? What can this Committee do to assist the 
Department to address these problems?
    Response. The Department issued a directive-type memorandum 
providing policy for the overall management of the DES. The guidance 
addressed the issues of GAO Report #06-362 and statutory changes from 
the Fiscal Year 2007 National Defense Authorization Act. The directive-
type memorandum, in addition to other policies, included a 
comprehensive review of compliance every 3 years and the establishment 
of reporting requirements. These would include sampling of decisions on 
disability ratings of medical conditions for Department-wide analyses. 
The directive also established the DES Annual Report and the Quarterly 
DES Performance Measures Report to the Under Secretary of Defense for 
Personnel and Readiness.
    In addition, other efforts inform our work, such as the current and 
future reports of the Veterans Affairs' (VAs) Disability Benefits 
Commission: the President's Commission on Care for America's Returning 
Wounded Warriors, DOD's Independent Review Group, and internal DOD and 
Military Department Inspector General review/audits.
    DOD needs authority to revolutionize DES rather than a new set of 
compliance standards that only serve to reinforce the present, failed 
system. A demonstration authority would empower the VA and DOD to 
operate a combined activity for rating those judged unfit by DOD and 
establish benefits under programs that transcend present law. The 
Committee's support of a demonstration effort would be appreciated.

    Question 2. The Department of Defense's Disability Advisory Council 
(DODDAC) provides recommendations for amending and adjusting the 
Department of Veterans Affairs Schedule for Ratings which is used for 
disability rating determinations by each service. The DODDAC was 
faulted by the GAO for a lack of oversight and participation in the 
process to determine fair and consistent disability ratings. Has this 
lack of oversight and participation been corrected since the March 2006 
GAO report was issued? What new compliance checks and procedures have 
been implemented to ensure DODDAC is more involved in the process?
    Response. The Department reinstituted and maintains an aggressive 
schedule of Disability Advisory Council meetings. These meetings are 
conducted quarterly and have intense agendas focused on oversight and 
revisions to policy and process to ensure consistency and accuracy of 
the Disability Evaluation System (DES).
    To improve oversight, the Department also issued a directive-type 
memorandum providing policy for the overall management of the DES. The 
guidance addressed the issues of the GAO report and statutory changes 
from the National Defense Authorization Act for Fiscal Year 2007. The 
directive-type memorandum included a comprehensive review of compliance 
every 3 years and established reporting requirements, to include 
sampling of decisions on disability ratings of medical conditions for 
Department-wide analyses. The directive also established the DES Annual 
Report and the Quarterly DES Performance Measures Report to the Under 
Secretary of Defense for Personnel and Readiness.

    Question 3. The April 12, 2007 Joint Armed Services-Veterans 
Affairs hearing testimony indicated that the current rating scheme does 
not accurately or fairly address the nature of wounds suffered during 
the Global War on Terror to include: Traumatic Brain Injuries, 
Amputations, Spinal injuries, Post-traumatic Stress Disorder, Hearing 
loss, and Diseases. Does the current rating scheme fairly compensate 
disabilities related to Traumatic Brain Injuries, Amputations, Spinal 
injuries, Post-traumatic Stress Disorder, Hearing loss, and Diseases?
    Response. By law, the Department of Veterans Affairs (VA) 
determines the rating scheme for disabilities through the VA Schedule 
of Rating Disabilities (VASRD). The VASRD considers loss of earnings 
capacity, and is governed by title 38. There are problematic conditions 
in the VASRD where the Department believes it should be updated. We are 
awaiting the Task Force results on Post Traumatic Stress Disorder and 
the VA Commission's review before we can adequately advise VA on the 
construct of the schedule.

                        TRAUMATIC BRAIN INJURIES

    Question 4. Traumatic Brain Injuries have been called the 
``signature wound'' of the Global War on Terror--TBI includes severe 
injuries as well as invisible wounds that result in trouble remembering 
appointments, holding down a job, and returning to civilian life. 
Additionally, the number of Post Traumatic Stress Disorder cases being 
diagnosed amongst returning OIF and OEF veterans is increasing with the 
number of repeated deployments and the stressful OPTEMPO. 
Distinguishing between mild TBI and Post Traumatic Stress Disorder is 
difficult because both conditions share common symptoms, such as 
irritability, anxiety and depression. Has DOD researched and developed 
any computer-based tests that would assess different basic functions 
(or domains) of cognition--such as memory, concentration, attention, 
and reaction time--that could be used to detect brain injury and 
distinguish TBI from Post Traumatic Stress Disorder?'' What updated 
methods and tests have been incorporated in pre-deployment screening 
for PTSD and TBI during pre-deployment activities?
    Response. While there is some overlap in symptoms associated with 
PTSD and with mild TBI, clinicians are able to distinguish between the 
two and establish a diagnosis using standard clinical procedures. There 
is no medically validated computer-based testing that can differentiate 
these two very dissimilar conditions. A clinical evaluation, history of 
exposure, and review of all symptoms are required. It is also possible 
for both TBI and PTSD to exist in the same individual at the same time, 
since the events that cause one can also cause the other, and they are 
not mutually exclusive. There is a procedure to assess for non-
deployable conditions during pre-deployment activities, but treated 
PTSD or previous TBI are not necessarily non-deployable conditions.
    Because TBI is a significant health concern for the Department, we 
are working to develop a comprehensive DOD program to identify, treat, 
document, and follow up on those who have suffered a TBI while either 
deployed or in garrison. This program will establish common TBI tools 
and clinical practice guidelines for screening, assessment, treatment, 
and follow-up. A preliminary conference of DOD experts met in May and 
another will convene June 25 and 26, where the Department of Veterans 
Affairs, leading universities, and civilian institutions will send 
experts. At that conference, we will discuss the medical and scientific 
validity of a computerized test mechanism to differentiate PTSD from 
TBI with these national experts, as well as other important issues 
related to this injury.

    Question 5. Servicemembers who have incurred severe TBI may never 
fully recover, and any chance of recovering the ability to perform 
daily tasks is dependent on access to intensive, specialized 
rehabilitation, including cognitive therapy. Active duty servicemembers 
can access a range of health care options including cognitive therapy--
which is necessary for TBI rehabilitation--under their TRICARE plan. 
However, once troops are medically retired, their TRICARE coverage 
doesn't provide access to cognitive therapies provided at private 
facilities. Are you aware of the discrepancy in medical treatment 
options available to active duty and medically retired servicemembers 
who have incurred a Traumatic Brain Injury (TBI)?
    Response. Rehabilitation therapy covered under the TRICARE basic 
program is available to both active duty Servicemembers and retirees, 
and includes physician-prescribed therapy to improve, restore, or 
maintain function, or to minimize or prevent deterioration of patient 
function. Rehabilitation therapy under the TRICARE basic program must 
be medically necessary and appropriate care keeping with accepted norms 
for medical practice in the United States, rendered by an authorized 
provider, necessary to the establishment of a safe and effective 
maintenance program, and must not be custodial or otherwise excluded 
from coverage.
    Covered rehabilitation services for TBI patients may include 
physical, speech, occupational, and behavioral services. Cognitive 
rehabilitation strategies may be integrated into these components of a 
rehabilitation program and may be covered under the TRICARE basic 
program when cognitive rehabilitation is not billed as a distinct and 
separate service. Beneficiaries, including active duty Servicemembers, 
may receive rehabilitation services in direct or purchased care 
facilities. Active duty Servicemembers and veterans may also receive 
TBI rehabilitation in specialized Department of Veterans Affairs (VA) 
treatment centers.
    Under the TRICARE basic program, cognitive rehabilitation, defined 
as ``services that are prescribed specifically and uniquely to teach 
compensatory methods to accomplish tasks which rely upon cognitive 
processes,'' are considered unproven, therefore, not appropriate care 
keeping with accepted norms for medical practice in the United States 
and are not covered when separately billed as distinct and defined 
services. Post-acute community reentry programs, work integration 
training, and vocational rehabilitation are also excluded. TBI 
rehabilitation excluded from coverage under the TRICARE basic benefit 
for retirees and dependents may be extended to active duty 
Servicemembers under the supplemental health care program (SHCP) if 
those services may potentially keep or make the active duty patient fit 
to remain on active duty.
    Coverage of cognitive rehabilitation by major health insurers is 
mixed. For example, Cigna, Aetna, and UniCare cover cognitive 
rehabilitation for TBI when it is determined to be medically necessary. 
Cigna excludes coverage of cognitive rehabilitation for mild TBI. 
Regence and Blue Cross/Blue Shield consider cognitive rehabilitation to 
be investigational and do not provide coverage for it. There is no 
Medicare national coverage determination for cognitive rehabilitation 
for TBI. In determining whether a medical treatment has moved from 
unproven to proven, TRICARE reviews reliable evidence, as defined in 32 
Code of Federal Regulations, Part 199. Research study of cognitive 
rehabilitation in neurological conditions, including TBI, is limited by 
differences between patients, and by variation in the type, frequency, 
duration, and focus of cognitive rehabilitation interventions. The 
TRICARE determination that cognitive rehabilitation for TBI is unproven 
is supported by a 2002 technical assessment performed by Blue Cross/
Blue Shield (updated in 2006), and by a 2004 technical assessment by 
Hayes, Inc. (also updated in 2006). Medical evidence is dynamic and 
evolving. We know that, in the future, some care considered unproven 
today will achieve the required evidence threshold and become covered 
under the TRICARE basic program. Care that is likely to become proven 
is periodically reevaluated to ensure that TRICARE coverage is current 
and consistent with the latest evidence. The Department of Defense 
(DOD) commissioned a formal technical assessment of the current 
scientific evidence supporting cognitive rehabilitation intervention 
for TBI. This evaluation will be completed in August 2007. DOD will 
reevaluate its coverage policy for cognitive rehabilitation under the 
TRICARE basic program at that time.
    DOD recognizes that as a determination is made, an active duty 
patient will not be able to return to active duty service, and 
transition is made from active duty to retired status changes in 
coverage may result in discontinuity in care for combat-wounded 
Servicemembers. DOD is exploring the feasibility of testing strategies 
for mitigating potential disruption in care using demonstration 
authority.

    Question 6. Many servicemembers who have incurred serious traumatic 
brain injuries are fortunate to have family members or loved ones act 
as caregivers. However, family members of returning soldiers with TBI 
are often ill-equipped to handle the demands of caring for their loved 
one, which in some bases can become a full-time responsibility. Does 
the VA have any data on the number of family caregivers who have 
relocated or quit their job in order to provide care for a traumatic 
brain injured servicemember?
    Response. We defer to the VA for the answer. The Department of 
Defense does not collect data related to this question.

         TRAUMATIC INJURY SERVICEMEMBERS' GROUP LIFE INSURANCE

    Question 7. On August 25, 2006, Director Thomas M. Lastowka, 
Veterans Affairs Regional Office and Insurance Center testified before 
the Senate Veterans' Affairs Committee on the Traumatic Injury 
Servicemembers' Group Life Insurance program. Director Lastowka 
testified that the TSGLI Program has denied 1,601 retroactive claims 
and 248 post-December 1 claims; approximately 40 percent of every 
claim. What quality control procedures have been implemented to improve 
the dismal approval rate for submitted claims? Has the Department of 
Veterans Affairs or the Department of Defense reviewed the denied 
claims and determined if they warrant a retroactive TSGLI award?
    Response. TSGLI legislation followed commercial Accidental Death 
and Dismemberment policies and enumerated a list of specific losses for 
which a TSGLI payment would be made. The VA, in coordination with DOD, 
created a schedule of losses against which the injuries are evaluated. 
Members are encouraged to submit the certification forms even if they 
may not qualify for payment, to ensure that the injuries are considered 
under the program. As a result, more claims are filed in which the 
medical evidence does not support the claimed loss. While this leads to 
increased disapprovals, we believe it is better for the branch of 
Service to deny more claims than to have perhaps eligible members fail 
to file a claim due to self-screening.
    The following are the quality control procedures used: If a claims 
examiner would like a second review, the claim is sent to a physician. 
The physician reviews the claim and provides a final recommendation. If 
a claim is disapproved, the member can request reconsideration. The 
claims examiner again reviews the claim. A physician is available to 
provide a final recommendation. If the claim is disapproved after 
reconsideration, the member may file an appeal. The claim is then 
reviewed at a higher level of authority. A history of the claim and all 
medical documentation are provided to officials, who make an appeal 
decision.
    The VA and the Office of Servicemembers' Group Life Insurance 
recently conducted a detailed review of approximately 230 completed 
claims, and confirmed that the claims were adjudicated correctly under 
current law and regulations.

                       ELECTRONIC MEDICAL RECORDS

    Question 8. Progress is being made by the Department of Veterans 
Affairs in utilizing electronic medical records. However, wounded 
soldiers continue to report that their paper medical records are being 
lost throughout the process. Why hasn't more progress been made in 
developing a seamless system whereby DOD and VA medical records systems 
would be able to integrate with one another? What is the current status 
of efforts to fix the medical records process in DOD so that we will 
not have wounded soldiers complaining of lost records?
    Response. The Department of Defense's (DOD) electronic medical 
record, Armed Forces Health Longitudinal Technology Application 
(AHLTA), is used worldwide to document approximately 112,000 outpatient 
encounters per day. DOD and VA share a significant amount of health 
information today (itemized below). By the end of 2007, DOD will be 
electronically sharing with VA nearly every health record data element 
identified in our VA/DOD joint strategic plan (JSP) for health 
information transfer. By 2008, we will be sharing the remaining 
electronic health record data elements identified in the VA/DOD JSP. 
However, a significant number of Servicemembers have their historical 
medical data on paper records that were generated prior to the full 
implementation of AHLTA.
Currently shared electronic medical record data
     Inpatient and outpatient laboratory and radiology results, 
allergy data, outpatient pharmacy data, and demographic data are 
viewable by DOD and VA providers on shared patients through 
bidirectional health information exchange (BHIE) from 15 DOD medical 
centers, 18 hospitals, and over 190 clinics and all VA facilities.
     Digital radiology images are being electronically 
transmitted from Walter Reed Army Medical Center (WRAMC) and National 
Naval Medical Center (NNMC) Bethesda to the Tampa and Richmond VA 
Polytrauma Centers for inpatients being transferred there for care.
     Electronic transmission of scanned medical records on 
severely injured patients transferred as inpatients from WRAMC to the 
Tampa and Richmond VA Polytrauma Centers.
     Pre- and Post-deployment Health Assessments and Post-
deployment Health Reassessments for separated Servicemembers and 
demobilized Reserve and National Guard members who have deployed.
     When a Servicemember ends their term in Service, DOD 
transmits laboratory results, radiology results, outpatient pharmacy 
data, allergy information, consult reports, admission, disposition and 
transfer information, elements of the standard ambulatory data record, 
and demographic data to the VA.
     Discharge summaries from 5 of the 13 DOD medical centers 
and hospitals using the Clinical Information System (CIS) to document 
inpatient care are available to the VA on shared patients.
Enhancement plans for 2007
     Expanding the electronic digital radiology image transfer 
capability to include images from WRAMC, NNMC, and Brooke Army Medical 
Center (BAMC) to all four VA Polytrauma Centers.
     Expanding the electronic transmission of scanned medical 
records on severely injured patients from WRAMC, NNMC, and BAMC to all 
four VA Polytrauma Centers.
     Making discharge summaries, operative reports, inpatient 
consults, and histories and physicals available for viewing by all DOD 
and VA providers from inpatient data at all 13 DOD medical centers and 
hospitals using CIS.
     Expanding BHIE to include all DOD facilities.
     Making encounters/clinical notes, procedures, and problem 
lists available to DOD and VA providers through BHIE.
     Making theater outpatient encounters, inpatient and 
outpatient laboratory and radiology results, pharmacy data, inpatient 
encounters, to include clinical notes, discharge summaries, and 
operative reports available to all DOD and VA providers via BHIE.
     Beginning collaboration efforts on a DOD and VA joint 
solution for documentation of inpatient care.
Enhancement plans for 2008
     Making vital sign data, family history, social history, 
other history, and questionnaires/forms available to DOD and VA 
providers through BHIE.
     Making discharge summaries, operative reports, inpatient 
consults and histories, and physicals available to VA on shared 
patients at Landstuhl Regional Medical Center, Germany.
                                 ______
                                 
    Response to Written Questions Submitted by Hon. Johnny Isakson 
 to Hon. David S.C. Chu, Under Secretary for Personnel and Readiness, 
                         Department of Defense

    Question 1. Should a VA representative be embedded in the Medical 
Evaluation Board process from the beginning? If not, should a VA 
representative at least be present for the Physical Evaluation Board 
process?
    Response. The primary focus of the MEB is to return a member to 
service, provide limited duty, or a protective profile. The primary 
focus of the PEB is to determine if a member is fit for continued 
military service. This function does not involve VA. Clearly, for those 
members who are unfit for further military service, the issue of rating 
the disability or disabilities is one that involves both departments. 
The two departments are now working on joint procedures to adjudicate 
more effectively disability system determinations in both departments.

    Question 2. Do the questions on the DD Form 2900 adequately address 
mental health, specifically related to Post-Traumatic Stress Syndrome 
and Traumatic Brain Injury?
    Response. The Post-deployment Health Reassessment (PDHRA) uses DD 
Form 2900 as a self-reporting tool. Similarly, the Post-deployment 
Health Assessment (PDHA) uses DD Form 2796. In both instances, the 
health assessment process does not rely solely on a form or 
questionnaire. The questionnaire is intended only to provide some 
structured information to aid the health care provider during an 
interview. The provider follows up on all concerns, whether physical, 
mental, or environmental, reported by the Servicemember during the 
interview.
    Both the PDHA and the PDHRA include the Primary Care PTSD scale, a 
scale validated in a primary care clinical setting and recommended by 
the Clinical Practice Guideline for Acute Stress Disorder and PTSD.
    The current version of the DD Form 2900 includes a question where 
the individual can indicate that he or she was in a situation that 
might have resulted in a TBI. The Department of Defense is currently in 
the process of adding additional TBI screening questions to both the DD 
Form 2900 and the DD Form 2796. These new questions are modeled after 
those used by the Department of Veterans Affairs. This approach is in 
keeping with current clinical practices and expert recommendations.
                                 ______
                                 
    Response to Written Question Submitted by Hon. Saxby Chambliss 
 to Hon. David S.C. Chu, Under Secretary for Personnel and Readiness, 
                         Department of Defense

                         RATIO OF CASE MANAGERS

    Question 1. I understand that the only DOD regulation related to 
the number of case managers required to manage personnel in a medical 
hold status is a 1 to 35 ratio of case managers to Guard/Reserve 
personnel in a medical holdover unit. By implication, there are no 
regulations for the ratio of case managers to personnel for Active Duty 
personnel in a medical hold status. Do you believe that the 1 to 35 
ratio for medical holdover personnel is adequate and do you think that 
DOD should establish a requirement standard for case managers for 
Active Duty personnel in medical hold?
    Response. The ratio for case management to personnel is not a ``one 
size fits all'' answer, including Servicemembers in the medical hold 
status. The Department of Defense (DOD) Medical Management Guide, dated 
January 2006, outlines a suggested caseload for case managers. The 
ratio is determined on several factors, including the experience of the 
case manager, Military Treatment Facility and community-based 
resources, and other variables. Currently, DOD supports the Case 
Management Society of America's recommendations that are based on 
acuity of the patient as illustrated in the following table:


----------------------------------------------------------------------------------------------------------------
                  Level                              Amount                               Type
----------------------------------------------------------------------------------------------------------------
Acute...................................  8-10 cases.................  Early injury/illness stages (case manager
                                                                        performs all coordination).
Mixed...................................  25-35 cases................  Acute and chronic cases (some requiring
                                                                        semi-annual or annual follow-up, some
                                                                        needed full-time case manager
                                                                        coordination).
Chronic.................................  35-50 cases................  Cases requiring 1-2 hours follow-up/
                                                                        month.
----------------------------------------------------------------------------------------------------------------


    Question 2. One focus of complaints related to DOD's rehabilitation 
process has been the role of case managers in the process. To what 
extent are there prescribed regulations related to the duties and 
responsibilities of DOD case managers of medical hold and holdover 
personnel?
    Response. DOD Instruction 6025.20, Medical Management Programs in 
the Direct Care System and Remote Areas, gives specific guidance on 
responsibilities for case management. Specific guidance regarding 
medical holdover personnel is addressed in Section II-17 of the DOD 
Medical Management Guide, dated January 2006. Coordination of care from 
the Military Health System to the Department of Veterans Affairs is 
also addressed in the Medical Management Guide.
    Question 3. Is there a required training program for case managers 
and regulations that govern their specific responsibilities on behalf 
of servicemembers or do those regulations vary from installation to 
installation and Service to Service?
    Response. There is a required training program for case managers, 
and the TRICARE Management Activity (TMA) provides medical management 
training which includes case management. The medical management 
training is typically held annually in each of TRICARE's three regions. 
Participants include Military Treatment Facility providers, case 
managers, utilization managers, and disease management managers.
    Additionally, Department of Defense Instruction 6025.20, Medical 
Management Programs in the Direct Care System and Remote Areas, gives 
specific guidance on responsibilities for not only case management, but 
also disease and utilization management. Additionally, there are Web-
based modules available for case management training through the TMA.
    The Assistant Secretary of Defense for Health Affairs is convening 
the Military Healthcare System Case Management Summit on 15-16 May. An 
action plan will be developed at the multi-agency, multi-disciplinary 
meeting that focuses on the way forward for addressing policy, 
training, and information sharing issues/challenges for injured, ill, 
and wounded warriors.

    Question 4. One of the responsibilities of case managers should be 
to better educate soldiers on the medical evaluation and disability 
process. Is that in fact one of their responsibilities?
    Response. The Department of Defense is bringing all of the involved 
members together for a Case Management Conference on May 15-16, 2007, 
to outline all requirements and assign responsibilities. The role of 
educating Servicemembers on the Physical Evaluation Board (PEB) process 
has traditionally been the role of the PEB Liaison Officer and not the 
case manager. We have to be careful we do not ``medicalize'' command 
and personnel responsibilities. While it is true that the case managers 
can assist with the education of Servicemembers on the medical 
evaluation and disability process, their major role will be to provide 
care coordination; ensuring that the Servicemember gets the right care 
at the right place and at the right time.

                           EVALUATION BOARDS

    Question 5. One complaint I have heard regarding the MEB/PEB 
process is that it was established in the 1970s, is outdated, and is 
extremely bureaucratic. For an Active Duty servicemember, the process 
requires between 22 and 27 pieces of paper, and even more for a Guard/
Reserve member. Some would argue that given the numerous opportunities 
for appeals during the process, that it is overly biased toward the 
servicemember, and maybe that is the way it should be. We want to give 
our servicemembers every opportunity to get well and, if they desire, 
continue their service in the military. I would appreciate your 
comments on the MEB/PEB process, and your thoughts regarding--if you 
had to do a ``lean event'' to streamline and remove the excess time and 
steps in the process--what would you change to make it more efficient 
and cause it to better serve our men and women in uniform?
    Response. The Disability Evaluation System (DES), which consists of 
the MEB and PEB processes, is complex, sometimes adversarial, and 
burdensome. Much of that is related to the statutory imperative for a 
fair and impartial system that affords due process protections (boards, 
legal representation, witnesses, an appellate process, etc.). The DES, 
as set forth in statute, allows the Department to provide additional 
guidance, but ultimately, the Secretaries of the Military Departments 
operate their DES consistent with their roles and missions, and apply 
ratings in accordance with how they interpret application of the 
Veterans Affairs (VA) Rating Schedule for Disabilities (VASRD).
    The complex and adversarial nature of the DES is partially a result 
of the magnitude of the benefits associated with the decisions on the 
rating. The disability rating determines whether the individual will 
separate with severance or with retirement benefits. For many, there is 
strong motivation to be declared fit to remain in uniform, despite 
injuries that would suggest otherwise.
    There are concerns that the VASRD has not kept current with the 
knowledge and service job environment, especially for brain injuries 
and pain as compared to other more physical injuries.
    We are looking at wholesale redesign of the complex and arcane DES, 
which dates back to constructs from 1949, but we need authority to 
waive current laws in fielding a new system. There is substantial 
precedent for this. It is highly effective and it points the way to 
legislative changes that could be enacted next year, as needed. DOD 
needs empowerment to revolutionize DES, rather than a new set of 
compliance standards that only serve to reinforce the present, failed 
system. A demonstration authority would empower VA and DOD to operate a 
combined activity for rating those judged unfit by DOD. It would also 
authorize the establishment of benefits under programs that transcend 
present law, and allow rapid proof of new concepts and quick response 
to the needs of the disabled. VA and DOD jointly would define the 
framework for conducting the demonstration. The Secretaries of VA and 
DOD would partner in making determinations with regard to waiving 
existing statutes and in managing congressional reporting.

    Question 6. One suggestion I have heard regarding how to speed up 
the MEB/PEB process within DOD and make it more efficient and easier 
for our servicemembers is to embed more VA personnel within DOD to help 
with the transition process. Specifically, VA personnel could begin 
working with soldiers and possibly take charge of their paperwork and 
medical requirements once it is clear that a servicemember cannot be 
retained in the Service. Can you comment on how embedding VA personnel 
might affect the MEB/PEB process and if you think, from our 
servicemembers' perspective, that this would be a good idea?
    Response. Yes, VA participation in the process could be helpful, 
and we are working with the VA to increase their involvement. We are 
looking at increasing VA liaison personnel in our Military Treatment 
Facilities, involving the VA in the process to determine a single 
disability rating, and more VA visibility in case management and 
tracking. We are also reviewing the Navy's recently released Severely 
Injured Marines and Sailors Pilot Program, which examined the pros and 
cons of an accelerated disability retirement program in order to 
maximize compensation and benefits to the most severely injured. The 
Navy conducted this pilot program in collaboration with the VA.

                       MEDICAL HOLDOVER PERSONNEL

    Question 7. One key to effectively handling medical holdover 
personnel is by having active and engaged case managers. The Army has 
three medical holdover units in Georgia, at Fort Gordon, Fort Benning, 
and Fort Stewart. The Fort Benning medical holdover unit relies in part 
on contract case managers. I am not fundamentally opposed to 
contractors performing this function, but I do think it can put the 
mission at risk if the contract expires and new case managers cannot be 
recruited and hired in time to replace the old ones. Do you think there 
should be a regulation requiring a certain percentage of case managers 
to be DOD civilians or military personnel?
    Response. Military personnel do not provide all health care in the 
DOD Military Health System. Federal civilians and contract staff 
supplement the military medical professionals in virtually all 
settings. Similarly, case management is not conducted using only 
military providers. Contract personnel are required to accomplish an 
activity of such scope and volume. However, it would not be good 
practice to mandate specific percentages for the mix of case managers. 
Instead, the mix at any particular medical care facility should be 
determined by the workload, budget, and other operational factors for 
that location.

    Question 8. In the event that contractors are utilized, what are 
you doing to ensure the medical holdover mission is not compromised and 
that our soldiers receive the necessary advocacy when they are in a 
medical holdover unit?
    Response. Supervision of all Servicemembers and the personnel 
supporting them takes an active and engaged command. Each Military 
Service will stay actively engaged in the care of all of its 
Servicemembers to ensure there are no lapses.

                     SHORTAGE OF MEDICAL PERSONNEL

    Question 9. My staff traveled across the State of Georgia last week 
and visited three DOD hospitals, and one comment that surfaced at every 
installation related to the Army's inability to offer attractive enough 
incentives to hire the doctors and nurses they need to execute their 
mission, as well as an overly burdensome bureaucratic hiring and 
contracting process that prevents military bases from getting the 
military, civilian, and contract health care providers that they need 
when they need them. I think you will agree that this is a problem 
across DOD. In my mind, we ought to be able to do whatever we need to 
streamline this process and give you the authorities you need to get 
the personnel you need in this area because it is one of the most 
critical areas facing our military. What, in your opinion, needs to be 
done here and how can Congress help?
    Response. While conducting the most recent Quadrennial Defense 
Review (QDR), the DOD identified a requirement to transform the process 
by which the Military Services acquire contracted medical professionals 
to work in MTFs. The QDR Roadmap for Medical Transformation includes an 
initiative titled ``Contracting for Professional Services,'' that will 
enable the Military Health System (MHS) to more effectively and 
efficiently employ contract medical personnel by providing an 
acquisition process that is consistent throughout the system and makes 
health care more accessible to beneficiaries.
    DOD is establishing a Strategic Sourcing Council for the 
acquisition of medical professional services. The council will oversee 
a collaborative and structured process by the Military Services to 
critically analyze the MHS spending for contracted medical personnel in 
order to optimize performance, minimize price, increase achievement of 
socio-economic acquisition goals, improve vendor access to business 
opportunities, and otherwise increase the value of each dollar spent. 
This transformed acquisition process will be first applied to 
establishing a common, standing contracting vehicle that all of the 
Military Services can use to quickly fill medical professional staffing 
needs as they arise in the MTFs. Congress has already provided the 
statutory authority needed to accomplish this.

                   POST-DEPLOYMENT HEALTH ASSESSMENT

    Question 10. I understand that the Army requires each soldier who 
redeploys from theater to undergo a post-deployment health reassessment 
90 to 180 days after their return. This is obviously a good idea since 
many conditions may not show up until several months after a 
deployment. However, I understand that these health assessments are not 
always done in person but can be done over the phone and by contractors 
versus military personnel. In my mind this is not ideal and allows for 
many conditions to be overlooked and go unreported which might then 
surface months or years later. Specifically, related to some of the 
most common conditions such as PTSD and TBI, I believe that it would be 
particularly hard if not impossible to diagnose these conditions over 
the phone. Regarding the post-deployment health assessment process, do 
you believe it would be wise for DOD and the Army to require these 
assessments to be conducted in person by military personnel?
    Response. The PDHRA is a DOD-wide requirement for every 
Servicemember who returns from an operational deployment. The PDHRA is 
a process that includes completion of an interview with a health care 
provider. A PDHRA does not result in a diagnosis, rather it allows the 
Servicemember to raise any concerns so that the health care provider, 
when interviewing the individual, can provide education and offer a 
referral for more detailed evaluation, as clinically appropriate. These 
assessments can be accomplished in person, or through a contract-
operated national call center.
    The call center follows established and well-accepted telehealth 
procedures to allow increased access to Servicemembers who are remotely 
located. It is not the standard for all members, but an option that 
makes the PDHRA more convenient for our Guard and Reserve members who 
may not drill with their unit. Call centers, nurse triage lines, and 
various other types of ``hot lines'' are widely used, accepted, and 
effective methods for various health screening programs. It is 
important to provide options to Servicemembers because not everyone 
communicates in the same way. Some people perceive a degree of 
anonymity over the telephone and are more comfortable answering 
personal questions under those conditions. Others are more open and 
honest during a face-to-face interview. While keeping both options 
available, we have initiated a program evaluation study to determine if 
there is any difference in effectiveness between these two approaches.
    Military personnel do not provide all health care in the DOD 
Military Health System. Federal civilians and contract staff supplement 
the military medical professionals in virtually all settings. 
Similarly, PDHRAs are not conducted using only military providers, even 
for active duty members. Contract personnel are required to accomplish 
an activity of such scope and volume. However, past military experience 
is preferred when hiring the contract staff and standardized training 
and guidelines help facilitate consistent processes and decisions.

    Question 11. How do DOD and the Army ensure that soldiers actually 
complete these health assessments?
    Response. The DOD has a well-established Post-deployment Health 
Assessment (PDHA) process. As required by current DOD policy and Joint 
Staff guidance, the assessments are accomplished by Servicemembers 
before leaving the theater. The completed forms are sent to the Defense 
Medical Surveillance System (DMSS) and are made available to military 
health care providers through TRICARE Online. The Services also check 
to ensure that Servicemembers returning from deployment complete a PDHA 
at their home station if they did not complete one in theater. All of 
the Services monitor their own compliance and Health Affairs measures 
PDHA compliance across the DOD as part of the overall force health 
protection quality assurance program. Health Affairs teams perform 
onsite visits and review physical medical records, and compare the 
findings with information contained in the DMSS. Generally, PDHA 
compliance rates have exceeded 90 percent.

    Chairman Levin. Thank you, Secretary England.
    I understand, Secretary Chu, that you do not have an 
opening statement, is that correct?
    Dr. Chu. No, sir. I couldn't say it better than Secretary 
England.
    Chairman Levin. Thank you. Secretary Cooper?

    STATEMENT OF HON. DANIEL L. COOPER, UNDER SECRETARY FOR 
           BENEFITS, DEPARTMENT OF VETERANS AFFAIRS; 
      ACCOMPANIED BY GERALD CROSS M.D., ACTING PRINCIPAL 
   DEPUTY UNDER SECRETARY FOR HEALTH, DEPARTMENT OF VETERANS 
                            AFFAIRS

    Mr. Cooper. Chairman Akaka, Senator Craig, and Members of 
the Veterans' Affairs Committee, Senator Levin, Senator McCain, 
Members of the Armed Services Committee, first, I respectfully 
request that my written statement be entered into the record.
    Chairman Levin. It will be made a part of the record.
    Mr. Cooper. It is my pleasure to be here today to discuss 
the transition of servicemembers from the Department of Defense 
to the Department of Veterans Affairs. I am pleased to be 
accompanied by Dr. Gerald Cross, Acting Principal Deputy Under 
Secretary for Health.
    The focus of my remarks will be the Seamless Transition 
Program for the seriously injured veterans of Operations Iraqi 
and Enduring Freedom. I will also discuss our joint efforts 
with DOD in data and information sharing as well as the VA's 
disability rating system.
    Seamless Transition is a jointly sponsored VA and DOD 
initiative for the most seriously injured OIF/OEF 
servicemembers and it is our highest priority. We must ensure 
that these courageous men and women transition seamlessly from 
DOD to VA, that they continue to receive the best care 
available, and are quickly awarded the benefits they have 
earned through their service and their 
sacrifice.
    VA has social workers and benefits counselors assigned to 
ten military treatment facilities, including Walter Reed. These 
social workers and counselors are the first VA representatives 
to meet with the injured servicemembers and their families. 
They provide information about health care, disability 
compensation and rehabilitation benefits, the Traumatic 
Servicemember's Group Life Insurance benefit, as well as 
educational and housing benefits. Our benefits counselors 
assist servicemembers and their families in completing the 
benefits claims and in gathering the supporting evidence. Our 
social workers assist in coordinating the future course of 
treatment for their injuries after they leave the service.
    Since last September, a VA Certified Rehabilitation 
Registered Nurse has been assigned to Walter Reed to provide 
patient updates to our Polytrauma Centers and to prepare 
servicemembers and their families for the transition to VA and 
the rehabilitation phase of their recovery.
    Secretary Nicholson recently announced an important new 
initiative. The VA will hire 100 new Transition Patient 
Advocates for the severely injured servicemembers. These 
Patient Advocates will travel to the MTFs to initiate contact 
with the servicemembers and their families and will work with 
them throughout the transition process to resolve problems and 
concerns.
    As servicemembers are transferred from the MTFs to other 
DOD facilities or to VA care, the benefits counselors notify 
the appropriate Regional Benefits Office of the transfer. All 
regional offices have established points of contact with the 
military and the VA hospitals and all regional offices have 
designated case managers who maintain regular contact with 
these seriously injured veterans to ensure that their needs are 
met. Each disability claim from a seriously injured OIF/OEF 
veteran is case managed to try to ensure expeditious 
processing.
    One important aspect of coordination between DOD and VA is 
access to clinical information, including a pre-transfer review 
of electronic medical information via remote access. The VA 
Polytrauma Centers have been granted direct access into 
inpatient clinical information systems at Walter Reed and 
Bethesda. Additionally, a new application known as the Veterans 
Tracking Application will enable VA to track servicemembers 
from the battlefield through Landstuhl, the MTFs, and to the VA 
medical facility. VTA is a modified version of DOD's Joint 
Patient Tracking application and will have all medically 
evaluated OIF/OEF servicemembers in the database. The 
application is also designed to identify where servicemembers 
have filed claims for disability and which VBA counselor 
assisted in the claims process. Full deployment of this process 
is scheduled to be completed by the end of April.
    The VA's schedule for rating disabilities is the guide that 
we use in the evaluation of disabilities resulting from 
diseases and injuries encountered as a result and during 
military service. By law, VA must evaluate all diseases and 
injuries claimed by the veteran, but also any inferred, 
secondary, or unclaimed problems or conditions for which 
service connection could potentially be granted. The ratings VA 
assigns under the schedule represent the average impairment in 
earning capacity resulting from such diseases or injuries in 
civil occupations. The disability medical examination by the VA 
is highly structured and includes examination worksheets to 
ensure that all elements of the rating schedule are addressed. 
The ratings assigned are in 10 percent increments.
    Servicemembers who are retiring or leaving the service and 
are not seriously wounded can apply for VA disability 
compensation under the Benefits Delivery at Discharge program. 
They then undergo a single medical examination while on active 
duty that is adequate for both VA and DOD purposes. Under the 
BDD program, servicemembers can complete an application for VA 
disability compensation up to 180 days prior to their 
discharge. Servicemembers are given one physical examination 
instead of both a separation exam from the military and a 
disability exam for the VA.
    VA has worked hard to improve the transition process for 
our deserving servicemen and women. We are not satisfied that 
we have achieved all that is possible or can be done. As you 
know, a Presidential Interagency Task Force and other 
commissions are working to improve the services provided to our 
wounded Global War on Terrorism servicemembers as well as for 
all veterans. VA is committed to assisting their work and 
continuing to work internally to ensure all is being done for 
those who have so admirably served their Nation.
    Mr. Chairman, this concludes my testimony. I would be 
pleased to answer any questions.
    [The prepared statement of Mr. Cooper follows:]

   Prepared Statement of Hon. Daniel L. Cooper, Under Secretary for 
                Benefits, Department of Veterans Affairs

    Chairman Akaka, Senator Craig, and Members of the Veterans Affairs 
Committee; Chairman Levin, Senator McCain, and Members of the Armed 
Services Committee: It is my pleasure to be here today to discuss the 
transition of servicemembers from the Department of Defense (DOD) to 
the Department of Veterans Affairs (VA) and the DOD and VA rating 
systems. I am also pleased to be accompanied today by Dr. Gerald Cross, 
Acting Principal Deputy Under Secretary for Health.
    The focus of my remarks will be the seamless transition program, 
especially as it relates to the care of seriously injured veterans of 
service in Operations Iraqi and Enduring Freedom (OIF/OEF). I will also 
discuss our joint efforts with DOD in the area of electronic records 
transfer and data and information sharing, as well as the disability 
rating systems used by DOD and VA.

                          SEAMLESS TRANSITION

    Seamless Transition is a jointly sponsored VA and DOD initiative 
that provides transition assistance to seriously injured 
servicemembers. In partnership with DOD, VA has implemented a number of 
strategies to provide timely, appropriate, and seamless transition 
services to the most seriously injured OIF/OEF active duty 
servicemembers and veterans. Our highest priority is to ensure that 
those returning from the Global War on Terror transition seamlessly 
from DOD military treatment facilities (MTFs) to VA Medical Centers 
(VAMCs), continue to receive the best possible care available anywhere, 
and receive all the benefits they have earned through their service and 
sacrifice in a timely manner. Toward that end, we continually strive to 
improve the delivery of our care and benefits.
    Veterans Health Administration (VHA) social worker liaisons and 
Veterans Benefits Administration (VBA) counselors are located at ten 
military treatment facilities (MTFs) that receive the most severely 
wounded patients, including Walter Reed Army Medical Center. These 
social workers and counselors are a critical part of the seamless 
transition process, assisting active duty servicemembers in their 
transition to VA medical facilities and the VA benefits system.
    The counselors and social workers assigned to the MTFs are usually 
the first VA representatives to meet with servicemembers and their 
families. They provide information about the full range of VA benefits 
and services, which include: health care and readjustment programs, 
disability compensation and related benefits, the traumatic injury 
benefit provided under the Servicemembers Group Life Insurance Program, 
as well as educational and housing benefits.
    VBA benefits counselors assist servicemembers in completing 
benefits claims and in gathering supporting evidence. While 
servicemembers are hospitalized, they are kept informed of the status 
of their pending claims and given their counselor's name and contact 
information should they have questions or concerns.
    VHA social worker liaisons play a very crucial role in the seamless 
transition of seriously injured servicemembers from MTFs to VA medical 
centers, where they receive the best possible care. Our social workers 
assist these servicemembers and their families in coordinating the 
future course of treatment for their injuries after they return home.
    VA's Seamless Transition Program also includes two Outreach 
Coordinators--a peer-support volunteer and a veteran of the Vietnam 
War--who regularly visit seriously injured servicemembers at Walter 
Reed and Bethesda National Navy Medical Center. Their visits enable 
them to establish a personal and trusted connection with patients and 
their families. They encourage patients to consider participating in 
VA's National Rehabilitation Special Events or to attend weekly dinners 
held in Washington, DC, for injured OIF/OEF returnees. In short, they 
are key to enhancing and advancing the successful transition of our 
servicemembers.
    VA has coordinated the transfer of over 6,800 OIF/OEF severely 
injured or ill active duty servicemembers and veterans from DOD to VA 
care and services. Since September 2006, a VA Certified Rehabilitation 
Registered Nurse (CRRN) has been assigned to Walter Reed to assess and 
provide regular updates to our Polytrauma Rehabilitation Centers (PRC) 
regarding the medical condition of incoming patients. The CRRN advises 
and assists families and prepares active duty servicemembers for 
transition to VA and the rehabilitation phase of their recovery.
    VA's social worker liaisons and the CRRN strive to fully coordinate 
care and information prior to a patient's transfer to our Department. 
Social worker liaisons meet with patients and their families to advise 
and ``talk them through'' the transition process. They register 
servicemembers or enroll recently discharged veterans in the VA health 
care system, and coordinate their transfer to the most appropriate VA 
facility for the medical services needed, or to the facility closest to 
their home.
    In transferring seriously injured patients, both the CRRN and the 
social worker liaison are an integral part of the MTF treatment team. 
They simultaneously provide input into the VA health care treatment 
plan and collaborate with both the patient and his or her family 
throughout the entire health care transition process. Video 
teleconference calls are routinely conducted between DOD MTF treatment 
teams and receiving VA polytrauma center teams. When feasible, the 
patient and family attend these video teleconferences to participate in 
discussions and to ``meet'' the VA PRC team.
    As servicemembers are transferred from the MTFs to other DOD 
treatment facilities or VA care, the VBA benefits counselors notify the 
appropriate regional office of the servicemember's transfer. All VA 
regional offices have established points of contact with all military 
hospitals and VA medical centers in their jurisdiction to ensure prompt 
notification of arrival, transfer, and discharge of seriously injured 
servicemembers. In addition to the established points of contact for 
medical facilities within their jurisdiction, all regional offices have 
designated OIF/OEF coordinators and case managers who maintain regular 
contact with injured veterans to ensure their needs are being met.
    Servicemembers are given VA contact information for their regional 
office OIF/OEF coordinator and case manager when they are being 
transferred to another medical facility, released to home, or awaiting 
discharge/retirement orders.
    Each claim from a seriously disabled OIF/OEF veteran is case-
managed to ensure seamless and expeditious processing. All claims are 
immediately placed under computer control in VBA's benefits delivery 
system and carefully tracked through all stages of processing. The 
regional office directors immediately call returning seriously disabled 
servicemembers and veterans when they first arrive in their 
jurisdiction to welcome them home and advise them that the OEF/OIF 
coordinator or a case manager will contact them and assist them through 
the claims process. The director ensures a case manager is assigned for 
each compensation claim received from a seriously disabled OIF/OEF 
veteran. The case manager becomes the primary VBA point of contact for 
the veteran.
    OIF/OEF case managers maintain a case history on each injured 
veteran throughout the claims process. All regional offices are also 
required to update a spreadsheet used to identify and track services 
provided to seriously injured OIF/OEF veterans on a national basis and 
monitored by VBA's Office of Field Operations.

                      TRANSITION PATIENT ADVOCATES

    Secretary Nicholson recently announced that VHA is hiring 100 new 
transition patient advocates who will serve as ombudsmen for severely 
injured OEF/OIF sevicemembers and veterans. These transition patient 
advocates will initiate contact with assigned servicemembers and their 
families while the servicemembers are still at the MTF. They will 
assist servicemembers and their families with any concerns, help 
resolve problems and work with case managers as well. The transition 
patient advocates travel to the MTF for the initial meeting with 
patients and their families.

                     VA AND DOD INFORMATION SHARING

    VA and DOD have made significant progress in the development of 
interoperable health technologies that support seamless transition from 
active duty to veteran status. Advances include the successful one-way 
and two-way transmission of electronic medical records between DOD and 
VA, and the adoption and implementation of data standards that support 
interoperability.
    One important aspect of coordination between DOD and VA prior to a 
patient's transfer to VA is access to clinical information, including a 
pre-transfer review of electronic medical information via remote 
access. The VA polytrauma centers have been granted direct access into 
inpatient clinical information systems at Walter Reed and Bethesda. 
This remote inpatient access is in addition to the existing 
bidirectional data sharing of pertinent outpatient data. VA and DOD are 
working together to ensure that appropriate users are adequately 
trained and connectivity exists for all four polytrauma centers.
    As stated above, in addition to sharing inpatient data, VA and DOD 
share outpatient data through the Bidirectional Health Information 
Exchange (BHIE). BHIE allows VA and DOD clinicians to share text-based 
outpatient clinical data between VA and select DOD military treatment 
facilities, including Walter Reed and Bethesda, and 18 hospitals, and 
more than 190 outlying clinics.
    VA and DOD information sharing successes have resulted directly 
from implementation of the DOD/VA Joint Electronic Health Records 
Interoperability (JEHRI) Plan. JEHRI is a comprehensive strategy to 
develop collaborative technologies and interoperable data repositories, 
as well as adoption of common data standards. VA and DOD have made 
significant progress with the implementation of JEHRI. Most recently, 
the departments have agreed to enhance sharing through JEHRI to 
collaborate on the feasibility, identification and development of a 
common inpatient electronic health record. Initial work on this project 
will begin this 
fiscal year.
    Additionally, a new application very near deployment will provide 
VA with the ability to track servicemembers from the battlefield 
through Landstuhl, Germany, the MTFs, and on to the VA medical 
facility. The new application, known as the Veterans Tracking 
Application (VTA), is a modified version of DOD's Joint Patient 
Tracking Application--a Web-based patient tracking and management tool 
that collects, manages, and reports on patients arriving at MTFs from 
forward-deployed locations.
    The VTA Web-based system allows approved VA users to access this 
real-time information about the servicemembers we serve and track 
injured active duty servicemembers while they transition to veteran 
status. VTA will have all medically evaluated OIF/OEF servicemembers in 
the database as necessary to provide VA care and benefit claims 
support. This application was developed for VA to coordinate care from 
an MTF to a VAMC to ensure that VA will know where the servicemember is 
currently located, where the patient came from, and who has seen the 
patient. The application is also designed to identify where 
servicemembers filed claims and which VBA counselor assisted the 
servicemember in the claims process. The application has an historic 
record feature to ensure we preserve all status changes. Deployment in 
VBA is underway. Full deployment in both VBA and VHA is scheduled to be 
completed by the end of April.
    The two departments are also working to expand VA access to DOD 
inpatient documentation, particularly for severely wounded and injured 
servicemembers being transferred to VA for care. An early version of 
this electronic capability is currently in use between Madigan Army 
Medical Center and the VA Puget Sound Health Care System, where 
inpatient discharge summaries are exchanged. Tripler Army Medical 
Center, Womack Army Medical Center, and Brooke Army Medical Center have 
also implemented this capability.

                  VA AND DOD DISABILITY RATING SYSTEMS

    Disability ratings and evaluations completed by VA are in 
accordance with Title 38 Code of Federal Regulations, Parts 3 and 4.
    Part 4, the VA Schedule for Rating Disabilities, is primarily a 
guide in the evaluation of disability resulting from all types of 
diseases and injuries encountered as a result of, or incident to, 
military service. The percentage ratings represent, as far as can 
practicably be determined, the average impairment in earning capacity 
resulting from such diseases and injuries and their residual conditions 
in civil occupations.
    The military service branches also use the VA Schedule for Rating 
Disabilities in determining disability ratings, although they have 
instituted an appendix that differs from the VA schedule.
    Although both VA and DOD use the VA Schedule for Rating 
Disabilities as the primary tool in the evaluation of disability 
resulting from disease or injury, there are a number of reasons why the 
resulting ratings might vary.
    The evaluation of disability is a process that involves the 
objective standards listed in the VA Schedule for Rating Disabilities, 
but also involves the evaluation of evidence. This is important from 
two perspectives. First, the medical evidence generated for the 
evaluation is derived differently by the two agencies. In VA, the 
compensation and pension disability examination process is highly 
structured with examination worksheets that ensure that all elements of 
the rating schedule dealing with a specific disability are addressed. 
Further, most VA examinations are performed solely to support the 
disability evaluation process. In DOD, we understand that treating 
physicians produce the medical evidence. Second, disability raters 
evaluate a unique fact pattern for each servicemember or veteran. This 
uniquely human analytical process will produce some variability within 
and across organizations, which is why both agencies employ appeals 
processes to ensure the claimant receives the most accurate rating.
    Currently, servicemembers who apply for disability compensation 
benefits under the Benefits Delivery at Discharge (BDD) program undergo 
a medical examination while still on active duty that is adequate for 
VA purposes. The BDD Program is a jointly sponsored VA and DOD 
initiative to provide transition assistance to separating 
servicemembers who have disabilities related to their military service.
    The BDD Program helps servicemembers file for VA service-connected 
disability compensation and related benefits prior to separation from 
service, so that payment of benefits can begin as soon as possible 
after discharge. Timely decisions on servicemembers' disability 
compensation claims also help to ensure continuity of medical care for 
their service-connected disabilities.
    Under the BDD Program, servicemembers can complete an application 
for VA disability compensation benefits up to 180 days prior to 
separation. VA and DOD have agreed to a cooperative separation 
examination process for servicemembers filing a VA claim for benefits. 
Servicemembers attend one physical examination, instead of both a 
separation exam for the military and a VA exam for the disability 
claim. VA fully develops the claim, and the single VA/DOD medical 
examination meets the military's needs for a separation physical and 
also fulfills VA's examination requirements for processing the 
disability claim.

               CLAIMS PROCESSING ACCURACY AND CONSISTENCY

    To increase the accuracy and consistency of our benefit decisions, 
we have established an aggressive and comprehensive program of quality 
assurance and oversight to assess compliance with VBA claims processing 
policy and procedures and assure consistent application.
    The Systematic Technical Accuracy Review (STAR) program includes 
review of work in three areas: rating accuracy, authorization accuracy, 
and fiduciary program accuracy. Overall station accuracy averages for 
these three areas are included in the regional office director's 
performance standard and the station's performance measures. STAR 
results are readily available to facilitate analysis and to allow for 
the delivery of targeted training at the regional office level. The 
Compensation and Pension (C&P) Service conducts satellite broadcast 
training sessions based on an analysis of national STAR error trends. 
Over the last 4 years, our rating decision quality has risen 
significantly from 81 percent to 89 percent.
    In addition to the STAR program, the C&P Service is identifying 
unusual patterns of variance in claims adjudication by diagnostic code, 
and then reviewing selected disabilities to assess the level of 
decision consistency among and between regional offices. These studies 
will be used to identify where additional guidance and training are 
needed to improve consistency and accuracy, as well as to drive 
procedural or regulatory changes.
    Site surveys of regional offices address compliance with 
procedures, both from a management perspective in the operation of the 
service center and from a program administration perspective, with 
particular emphasis on current consistency issues. Training is 
provided, when appropriate, to address gaps identified as part of the 
site survey.
    It is critical that our employees receive the essential guidance, 
materials, and tools to meet the ever-changing and increasingly complex 
demands of their decisionmaking responsibilities. To that end VBA has 
deployed new training tools and centralized training programs that 
support accurate and consistent decisionmaking.
    New hires receive comprehensive training and a consistent 
foundation in claims processing principles through a national 
centralized training program called ``Challenge.'' After the initial 
centralized training, employees follow a national standardized training 
curriculum (full lesson plans, handouts, student guides, instructor 
guides, and slides for classroom instruction) available to all regional 
offices. Standardized computer-based tools have been developed for 
training decisionmakers (69 modules completed and an additional eight 
in development). Training letters and satellite broadcasts on the 
proper approach to rating complex issues are provided to the field 
stations. In addition, a mandatory cycle of training for all Veterans 
Service Center employees has been developed consisting of an 80-hour 
annual curriculum.
    VA has worked hard to improve the transition process for our 
deserving servicemen and women. Yet, we are not satisfied that we have 
achieved all that is possible. As you know, a Presidential Interagency 
Task Force and other Commissions are working to improve the services 
provided to our returning wounded Global War on Terror military 
personnel and veterans. VA is committed to assisting their work in a 
collaborative effort to ensure all is being done for those who so 
admirably serve our Nation.
    Mr. Chairman, this concludes my testimony. I would be pleased to 
answer any questions you may have.
                                 ______
                                 
    Response to Written Questions Submitted by Hon. Daniel K. Akaka 
 to Hon. Daniel L. Cooper, Under Secretary for Benefits, Department of 
                            Veterans Affairs

    Question. If VBA were to assume responsibility for making active 
military disability ratings, what would be the impact on VBA's other 
responsibilities?
    Response. If the Veterans Benefits Administration (VBA) assumed 
responsibility for making active military disability ratings, we would 
factor any additional demands into our future budget requests to 
Congress to ensure continued improvement in timeliness of disability 
claims processing.
                                 ______
                                 
    Response to Written Questions Submitted by Hon. Larry E. Craig 
 to Hon. Daniel L. Cooper, Under Secretary for Benefits, Department of 
                            Veterans Affairs

    Question 1. There is a wide array of benefits and services provided 
by both the Department of Veterans Affairs (VA) and the Department of 
Defense (DOD), yet there are discrepancies between benefits available 
for those on active duty versus those who are medically retired and in 
veteran status. This discrepancy may lead to confusion among family 
members who do not understand why legal distinctions exist for benefits 
meant to help those wounded in combat, irrespective of their status. 
The Wounded Warrior Project has recommended legislation to authorize a 
blanket overlap of DOD and VA benefits for a period of 2 years 
following the medical retirement of an injured servicemember or for the 
length of time a servicemember is held on Temporary Disability 
Retirement List (TDRL), whichever is later. What are your views on this 
idea?
    Response. A combat-injured veteran should have access to the best 
services that are available from DOD and VA. We believe that to ensure 
accountability and clarity, the responsibilities of each Department 
must be clearly defined. We do not believe there should be different 
eligibility periods for those placed on the permanent disability 
retired list versus those placed on TDRL. A member placed on TDRL may 
remain on the TDRL for a maximum of 5 years. The Wounded Warrior 
Project proposal would give servicemembers placed on TDRL, a population 
whose injuries the physical evaluation board (PEB) judged to have 
potential for improvement, greater benefits than those servicemembers 
with disabilities so severe as to warrant permanent retirement.
    Question 2. There exists a VA Office of Seamless Transition (OST) 
with a mission to facilitate the transition of servicemembers from 
active duty to civilian lives by coordinating VA benefits and services 
with those provided by DOD. Yet the OST reports only to the Under 
Secretary of Health. Within DOD, the Military One Source Center is 
designed to augment and support transition services, yet problems with 
coordination of the support services provided by the military services 
persist.
    Question 2(a). Is there a need for an organizational restructuring 
within VA so that the transition office has authority over ALL VA 
benefits and services and reports directly to the Deputy Secretary of 
VA?
    Response. The Office of Seamless Transition (OST) focuses on the 
issues related to the transition of severely injured servicemembers. 
While OST is organizationally within the Veterans Health Administration 
(VHA), the office has critical VBA staff who work closely on all 
benefits-related issues. Also, OST managers work directly with and 
report to VBA leadership to identify and resolve issues related to 
transition of servicemembers with severe injuries. Transition 
coordination is accomplished through the efforts of many offices 
throughout VA and at DOD, including the Joint Executive Council, Health 
Executive Council, Benefits Executive Council, and various DOD/VA 
working groups.
    For example, the Deputy Secretary of VA and the Deputy Under 
Secretary of Defense for Personnel and Readiness recently established a 
Joint Communications Work Group to improve stakeholder awareness of 
sharing and collaboration initiatives and to communicate and promote 
results and best practices throughout the two departments. The Joint 
Communications Work Group will improve information flow between the two 
departments and ensure coordinated messages and statistics are 
communicated.
    VA has also established a VA/DOD Coordination Office, which 
incorporates both the Office of Seamless Transition and the DOD Liaison 
Sharing Office. The establishment of this office reflects VA's ongoing 
commitment to ease the transition process for all veterans, and to 
provide the additional assistance that seriously injured veterans 
require. The VA/DOD Coordination Office is able to provide assistance 
for both the health care and benefits needs of seriously injured 
servicemembers and veterans.

    Question 2(b). To increase interagency transition coordination, 
should DOD establish a mirror transition office that reports directly 
to the Under Secretary for Personnel and Readiness?
    Response. VA cannot comment on DOD's organizational structure. We 
defer to DOD for response.

    Question 3. If we were to start from scratch and design a new 
system of compensation for those who are severely injured in service, 
what should that system look like?
    Response. Redesign of the current disability compensation system is 
an extremely complex task that requires extensive study. The Veterans 
Disability Benefits Commission has been charged by the Congress to 
conduct such a study and recommend changes. The Commission is expected 
to submit its findings in October 2007. Given the extensive research 
the Commission has conducted, we believe the Commission's report will 
form a good starting point for discussion on any fundamental changes to 
the system of compensation for those who are disabled as a result of 
their military service.

    Question 4. What do you think should be the purpose of a modern 
compensation program and how should we regularly determine whether the 
program, as designed, is meeting its intended purpose?
    Response. The primary intent of VA's disability compensation 
program is to provide compensation for loss of earning capacity. This 
loss of earning capacity is not intended to be based on the disabled 
veteran's individual impaired capacity, but the average impairment 
resulting from such injuries. To an extent based on periodic 
legislative changes, VA's disability compensation program also 
compensates for reduction in quality of life due to service-connected 
disability.
    To determine whether VA benefit programs meet their intended 
purpose, Congress requires VA to complete program outcome studies. 
These studies provide valuable information to VA and to Congress, 
including changes that need to be made to the benefit programs. A 
number of these studies have been completed or are currently underway, 
including studies of the dependency and indemnity compensation (DIC) 
program, Insurance, veterans and survivors pension programs, and burial 
benefits.
                                 ______
                                 
      Response to Written Questions Submitted by Hon. John McCain 
 to Hon. Daniel L. Cooper, Under Secretary for Benefits, Department of 
                            Veterans Affairs

                 CAPACITY OF THE VA HEALTH CARE SYSTEM

    Question 1. Unlike DOD, which is bound by health care access 
standards to purchase care from the civilian sector when it cannot be 
provided in-house, the VA has no legal obligation to provide care 
within a specified time frame, nor an obligation to purchase services 
from the private sector. Isn't it time to change this paradigm, 
especially for veterans with care needs related to their military 
service? Otherwise, how will VA meet the demand for health services 
that is one of the consequences of the war, including increased demands 
for rehabilitative and mental health services?
    Response. Although VA has no legal obligation to provide care 
within a specified timef rame, VA does have established access 
standards in place which apply to all veterans. These standards are.

     96 percent of primary care appointments should be within 
30 days of desired date or from the creation date if a new patient.
     93 percent of specialty care appointments should be within 
30 days of the patient's desired date or from the creation date if a 
new patient.

    In the instances when the demand for service is great and these 
standards cannot be met, medical centers have the authority in current 
law to purchase that care in the community.
      projection of future health care needs by america's veterans
     Question 2. A column by Harvard researcher Linda Bilmes asserts 
that ``the seeds of the Walter Reed Army Medical Center scandal were 
sown in . . . a failure to foresee the sheer number and severity of 
casualties.'' Do you agree with that statement?
    Response. VA cannot comment on Ms. Bilmes' assertion. VA is 
committed to ensuring it meets the needs of all veterans, including 
those who serve in Operations Enduring Freedom and Iraqi Freedom (OEF/
OIF). VA has made every effort to account for the needs of OEF/OIF 
veterans within the VA enrollee health care projection model. To 
identify OEF/OIF veterans, we started using a DOD personnel roster in 
Fiscal Year (FY) 2002. The model develops projections based on the 
actual enrollment and use patterns of OEF/OIF veterans. However, the 
number and type of services that VA will need to provide OEF/OIF 
veterans are influenced by many unknowns, including the duration of the 
conflict, when OEF/OIF veterans are demobilized, and the impact of our 
enhanced outreach efforts. Therefore, we have included additional 
investments for OEF/OIF in the Fiscal Year 2008 budget to ensure that 
VA is able to care for al[ of the health care needs of our returning 
veterans.
    Question 3. What joint planning or analytical process exists today 
between DOD and the VA that did not exist in the past which will ensure 
a more complete understanding of the near- and long-term needs of our 
returning servicemembers?
    Response. VA and DOD are committed to increasing collaborative and 
sharing activities between the Departments. This commitment is embodied 
in the work of the three joint councils established to facilitate 
collaborative initiatives and the workgroups and task forces that have 
emerged from them. Additional efforts to enhance cooperation and 
collaboration between the Departments have been initiated by individual 
offices/interest groups. Currently, there are three primary joint 
councils:

    (1) VA/DOD Joint Executive Council (JEC) chaired by the Deputy 
Secretary of VA and the Under Secretary of Defense for Personnel and 
Readiness;
    (2) VA/DOD Health Executive Council (HEC), chaired by the VA Under 
Secretary for Health and the Assistant Secretary of Defense for Health 
Affairs; and
    (3) VA/DOD Benefits Executive Council (BEC), chaired by the VA 
Under Secretary for Benefits and the Assistant Secretary of Defense for 
Force Management.
    In May 2007, VA and DOD collaborated on the formation of the senior 
oversight committee (SOC) to focus on opportunities to directly support 
the seriously ill and wounded. The SOC is co-chaired by the Deputy 
Secretaries of each Department and is organized around business lines 
of action in clinical, administrative and personnel domain areas.
    In partnership with DOD, VA has implemented a number of strategies 
to provide timely, appropriate, and seamless transition services to the 
most seriously injured OEF/OIF active duty servicemembers and veterans.
    VA's work to create a seamless transition for men and women as they 
leave the service and take up the honored title of ``veteran'' begins 
early on. Our benefits delivery at discharge program enables active 
duty members to register for VA health care and to file for benefits 
prior to their separation from active service. Our outreach network 
ensures returning servicemembers receive full information about VA 
benefits and services. And each of our medical centers and benefits 
offices now has a nurse or social worker program manager assigned to 
work with veterans returning from service in OEF/OIF.
    VA has coordinated the transfer of over 6,800 severely injured or 
ill active duty servicemembers and veterans from DOD to VA. Our highest 
priority is to ensure that those returning from the Global War on 
Terror (GWOT) transition seamlessly from DOD military treatment 
facilities (MTF) to VA medical centers (VAMC) and continue to receive 
the best possible care available anywhere.
    VA nurses, social workers, benefits counselors, and outreach 
coordinators explain the full array of VA services and benefits. These 
liaisons and coordinators assist active duty servicemembers as they 
transfer from MTFs to VAMCs. In addition, our VHA Liaisons help newly 
wounded servicemembers and their families plan a future course of 
treatment for their injuries after they return home. Currently, VHA 
liaisons and benefit counselors are located at 10 MTFs, including 
Walter Reed Army Medical Center, the National Naval Medical Center in 
Bethesda, the Naval Medical Center in San Diego, and Womack Army 
Medical Center at Ft. Bragg. A national memorandum of understanding 
(MOU) has been signed between VA and DOD as directed by the GWOT task 
force, with memorandums of agreement (MOA) in place at each local 
facility.
    Since September 2006, a VA certified rehabilitation registered 
nurse (CRRN) has been assigned to Walter Reed to assess and provide 
regular updates to our polytrauma rehabilitation centers (PRC) 
regarding the medical condition of incoming patients. The CRRN advises 
and assists families and prepares active duty servicemembers for 
transition to VA and the rehabilitation phase of their recovery. A 
second nurse liaison is being hired for national Naval Medical Center, 
Bethesda, and should be in place by September 2007.
    Another important aspect of coordination between DOD and VA prior 
to a patient's transfer to VA is access to clinical information. This 
includes a pre-transfer review of electronic medical information via 
remote access capabilities. VA PRCs have been granted direct access 
into inpatient clinical information systems from Walter Reed Army 
Medical Center and National Naval Medical Center. VA and DOD are 
currently working together to ensure that appropriate users are 
adequately trained and connectivity is working and exists for all four 
PRCs. As of July 2007, Walter Reed Army Medical Center, Bethesda 
National Naval Medical Center and Brooke Army Medical Center all have 
achieved the capability to transmit digital radiology images and 
scanned inpatient records to the four PRCs.
    For inpatient data not available in DOD's information systems, VA 
social workers embedded in the MTFs routinely ensure that the paper 
records are manually transferred to the receiving PRC.
    The bidirectional health information exchange (BHIE) is a data 
exchange system that allows VA and DOD facilities. As of July 2007, 
BHIE data, which includes laboratory results, pharmacy and allergy data 
and radiology reports, may be exchanged between all DOD and all VA 
facilities. BHIE also now supports the ability to share discharge 
summaries between all VA facilities and eight DOD facilities, including 
the military treatment facilities in the National Capitol area.
    VA understands the critical importance of supporting families 
during the transition from DOD to VA. We established a polytrauma call 
center in February 2006, to assist the families of our most seriously 
injured combat veterans and servicemembers. The call center operates 24 
hours a day, 7 days a week to answer clinical, administrative, and 
benefit inquiries from polytrauma patients and family members. The 
center's value is threefold: it furnishes patients and their families 
with a one-stop source of information; it enhances overall coordination 
of care; and it immediately elevates any system problems to VA for 
resolution.
    VA's Office of Seamless Transition includes outreach coordinators 
who regularly visit seriously injured servicemembers at Walter Reed and 
Bethesda. Their visits enable them to establish a personal and trusted 
connection with patients and their families.
    These outreach coordinators help identify gaps in VA services by 
submitting and tracking follow-up recommendations. They encourage 
patients to consider participating in VA's national rehabilitation 
special events or to attend weekly dinners held in Washington, DC, for 
injured OEF/OIF returnees. In short, they are key to enhancing and 
advancing the successful transition of our service personnel from DOD 
to VA, and, in turn, to their homes and communities.
    In addition, VA has developed a vigorous outreach, education, and 
awareness program for the National Guard and Reserve. To ensure 
coordinated transition services and benefits, VA signed a MOA with the 
National Guard in 2005. Combined with VA/National Guard State 
coalitions in 54 States and territories, VA has significantly improved 
its opportunities to access returning troops and their families. We are 
continuing to partner with community organizations and other local 
resources to enhance the delivery of VA services. At the national 
level, MOAs are under development with both the United States Army 
Reserve and the United States Marine Corps. These new partnerships will 
increase awareness of, and access to, VA services and benefits during 
the demobilization process and as service personnel return to their 
local communities.
    VA is also reaching out to returning veterans whose wounds may be 
less apparent. VA is a participant in the DOD's post deployment health 
reassessment (PDHRA) program. DOD conducts a health reassessment 90-180 
days after return from deployment to identify health issues that can 
surface weeks or months after servicemembers return home. DOD is 
sending VA electronic pre- and post-deployment health assessment 
(PPDHA) and PDHRA information on separated Service members and National 
Guard and Reserve members if the servicemember is in the VA patient 
treatment file (PTF).
    VA actively participates in the administration of PDHRA at Reserve 
and Guard locations in a number of ways. We provide information about 
VA care and benefits; enroll interested Reservists and Guardsmen in the 
VA health care system; and arrange appointments for referred 
servicemembers. As of June 30, 2007, an estimated 109,117 
servicemembers were screened, resulting in over 25,055 referrals to VA 
medical facilities and 12,624 referrals to Vet Centers. Of those 
referrals, 47.9 percent were for mental health and readjustment issues; 
the remaining 52.1 percent were for physical health issues.
    In April 2007, VA sponsored a conference to educate VA and DOD 
staff about services and programs for OEF/OIF veterans. Specialized 
educational tracts included mental health, polytrauma and Traumatic 
Brain Injury, diversity and women's health, pain management, seamless 
transition, and prosthetics and sensory aids. Each Veterans Integrated 
Service Network (VISN) developed an action plan for management of OEF/
OIF veterans.
    In May 2007 VA and DOD established a work group for seamless 
transition clinical case management to improve the delivery of safe, 
high-quality, and timely medical care to injured or ill servicemembers 
through the seamless provision of case-management services in both the 
DOD and VA systems. The work group will use a clinical case management 
model to address the transition issues of our servicemembers and 
veterans. It will identify policies, assist in the development of 
qualifications and functions, and help identify potential gaps in 
tracking of the severely wounded from agency to agency.

                 DOD AND VA HEALTH INFORMATION SHARING

    Question 4. According to DOD, health assessment data on separating 
servicemembers is being provided to VA on a monthly and weekly basis. 
How does VA use this data to support care of veterans today?
    Response. Beginning in October 2003, the DOD Defense Manpower Data 
Center (DMDC) sends VA's Office of Public Health and Environmental 
Hazards a periodically updated personnel roster of troops who 
participated in OEF/OIF and who separated from active duty and became 
eligible for VA benefits. The latest DMDC file (received in January 
2007) indicates that there are a total of 686,306 OEF/OIF veterans who 
separated following deployment to Afghanistan and Iraqi theaters of 
operation up to November 2006. For each veteran, demographics (social 
security number, name, date of birth, gender, education, etc.) and 
military service specific data (branch, rank, unit component, 
deployment dates, etc) are included in the record received from DOD.
    VA uses this roster to evaluate the use of VA healthcare and 
benefits by OEF/OIF veterans. This analysis is very useful to plan 
allocation of VHA healthcare resources. The roster is checked against 
VA's inpatient and outpatient electronic patient records to determine 
which veterans sought treatment in VA facilities as well as the 
International Classification of Disease (ICD-9) diagnostic codes used 
to describe their diagnoses. These data indicate what types of health 
problems OEF/OIF veterans who presented to VA developed since 
deployment. The most recent report of OEF/OIF healthcare use is 
attached.
    In addition to VA healthcare utilization data, which is based on 
the troop roster supplied by DMDC, DOD performs health assessments of 
servicemembers just prior to deployments and at the time of return from 
deployments. The purpose of these assessments is to screen for health 
concerns that warrant further medical evaluation. Since September 2005, 
DOD sent VA their electronic pre-deployment and post-deployment health 
assessments (PPDHA) of servicemembers who deactivated back to the 
Reserve and National Guard or who separated entirely from service. This 
transfer takes place monthly. More recently, DOD developed the PDHRA. 
The purpose of the PDHRA is to screen for physical health and mental 
health concerns at 90 to 180 days after return from deployments. In 
November 2006, DOD began monthly electronic transfers of PDHRA data to 
VA, and as of June 2007, VA received over 1.7 million PPDHA and PDHRA 
assessments on more than 706,000 separated servicemembers and 
deactivated Reserve/National Guard members.
    The DOD deployment health assessments are available to VA health 
care workers in the VHA electronic health record, which is accessed 
during each patient encounter. These health data are used by VA 
clinicians to aid in the diagnosis and care of OEF/OIF veterans.

    Question 5. Is the data useful for projecting future care needs, 
for example, for TBI, Post Traumatic Stress Disorder (PTSD), and 
prosthetic care? If not, are there joint efforts underway by the two 
departments to improve the ability to project future health care needs?
    Response. Data derived from DOD's PDHRA does not allow for 
projecting servicemembers' need for services for Traumatic Brain Injury 
(TBI) and prosthetics. Data are analyzed within VA for both mental 
health and prosthetics to project service needs based on recent 
workloads for mental health programs, as well as workloads for 
prosthetic equipment and sensory aids and devices.
    As of the second quarter of Fiscal Year 2007, 35 percent (252,095) 
of veterans eligible for care came to VA for clinical services. Of 
these, 37.7 percent received provisional diagnoses of mental disorders 
including 45,330 with a provisional Post Traumatic Stress Disorder 
(PTSD) diagnosis. These are cumulative data, and not all these veterans 
are found to actually have a mental disorder or, if they do, the 
problem may be resolved with treatment.
    As of July 2007, an estimated 109,117 servicemembers were screened, 
resulting in more than 25,055 referrals to VA for follow-up health 
care. In addition to mental health, 52.1 percent of the referrals were 
for physical health issues.
    VHA prosthetics and clinical logistics provided prosthetics, 
medical equipment, and supplies to 22,910 OEF/OIF veterans in Fiscal 
Year 2006, this includes limbs for amputees, surgical implants, visual 
and hearing aids, wheel chairs, braces and other orthotic devices, 
canes and crutches. As of second quarter Fiscal Year 2007, 18,367 OEF/
OIF veterans received care in prosthetics. Based on the trend this 
Fiscal Year, VA anticipates a significant increase in the number of 
OEF/OIF veterans we will care for. These data are based on matching 
unique NPPD (National Prosthetic Patient Data base) patient IDs to the 
OEF/OIF roster obtained from VHA support service center. On a monthly 
basis, DOD provides VA with the latest amputee statistics from DOD's 
amputee patient care program-clinical databasese. This allows VA to 
project the number of amputees that will be discharged from MTFs and 
transitioned into VA care. NPPD is currently being enhanced to alert 
staff and flag patients' records when a consult for an OEF/OIF patient 
is initiated for a prosthetic appliance. This allows VA's prosthetic 
departments to better prioritize requests for OEF/OIF veterans.
    In partnership with DOD, VA implemented a number of strategies and 
innovative programs to provide timely, appropriate, and seamless 
services to the most seriously injured OEF/OIF active duty members and 
veterans. One such program enables active duty members to register for 
VA health care and initiate the process for benefits prior to 
separation from active service. The centerpiece program supporting the 
seamless transition of seriously injured servicemembers and veterans 
involves placement of VA social work liaisons, benefit counselors, and 
outreach coordinators at MTFs to educate servicemembers about VA 
services and benefits.
    VA and DOD continue to collaborate in the screening process for 
TBI. A TBI screening instrument was developed based on the experience 
of VA, MTFs, and the Defense and Veterans Brain Injury Center. As of 
April 2, 2007, VA mandated administration of the TBI screening to all 
OEF/OIF veterans who receive medical care from VA. Every possible reply 
in the TBI screening reminder generates a unique ``health factor'' that 
is stored in the ``health factors file'' in the VA databaseses. This 
will further improve VA's ability to project healthcare needs of 
veterans with TBI.

              PRIVACY RULES AND THE SHARING OF DOD AND VA 
                          MEDICAL INFORMATION

    Question 6. Congress enacted the Health Insurance Portability and 
Accountability Act (HIPAA) of 1996 (Public Law 104-191) to prevent the 
disclosure of certain personal medical information) but permits DOD and 
VA to share information on individuals being treated in both systems. 
Yet HIPAA is often cited as a baffler to easy sharing of health data 
between DOD and VA. In 2003 a Presidential task force recommended that 
the two departments be declared a single health care system for the 
purposes of implementing HIPAA--in order to smooth transition of 
servicemembers from DOD to the VA, and to accelerate the development of 
shared health care information technology. What did the two departments 
do, if anything, in response to this recommendation?
    Response. As a rule, there are no HIPAA constraints on sharing 
electronic data between VA and DOD. In general, the HIPAA Privacy Final 
Rule prohibits covered entities--health care providers that conduct 
certain transactions electronically, health plans, and healthcare 
clearinghouses--from disclosing protected health information unless a 
specific permitted disclosure is applicable. One special exemption 
pertains to DOD's sharing data with VA. This permitted disclosure, 45 
CFR 164.512(k)(1)(ii), allows DOD to ``disclose to VA the protected 
health information on an individual who is a member of the Armed Forces 
upon separation or discharge of the individual from military service 
for the purpose of a determination by VA of the individual's 
eligibility for or entitlement to benefits under laws administered by 
the Secretary of Veterans Affairs.'' The VA and DOD HIPAA, privacy and 
General Counsel staffs worked diligently to resolve any differences in 
interpretation of these authorities. In June 2005, DOD and VA 
implemented a data-sharing MOU that outlines these agreed-upon 
authorities.

    Question 7. Why is HIPAA still cited as a barrier to information 
sharing?
    Response. VA does not view the HIPAA Privacy Rule as a barrier to 
VA/DOD information sharing.
                                 ______
                                 
Response to Written Questions Submitted by Hon. John D. Rockefeller IV 
 to Hon. Daniel L. Cooper, Under Secretary for Benefits, Department of 
                            Veterans Affairs

    Question 1. At an earlier hearing this year, VA testified that 
disability claims for PTSD more than double since 2000, from 130,000 to 
nearly 270,000 VA claims. Such claims are hard to process, and even 
harder to ensure consistency. What efforts are underway to help Guard 
and Reserves get screened for PTSD, and get the care and benefits they 
deserve during their 2-year window of eligibility? And I believe that 
this should be extended to at least 5 years.
    Response. There are a variety of outreach approaches to assess 
members of the National Guard and Reserves for their clinical needs and 
benefits, including the presence of PTSD or other war-related problems.

     DOD is carrying out PDHRA in the 90-180 days following 
return from deployment for all servicemembers including Guards and 
Reserves. VA staffs from Vet Centers, VAMCs, and VBA regional offices 
attend PDHRA screenings, as well as Guard and Reserve meetings, to 
ensure that servicemembers are aware of VA services.
     The Secretary sends a letter about medical care and other 
benefits to each servicemember who is discharged from active duty. 
Every time a member of the Guards or Reserves returns from a war-zone 
deployment, the ``2-year window'' for free healthcare eligibility is 
re-activated.
     Vet Centers have no eligibility time limitation for 
services to veterans of any combat era, including OEF/OIF veterans.
     Local public service announcements are also used to alert 
servicemembers of the availability of VA services.
     With regard to screening for PTSD within VAMCs, whenever 
OEF/OIF veterans initially present for clinical care, they are screened 
with a set of questions for PTSD, depression, alcohol abuse, and 
infectious diseases endemic to Southwest Asia. The PTSD questions are 
repeated annually for the first 5 years after first contact and every 5 
years thereafter. Depression and alcohol screens are done annually for 
all veterans.
     In April 2007, a set of screening questions for mild TBI 
was added to the set of screening questions.

    Question 2. Is DOD and/or VA studying how delays in care and 
disability benefits affects soldiers who are struggling with mental 
health issues, particularly PTSD? How can such stress be minimized?
    Response. There is one VA study currently underway entitled 
``Barriers and Facilitators to Treatment-Seeking for PTSD'' that may be 
relevant to the issue of the impact of delays in care for veterans 
suffering from PTSD or other mental health issues. This study is 
anticipated for completion in December 2007. It is believed, however, 
based on clinical experience, that the longer a person waits to receive 
help, the greater the risk of a psychosocial problem deteriorating into 
a true mental disorder, or a mild form of a disorder developing more 
severe forms of pathology or co-occurring conditions. For example, a 
veteran struggling with symptoms of PTSD may attempt to control 
symptoms with alcohol or other drugs, which only worsens the situation 
and makes treatment more difficult when the person does present for 
care.
    The solution to this potential dilemma and the way to minimize the 
stress of prolonged struggling with emotional or behavioral problems is 
to bring veterans into treatment as soon as possible, and there are a 
variety of approaches being used to achieve this goal. The outreach 
approaches mentioned above provide opportunities to draw veterans into 
seeking health care, particularly mental health care. In addition to 
the hiring of 100 OEF/OIF veterans by VA's readjustment counseling 
service to serve as outreach workers and counselors for OEF/OIF 
veterans, VA's mental health service has funded special returning 
veterans outreach, education and care (RVOEC) teams across the country 
specifically tasked to rapidly assess and address psychosocial and 
mental health problems of veterans who come to VAMCs and clinics for 
care. RVOEC staffs specialize in ``in-reach'': contacting OEF/OIF 
veterans in primary-care sites including community based outpatient 
clinics (CBOCs) so veterans do not have to risk the potential stigma of 
going to a site labeled as a ``mental health'' for care. Indeed, stigma 
is a major barrier to a person seeking care for emotional or behavioral 
problems.
    Education in the form of teaching coping skills for problems and 
spreading the word about the efficacy of mental health care through 
positive media presentations are ways to combat stigma.

    Question 3. How are DOD and VA treating our National Guards and 
Reserves and their families? What special outreach is underway? And 
isn't it odd that less Guards and Reservists are seeking service than 
active duty? One would intuitively think that active duty soldiers have 
more training and support. Could it be that Guard and Reservists are 
just unaware of the options and benefits?
    Response. VA makes absolutely no distinctions in processing claims 
from active duty or Guard and Reserve personnel. All claims are 
considered using the same laws and regulations to determine entitlement 
to benefits and establish the appropriate disability evaluation.
    While the data do reflect differences in claims activity between 
active duty and Reserve and National Guard personnel, we believe a 
significant factor may be length of service. The majority of service-
related disabilities are chronic diseases or disabilities that develop 
over time. Generally, Reserve or National Guard service is 
significantly shorter than regular active duty service, resulting in a 
reduced likelihood that these veterans developed chronic service-
related disabilities.
    Additionally, our historical data indicates military retirees are 
four times as likely to receive disability compensation as non-
retirees. A portion of the retiree population is comprised of veterans 
who suffered serious injuries while on active duty, were medically 
discharged, and are retired on disability. This group also includes 
National Guard and Reserve members who are seriously injured while on 
active duty and medically discharged by the military. These veterans 
are not counted as National Guard or Reserve members for purposes of 
evaluating VA benefits activity, but rather as part of the active duty 
population.
    Since the initiation of OEF/OIF, we have recognized the additional 
challenges presented in reaching activated Reserve and Guard troops to 
ensure they are fully informed about VA benefits and services. We have 
therefore made special efforts to reach out to returning Guard and 
Reserve members to ensure they are aware of the VA benefits and 
services available to them and provided assistance in filing claims.
    VA provides transitional services to returning Guard and Reserve 
members through the transition assistance program, a collaborative 
effort of VA, DOD, and the Department of Labor. Our regional offices 
also provide benefits briefings at large demobilization sites and, in 
partnership with DOD, conduct retirement briefings and healthcare 
services and benefits briefings at town hall meetings, family readiness 
groups, and during unit drills near the home of returning Guard and 
Reserve members. Working with DOD, we developed a special informational 
brochure that summarizes benefits for National Guard and Reserve 
personnel. This brochure is distributed both by DOD and VA at all of 
our benefits briefings.
    We have trained 54 National Guard transition assistance advisors 
(TAA)--one for each of the 50 States and 4 territories. These TAAs 
serve as the State-wide point of contact and coordinator for Guard 
members and their families regarding VA benefits and services, and 
assist in resolving problems with VA healthcare, benefits, and TRICARE.
    As the Reserve and Guard members separate, they receive a ``Welcome 
Home Package'' that includes a letter from the Secretary, a VA pamphlet 
summarizing all VA benefit programs, and a timetable for submitting 
applications. A follow-up letter with similar information is sent 6 
months following separation.
    VA continues to explore additional ways to meet the needs of both 
the active duty and Reserve and Guard members supporting OEF/OIF, 
including identifying additional enhancements that can be made to our 
outreach program for Reserve and Guard members. On May 18, 2005, VA 
signed a MOU with the National Guard to provide returning OEF/OIF 
servicemembers with information about VA benefits and services. The 
National Guard includes both the Army Guard and Air Guard. Both VHA and 
VBA signed the MOU.
    VA is also working on MOUs with the other Reserve components. The 
MOU with the Army Reserve is expected to be signed shortly. VA has also 
submitted draft MOUs to the Marine Corps Reserve and Navy Reserve. Each 
is under review by the respective components. VA has drafted MOUs for 
the Air Force Reserve and the Coast Guard Reserve, and we are in the 
process of contacting each of those services to begin the review 
process. Additionally, the National Guard is in the process of 
electronically scanning the service medical records of it members. They 
expect to complete the process in September of 2007. We are working 
with them to develop a means of electronically accessing the records of 
any National Guard member who files a claim for VA disability 
compensation.

    Question 4. These questions pertain to the VA/DOD Joint Executive 
Council FY 2006 annual report published in February 2007. The JEC was 
established by Congress and has been meeting for 4 years. However, it 
has taken 4 years to produce broad recommendations and the group 
proposed additional working groups to examine the issues further. In 
July 2006, the JEC approved a proposal to establish a VA/DOD Joint 
Coordination Transition Working Group that will be focused on achieving 
an even greater integrated approach to coordinated transition for 
injured and ill servicemembers and their families.
    Question 4(a). Why did the JEC feel a group needed to be developed 
in order to achieve this approach?
    Response. The JEC felt that, in order to institutionalize the 
seamless transition process, a joint coordinated transition working 
group (JCTWG) needed to be established. This working group would be 
responsible for establishing and promulgating an agreed-upon definition 
of seamless transition, and for developing performance measures and 
tracking performance.

    Question 4(b). Who has been chosen/assigned to this working group?
    Response. The proposed membership of the JCTWG is:
DOD
    Program manager, policy, reports and analysis, DOD/VA
      Program Coordination Office
    Military Services' Severely Injured Programs
    Director, DOD Transition Assistance Program
    Reserve Affairs
    National Guard Bureau
    Health Affairs Information Management Office
    DUSD P&R, Program Integration (DMDC)
    Military Service PEB Offices VA
    Director, Office of Seamless Transition
    Director, Compensation and Pension (C&P) procedures staff
    VBA OEF/OIF support team representative

    Question 4(c). Have they met yet? If so, what have they developed 
so far?
    Response. The charter for JCTWG has not been signed yet. Therefore, 
there have been no meetings to date.

    Question 4(d). Why has it taken so long to acknowledge this problem 
needed another group to address transition issues for injured and ill 
servicemembers?
    Response. Since 2004, VA and DOD have launched 28 different 
initiatives in order to better meet the needs of veterans and 
servicemembers. The intent of these initiatives is to improve care for 
injured and ill servicemembers returning from OEF/OIF. With such a 
multitude of programs operating independently of each other, the Health 
Executive Council determined that there was a need to coordinate these 
programs. Since then, there has been extensive discussion about the 
need to involve the Benefits Executive Council because of related 
benefits issues. Also, the need to improve the coordination of 
processes for physical exams in both DOD and VA has been discussed.

    Question 4(e). The JEC has been meeting for 4 years and was 
established by Congress. However, it has taken 4 years to produce broad 
recommendations and proposed additional working groups to examine the 
issue further. I would request a breakdown of each council, working 
group, members of each, and dates of meetings. This information would 
be helpful in determining their level of commitment to the joint 
project(s).
    Response. Membership to JEC, HEC and BEC and breakdown of council 
and working group is provided below:

[GRAPHIC] [TIFF OMITTED] T5997.036

[GRAPHIC] [TIFF OMITTED] T5997.037

[GRAPHIC] [TIFF OMITTED] T5997.038

[GRAPHIC] [TIFF OMITTED] T5997.039

    The Councils have conducted the following meetings:
    JEC: June 2004; November 2004; March 2005; June 2005; September 
2005; January 2006; April 2006; August 2006; October 2006; January 
2007; March 2007.
    HEC: February 2004; September 2004; March 2005; May 2005; November 
2005; March 2006; May 2006; August 2006; November 2006; February 2007
    BEC: March 2005; May 2005; September 2005; December 2005; March 
2006; July 2006; September 2006; December 2006; January 2007; March 
2007.
                                 ______
                                 
Response to Written Questions Submitted by Hon. Hillary Rodham Clinton 
 to Hon. Daniel L. Cooper, Under Secretary for Benefits, Department of 
                            Veterans Affairs

                        TRAUMATIC BRAIN INJURIES

    Question 1. Traumatic Brain Injuries have been called the 
``signature wound'' of the Global War on Terror--TBI includes severe 
injuries as well as invisible wounds that result in trouble remembering 
appointments, holding down a job, and returning to civilian life. 
Additionally, the number of Post Traumatic Stress Disorder cases being 
diagnosed amongst returning OIF and OEF veterans is increasing with the 
number of repeated deployments and the stressful OPTEMPO. 
Distinguishing between mild TBI and Post Traumatic Stress Disorder is 
difficult because both conditions share common symptoms, such as 
irritability, anxiety and depression.
    Has DOD researched and developed any computer-based tests that 
would assess different basic functions (or domains) of cognition--such 
as memory, concentration, attention, and reaction time--that could be 
used to detect brain injury and distinguish TB! from Post Traumatic 
Stress Disorder? What updated methods and tests have been incorporated 
in pre-deployment screening for PTSD and TBI during pre-deployment 
activities?
    Response. VA defers to DOD as to its research and development of 
test to detect brain injury and distinguish TBI from PTSD.

    Question 2. Servicemembers who have incurred severe TBI may never 
fully recover, and any chance of recovering the ability to perform 
daily tasks is dependent on access to intensive, specialized 
rehabilitation, including cognitive therapy. Active duty servicemembers 
can access a range of health care options including cognitive therapy--
which is necessary for TBI rehabilitation--under their TRICARE plan. 
However, once troops are medically retired, their TRICARE coverage 
doesn't provide access to cognitive therapies provided at private 
facilities. Are you aware of the discrepancy in medical treatment 
options available to active duty and medically retired servicemembers 
who have incurred a Traumatic Brain Injury (TBI)?
    Response. VA defers to DOD as to any discrepancies between medical 
treatment options available to active duty and medically retired 
servicemembers who have incurred TBI.

    Question 3. Many servicemembers who have incurred serious traumatic 
brain injuries are fortunate to have family members or loved ones act 
as caregivers. However, family members of returning soldiers with TBI 
are often ill-equipped to handle the demands of caring for their loved 
one, which in some bases can become a full-time responsibility. Does 
the VA have any data on the number of family caregivers who have 
relocated or quit their job in order to provide care for a traumatic 
brain injured servicemember?
    Response. VA does not maintain a databasese of the number of 
families that relocate or quit jobs in order to care for the severely 
wounded with TBI. However, VA facilities and programs that serve the 
seriously wounded throughout the polytrauma/TBI system of care provide 
extensive logistical, clinical, and emotional assistance to family 
caregivers. VA tracks family needs clinically through polytrauma/TBl 
case mangers that coordinate the support efforts to match the needs of 
each family, including those who live away from home and make changes 
in their employment status to be with their injured family members.
    To assist family members in understanding and managing the health 
care demands of the veteran, every veteran admitted to one of the 
facilities in the polytrauma/TBI system of care is assigned a social 
worker case manager who is responsible for coordinating care, ensuring 
access to psychosocial services for patient and family, providing 
caregiver support within their scope of practice, and matching support 
services to meet family needs. polytrauma teams of specialists actively 
engage family members in treatment and treatment decisions. Family 
members are invited to join therapy sessions so that they can learn how 
to help the patient be as independent as possible in the home 
environment.
    VA makes efforts to ease the financial burden of family caregivers 
who are away from home and work in order to support their loved ones 
through the rehabilitation process. Generous donations from VA 
voluntary services, Operation Helping Hand, Fisher House Foundation, 
other foundations and agencies, and local businesses frequently provide 
free housing, free or discounted meals, transportation, and 
entertainment.
    VA services provided directly to families of combat veterans 
include: screening, assessment, education and treatment for marital and 
family related problems. Family members may also receive respite care, 
home maker home health services, education regarding care of veteran, 
referral to community resources, limited bereavement counseling, and 
support group services.

         TRAUMATIC INJURY SERVICEMEMBERS' GROUP LIFE INSURANCE

    Question 4. On August 25, 2006, Director Thomas M. Lastowka, 
Veterans Affairs Regional Office and Insurance Center, testified before 
the Senate Veterans' Affairs Committee on the Traumatic Injury 
Servicemembers' Group Life insurance program. Director Lastowka 
testified that the TSGLI Program has denied 1,601 retroactive claims 
and 248 post-December 1 claims; approximately 40 percent of all claims. 
What quality control procedures have been implemented to improve the 
dismal approval rate for submitted claims? Has VA or DOD reviewed the 
denied claims and determined if they warrant a retroactive TSGLI award?
    Response. Traumatic Injury Protection under the Servicemembers' 
Group Life Insurance program (TSGLI) became effective December 1, 2005, 
with retroactive benefits extending back to October 7, 2001, for 
individuals injured in OEF/OIF. The program provides short-term 
financial assistance to severely injured servicemembers to help them 
and their families cope with expenses incurred when family members 
temporarily relocate to be with the member during recovery and 
rehabilitation. To date $203 million has been paid to nearly 3,200 
individuals, with an average award of just over $64,000.
    Following the practice of commercial accidental death and 
dismemberment policies the TSGLI legislation enumerated injuries for 
which payment would be made. Recognizing that there were many other 
traumatic injuries that members incur that would cause members to 
undergo the same significant recovery and rehabilitation times, VA used 
its authority under the legislation to extend TSGLI protection to 
other, non-specific, severe injuries.
    Since there is a wide range of ``severe injuries,'' VA wanted to 
develop a method to ensure that payments under this category were set 
on an equitable basis that takes into account the severity of the 
losses cited in the original legislation. After considering several 
possibilities, VA, in consultation with DOD and with the support of 
other stakeholders, determined that the best method would be to make 
payment based on how the injury impacts a member's ability to perform 
the activities of daily living (ADL) for an extended period of time. 
ADL is a standard used by the commercial insurance industry for 
disability and long-term-care policies.
    VA published regulations stating that, if a member is unable to 
independently perform at least two of the six widely recognized ADL 
(bathing, continence, dressing, eating, toileting, or transferring), 
TSGLI would be payable. In addition, milestones of time were used as 
the determining factor. For example, $25,000 is payable on the 30th 
consecutive day of the inability to perform two ADL due to the injury. 
Another $25,000 is payable on the 60th day if the member still cannot 
perform at least two ADL, and so on until the 120th day when the final 
payment is made and the maximum benefit of $100,000 has been reached.
    The nature of ADL-related conditions is subjective, compared to 
more readily identified losses such as amputations or loss of vision. 
Consequently, ADL-related claims are often filed by claimants who are 
uncertain whether they are eligible for TSGLI based on their 
conditions. VA recognizes that this degree of uncertainty results in a 
higher percentage of claims being disapproved. However, VA supports 
allowing servicemembers to submit claims and have the branches of 
service make the final determination of entitlement.
    By law, the branches of service are charged with making TSGLI 
eligibility determinations, based on criteria established by VA. We 
believe the branches are making accurate and informed TSGLI benefit 
decisions based on a tiered-review approach. VA and the Office of 
Servicemembers' Group Life Insurance (OSGLI) jointly conducted a 
detailed review of approximately 230 completed claims and confirmed 
that the claims were adjudicated correctly under current law and 
regulations.
    Specialized claims examiners within the TSGLI offices of each 
branch of service review every claim to determine whether it meets the 
required eligibility standards. If a claim presents complex medical 
issues or the claims examiner would like a second review by a medical 
professional, the claim is sent to a physician who provides a final 
recommendation for a decision.
    If a claim is disapproved, the servicemember can ask the branch of 
service TSGLI office to review the claim again, with or without 
submitting new medical evidence. If new evidence is provided, it is 
reviewed to see if it impacts the final decision. If the claim is 
disapproved after reconsideration, the claimant may file an appeal. The 
claim is then reviewed at a higher level of authority within each 
branch of service. A history of the claim and all medical documentation 
are provided to the officials conducting the appeal proceeding.
    Now that TSGLI has been in effect for 1 year, VA, OSGLI and DOD are 
conducting a ``Year One'' review of the program, including plan design, 
administrative processes, and outreach. As part of the review, we are 
examining the need for changing the conditions covered to ensure that 
the intent of the program is met.

                       ELECTRONIC MEDICAL RECORDS

    Question 5. Progress is being made by the Department of Veterans 
Affairs in utilizing electronic medical records. However, wounded 
soldiers continue to report that their paper medical records are being 
lost throughout the process. Why hasn't more progress been made in 
developing a seamless system whereby DOD and VA medical records systems 
would be able to integrate with one another? What is the current status 
of efforts to fix the medical records process in DOD so that we will 
not have wounded soldiers complaining of lost records?
    Response. New technological and personnel initiatives are reducing 
the possibility that medical records will be lost. Technologically, VA 
recently deployed the veterans tracking application (VTA), which brings 
data from three sources, DOD, VHA and VBA, together for display on one 
platform creating the beginning of a truly veteran-centric patient 
tracking record. The starting point for the electronic transfer of 
clinical information from DOD to VA is in Afghanistan or Iraq. 
Information from that point on is entered in the joint patient tracking 
application (JPTA). When the patient is ready to be transferred to a 
VAMC, VA staff working at the military hospital copy the record and fax 
it to the VA facility, which prepares to receive the patient. VTA 
contains all the information in JPTA except information deemed 
sensitive to military activities. DOD has begun to transform key 
portions of these records into electronic documents accessible through 
VTA. This reduces the number of documents that must be copied and 
faxed.
    The patient may ultimately be cared for at several VA and military 
facilities. VA is increasingly using VTA to track patients through each 
of these steps. VA also successfully implemented bidirectional 
capability at every VA medical facility, meaning that VA and DOD are 
able to exchange information directly from facility to facility. As of 
July 2007, BHIE data are now available between all DOD facilities and 
all VA facilities. These sites include the Walter Reed Army Medical 
Center and the Bethesda National Naval Medical Center, the Landstuhl 
Regional Medical Center in Germany and the Naval Medical Center, San 
Diego. VA is working closely with DOD to increase the scope of data 
available between DOD and VA. Throughout the remainder of the year and 
into 2008, the types of data shared bi-directionally will increase by 
adding domains such as progress notes and problem lists.
    In March 2007, VA added a personal touch to seamless transition by 
creating 100 new transition patient advocates (TPA). TPAs are dedicated 
to assisting our most severely injured veterans and their families. The 
TPA's job is to ensure a smooth transition to VA health care facilities 
throughout the Nation and cut through red tape for other VA benefits. 
Recruitment to fill the TPA positions began in March, and to date VAMCs 
have hired 46 TPAs. Interviews are being conducted to fill the 
remaining 54 positions. Until these positions are filled, each VAMC 
with a vacant TPA position has detailed an employee to perform that 
function. We believe these new patient advocates will help VA assure 
that no severely injured Afghanistan or Iraq veteran falls through the 
cracks. VA will continue to adapt its health care system to meet the 
unique medical issues facing our newest generation of combat veterans 
while locating services closer to their homes. DOD and VA sharing 
electronic health records facilitate this process.
                                 ______
                                 
     Response to Written Questions Submitted by Hon. Barack Obama 
 to Hon. Daniel L. Cooper, Under Secretary for Benefits, Department of 
                            Veterans Affairs

    Question 1. I want to raise an issue with you that was reported by 
Salon, the online magazine, just yesterday. Based on documents they 
obtained, it appears that the VA's Seamless Transition Task Force knew 
in 2004 about the bureaucratic mess at Walter Reed and within the 
military health care system. I am deeply concerned that one of the 
officials that should have known about this, Dr. Michael Kussman, has 
been nominated by President Bush to be Under Secretary for Health for 
the Veterans Health Administration. I am writing the President today to 
convey my concerns over this matter and obtain additional information 
before we confirm Dr. Kussman.
    But I also want to ask you about your knowledge of this situation. 
Were you briefed at the time on the results of the Task Force's work? 
Did you report these issues to DOD? What other steps did the VA take 
when it knew of these issues?
    Response. Salon magazine was incorrect in its assertion that VA 
knew of serious problems at Walter Reed Army Medical Center as early as 
2004. Salon magazine cited as its source a report entitled ``Walter 
Reed Focus Groups: OEF/OIF Service members and their Caregivers,'' 
prepared for VA's Seamless Transition Task Group. The report is a 
description of the results of two interview sessions conducted at 
Walter Reed on August 19, 2004. These interview sessions were held to 
elicit from seriously wounded or ill OEF/OIF servicemembers and their 
families their perspective on how well VA was assisting them in 
understanding their transition from a MTF to the VA system. The focus 
groups were not designed to determine conditions at Walter Reed or at 
any MTF. This report was used by the seamless transition task force to 
develop an action plan to improve the transition of the seriously 
wounded to VA's health care system.

    Question 2. A VA focus group report obtained by Salon magazine 
noted that Walter Reed officials had assumed that a soldier chasing 
down benefits in a wheelchair was ``ambulatory enough'' to get the 
checklist done. In the soldier's words: ``I was in a wheelchair and 
they expected me to push myself all the way over to Building 11 back 
and forth. One hand was in a bandage and one leg I couldn't use and 
they wanted me to push myself around the post pretty much. It just 
became more of a hassle and my mom did it.'' Did you know your Agency's 
report said this?
    Response. The intent of the VA focus groups referenced by Salon 
magazine was not to examine the conditions of Walter Reed Army Medical 
Center. Rather, the purpose of the focus groups was to gather first 
hand information and perspectives from seriously wounded or ill OEF/OIF 
veterans and their families on how well VA was assisting them in 
understanding their transition from a military treatment facility to 
VA's system of health care and benefits.
    The results from these focus groups were shared with DOD's members 
of the joint seamless transition task force and helped identify and 
validate the need for numerous initiatives to ease the transition of 
servicemembers to VA's system. Examples of these initiatives include 
placing full-time VA caseworkers at military treatment facilities, 
improving VA's ability to receive medical records from DOD, and 
creating regular consultations between DOD and VA physicians to improve 
care for individual patients.

    Question 3. According to VA data obtained by Veterans for America 
through the FOIA process, Guard and Reservists are half as likely to 
file a VA claim, as compared to active-duty servicemembers. And it 
appears that VA claims of Guard and Reservists are twice as likely to 
be rejected. What is being done to address this disparity?
    Response. VA makes absolutely no distinctions in processing claims 
from active duty or Guard and Reserve personnel. All claims are 
considered using the same laws and regulations to determine entitlement 
to benefits and establish the appropriate disability evaluation.
    While the data does reflect differences in claims activity between 
active duty and Reserve and National Guard personnel, we believe a 
significant factor may be length of service. The majority of service-
related disabilities are chronic diseases or disabilities that develop 
over time. Generally, Reserve or National Guard service is 
significantly shorter than regular active duty service, resulting in a 
reduced likelihood that these veterans developed chronic service-
related disabilities.
    Additionally, our historical data indicates military retirees are 
four times as likely to receive disability compensation as non-
retirees. A portion of the retiree population is comprised of veterans 
who suffered serious injuries while on active duty, were medically 
discharged, and are retired on disability. This group also includes 
National Guard and Reserve members who are seriously injured while on 
active duty and medically discharged by the military. These veterans 
are not counted as National Guard or Reserve members for purposes of 
assessing VA benefits activity, but rather as part of the active duty 
population.
    Since the initiation of OEF/OIF, we have recognized the additional 
challenges presented in reaching activated Reserve and Guard troops to 
ensure they are fully informed about VA benefits and services. We have 
therefore made special efforts to reach out to returning Guard and 
Reserve members to ensure they are aware of VA benefits and services 
available to them and provided assistance in filing claims.
    VA provides transitional services to returning Guard and Reserve 
members through the Transition Assistance Program, a collaborative 
effort of VA, DOD, and the Department of Labor. Our regional offices 
provide benefits briefings at large demobilization sites and, in 
partnership with DOD, conduct retirement briefings and healthcare 
services and benefits briefings at town hall meetings, family readiness 
groups, and during unit drills near the home of returning Guard and 
Reserve members. Working with DOD, we developed a special informational 
brochure that summarizes benefits for National Guard and Reserve 
personnel. This brochure is distributed both by DOD and VA at all of 
our benefits briefings.
    We have trained 54 National Guard TAAs--one for each of the 50 
States and 4 territories. These TAAs serve as the State-wide point of 
contact and coordinator for Guard members and their families regarding 
VA benefits and services, and assist in resolving problems with VA 
healthcare, benefits, and TRICARE.
    As the Reserve and Guard members separate, they receive a ``Welcome 
Home Package'' that includes a letter from the Secretary, a VA pamphlet 
summarizing all VA benefit programs, and a timetable for submitting 
applications. A follow-up letter with similar information is sent 6 
months following separation.
    VA continues to explore additional ways to meet the needs of both 
the active duty and Reserve and Guard members supporting OEF/OIF, 
including identifying additional enhancements that can be made to our 
outreach program for Reserve and Guard members. On May 18, 2005, VA 
signed a MOU with the National Guard to provide returning OEF/OIF 
servicemembers with information about VA benefits and services. The 
National Guard includes both the Army Guard and Air Guard. Both VHA and 
VBA signed the MOU.
    VA is also working on MOUs with the other reserve components. The 
MOU with the Army Reserve is expected to be signed by the end of May 
2007. VA has also submitted draft MOUs to the Marine Corps Reserve and 
Navy Reserve. Each is under review by the respective components. VA has 
drafted MOUs for the Air Force Reserve and the Coast Guard Reserve, and 
we are in the process of contacting each of those services to begin the 
review process. Additionally, the National Guard is in the process of 
electronically scanning the service medical records of its members. 
They expect to complete the process in September of 2007. We are 
working with them to develop a means of electronically accessing the 
records of any National Guard member who files a claim for VA 
disability compensation.
                                 ______
                                 
     Response to Written Questions Submitted by Hon. Mark Pryor to 
  Hon. Daniel L. Cooper, Under Secretary for Benefits, Department of 
                            Veterans Affairs

    Question 1. TRICARE currently allows beneficiaries direct access to 
non-physician mental health professionals, such as clinical social 
workers, marriage and family therapists, and psychiatric nurses. 
Beneficiaries seeking treatment from licensed TRICARE mental health 
counselors, however, are first required to obtain a physician referral 
prior to seeing a counselor. What is the intent of this restriction, 
and with such a notably low number of available mental health 
professionals available to the VA, doesn't this restriction contribute 
to the already severe backlog in cases?
    Response. VA would like to clarify that we do not have ``a notably 
low number of available mental health professionals available to the 
VA.'' VA has a large system of mental health professionals--
psychiatrists, psychologists, social workers, psychiatric nurses, and 
other mental health providers--and that system is expanding rapidly to 
meet the needs of returning veterans. Data confirm that mental health 
staffing has increased steadily since Fiscal Year 2005, and it is 
projected to continue to increase in Fiscal Year 2008.
    VA defers to the Department of Defense to respond to the inquiry 
regarding TRICARE needs or policies.

    Question 2. When a soldier is killed in the line of duty, a 
surviving spouse is entitled to annuities such as the Survivor Benefit 
Plan (SBP) and Dependency and Indemnity Compensation (DIC), among 
others. It is my understanding that in certain cases the SBP and DIC 
are offset (the DIC is subtracted from the SBP), thereby reducing the 
monetary compensation for 1,800 line-of-duty and 57,000 retiree 
surviving spouses. What circumstances warrant this offset? Could we 
eliminate the offset and plausibly create two independent annuities?
    Response. As required by 10 U.S.C. 1450(c)(1), if an SBP 
beneficiary becomes eligible for DIC payments, his or her SBP payment 
is reduced by an amount equal the DIC benefit. If the DIC benefit 
exceeds the SBP payment, the beneficiary is no longer entitled to 
receive SBP benefits. The current offset is consistent with benefits 
provided in the private sector. It avoids duplication of two 
complementary Federal benefits programs established for the same 
purpose--providing a lifetime annuity for the survivor of an active, 
retired, or former servicemember.
                                 ______
                                 
     Response to Written Question Submitted by Hon. Johnny Isakson 
 to Hon. Daniel L. Cooper, Under Secretary for Benefits, Department of 
                            Veterans Affairs

    Question. Should a VA representative be embedded in the Medical 
Evaluation Board Process from the beginning? If not, should a VA 
representative at least be present for the Physical Evaluation Board 
process?
    Response. The Secretary of VA chaired the President's Interagency 
Task Force on Returning Global War on Terror Heroes, which reviewed 
VA's and DOD's disability evaluation processes. The task force report 
recommended development of a joint DOD/VA process for disability 
benefits determinations by establishing a cooperative medical and 
physical evaluation board process within the military service branches 
and the VA care system.
    We do not see a role for VA in the medical evaluation board (MEB) 
process. The MEB process recommends a servicemember's retention, 
reclassification, or referral to the Service's physical evaluation 
board (PEB). In our view, responsibility for these decisions belongs to 
DOD. However, VA could play a role following the MEB's referral to the 
PEB.
    For example, VA could conduct the examinations for the conditions 
that have resulted in the referral to the PEB, as well as any other 
conditions the servicemember believes might warrant service connection. 
We believe that only one evaluation should be assigned for any 
potentially disqualifying condition, and that VA should assign the 
evaluation using VA guidelines. The PEB would retain the uniquely 
military responsibilities of establishing fitness-for-retention 
standards and determining whether an individual servicemember meets 
those standards. VA could play a further role in reviewing new medical 
evidence submitted by the member if he/she appealed the initial 
determination. VA could then sustain or revise the previous evaluation.
                                 ______
                                 
   Response to Written Question Submitted by Hon. Saxby Chambliss to 
  Hon. Daniel L. Cooper, Under Secretary for Benefits, Department of 
                            Veterans Affairs

    Question. One suggestion I have heard regarding how to speed up the 
MEB/PEB process within DOD and make it more efficient and easier for 
our servicemembers is to embed more VA personnel within DOD to help 
with the transition process. Specifically, VA personnel could begin 
working with soldiers and possibly take charge of their paperwork and 
medical requirements once it is clear that a servicemember cannot be 
retained in the service. Please comment on how embedding VA personnel 
might affect the MEB/PEB process and if you think, from our 
servicemembers' perspective, that this would be a good idea.
    Response. The Secretary of VA chaired the President's Interagency 
Task Force on Returning Global War on Terror Heroes, which reviewed 
VA's and DOD's disability evaluation processes. The Task Force Report 
recommended development of a joint DOD/VA process for disability 
benefits determinations by establishing a cooperative medical and 
physical evaluation board process within the military service branches 
and the VA care system.
    We do not see a role for VA in the medical evaluation board (MEB) 
process. That DOD process recommends retention, reclassification, or 
referral to the Service's physical evaluation board (PEB). In our view, 
responsibility for these decisions belongs to DOD. However, VA could 
play a role following the MEB's referral to the PEB.
    For example, VA could conduct the examinations for the conditions 
that have resulted in the referral to the PEB, as well as any other 
conditions the servicemember believes might warrant service connection. 
We believe that only one evaluation should be assigned for any 
potentially disqualifying condition and that VA should assign the 
evaluation using VA guidelines. The PEB would retain the uniquely 
military responsibilities of establishing fitness-for-retention 
standards and determining whether an individual servicemember meets 
those standards. VA could play a further role in reviewing new medical 
evidence submitted by the member if he/she appealed the initial 
determination. VA could then sustain or revise the previous evaluation.
                                 ______
                                 
  Response to Written Questions Submitted by Hon. Daniel K. Akaka to 
Gerald Cross, M.D., Acting Principal Deputy Under Secretary for Health, 
                     Department of Veterans Affairs

    Question 1. Can you share examples of successful efforts between 
DOD and VA that have helped promote a smoother transition of injured 
servicemembers between the health care systems of the two departments?
    Response. In August 2003, the Under Secretaries for Health and 
Benefits established a task force to improve collaboration between 
Veterans Health Administration (VHA), Veterans Benefits Administration 
(VBA) and the Department of Defense (DOD) to ensure world class service 
to the men and women who served in the U.S. Armed Forces as they 
transition from the military to veteran status. In January 2005, the 
Department of Veterans Affairs (VA) established a permanent Office of 
Seamless Transition which reports through VA/DOD Coordination Officer 
to the Principal Deputy Under Secretary for Health and is composed of 
representatives from VHA and VBA, as well as an active duty Marine 
Corps officer and an Army officer. Since its inception, the seamless 
transition program has achieved numerous accomplishments that result in 
great strides toward the seamless transition of Operation Enduring 
Freedom/Operation Iraqi Freedom (OEF/OIF) servicemembers into civilian 
life. The ability to register for VA health care and file for benefits 
prior to separation from active duty is the result of the seamless 
transition process.
    VA/DOD social work liaisons and VBA benefit counselors are now 
located at 10 military treatment facilities (MTFs) to assist injured 
and ill servicemembers in transferring their healthcare needs to VA 
medical facilities closest to their home or most appropriate for their 
medical needs and to ensure that returning servicemembers receive 
information and counseling about VA benefits and services. VHA staff 
has coordinated over 7,000 transfers of OEF/OIF servicemembers and 
veterans from a MTF to a VA medical facility. Active duty Army liaison 
officers are assigned to each of the four VA polytrauma rehabilitation 
centers to assist servicemembers and their families from all branches 
of service on issues such as pay, lodging, travel, movement of 
household goods, and non-medical attendant care orders. The Office of 
Seamless Transition established an OEF/OIF Polytrauma Call Center to 
assist our most seriously injured veterans and their families with 
clinical, administrative, and benefit inquiries. The Call Center which 
opened February 2006, is operational 24 hours a day, 7 days a week to 
answer clinical, administrative, and benefit inquiries from polytrauma 
patients and their families. In addition, the Call Center has contacted 
870 veterans since February 2007. Through these outreach phone calls, 
we have been able to provide these veterans additional assistance with 
outstanding health or benefits concerns.
    VA has implemented an automated tracking system to track 
servicemembers and veterans transitioning from MTFs to VA facilities. 
As part of this system, VHA implemented a 2007 performance measure to 
ensure that VHA assigns a case manager to seriously injured 
servicemembers being referred from a MTF to a VA treatment facility in 
a timely fashion. This performance measure monitors the percent of 
severely ill/injured servicemembers and veterans who are contacted by 
their assigned VA case manager within 7 days of notification of 
transfer to the VA system. During the period October 2006 through May 
31, 2007, 169 severely ill/injured patients were transferred from MTFs 
to VA medical centers (VAMC). Eighty-eight percent (148) were contacted 
by their assigned VA case manager within 7 days of notification of 
transfer to VA. In April 2007, VA integrated the tracking system with 
DOD's joint patient tracking application (JPTA) which tracks 
servicemembers from the battlefield through Landstuhl, Germany, to MTFs 
in the states. The new application, known as the veterans tracking 
application (VTA), is a modified version of DOD's JPTA--a web-based 
patient tracking and management tool that collects, manages, and 
reports on patients arriving at MTFs from forward-deployed locations. 
VTA is completely compatible with JPTA allowing the electronic transfer 
of DOD tracking and medical data in JPTA on medically evacuated 
patients to VA on a daily basis.
    VA is participating in DOD's post deployment health reassessment 
(PDHRA) program for returning deployed servicemembers. Since its 
inception, over 107,119 Reserve and Guard members have completed the 
PDHRA onsite screen resulting in over 25,055 referrals to VA facilities 
and 12,624 referrals to Vet Centers.
    In order to ensure that OEF/OIF combat veterans receive high 
quality health care and coordinated transition services and benefits as 
they transition from the DOD system to the VA, VA developed a robust 
outreach, education and awareness program. The signing of a memorandum 
of agreement (MOA) between the National Guard and VA, in May 2005, and 
the formation of VA/National Guard State coalitions in each of the 54 
States and territories now provides the opportunity for VA to gain 
access to returning troops and families as well as join with community 
resources and organizations to enhance the integration of the delivery 
of VA services to new veterans and families. This is a major step in 
closer collaboration with the National Guard soldiers and airmen. A 
similar MOA is being developed with the U.S. Army Reserve Command and 
the U.S. Marine Corps at the national level. VA and the National Guard 
Bureau teamed up to train 54 National Guard transition assistance 
advisors who assist VA in advising Guard members and their families 
about VA benefits and services.

    Question 2. Can you describe instances where there has been a 
significant failure of cooperation or coordination that has impeded the 
smooth transition of injured servicemembers?
    Response. A challenge to ensuring the smooth transition of injured 
servicemembers between DOD and VA is coordination on the medical 
evaluation board/physical evaluation board (MEB/PEB) process. VA and 
DOD are collaborating to ensure VA is notified of severely ill or 
injured servicemembers transitioning to VA care and civilian life. 
Under this initiative, DOD began transmitting names of servicemembers 
entering the PEB process to VA in October 2005. When the system is 
fully operational, the monthly list will enable VA to contact 
servicemembers to inform them of potential VA benefits and to initiate 
transfer of healthcare services to a VAMC prior to discharge from the 
military.
    DOD made extra efforts to make this data available to VA for 
outreach. However, due to a number of issues, use of the list has been 
limited thus far. The problems with receipt of the data include quality 
issues that vary widely with each file and are therefore difficult to 
mitigate. Further, electronic transmission of the list was interrupted 
from May 2006 to June 2007 due to data security issues. During this 
time, DOD hand-carried several lists to VA. DOD successfully 
transmitted lists to VA electronically in June and July 2007. VA 
expects that DOD will continue this electronic transmission on a 
monthly basis hereafter. The VA Inter-agency task force on Returning 
Global War on Terror Heroes closely examined issues related to better 
coordinating the MEB/PEB process between the VA and DOD.
                                 ______
                                 
 Response to Written Questions Submitted by Hon. John McCain to Gerald 
   Cross, M.D., Acting Principal Deputy Under Secretary for Health, 
                     Department of Veterans Affairs

                 CAPACITY OF THE VA HEALTH CARE SYSTEM

    Question 1. Unlike DOD, which is bound by health care access 
standards to purchase care from the civilian sector when it cannot be 
provided in-house, the VA has no legal obligation to provide care 
within a specified time frame, nor an obligation to purchase services 
from the private sector. Isn't it time to change this paradigm, 
especially for veterans with care needs related to their military 
service? Otherwise, how will VA meet the demand for health services 
that is one of the consequences of the war, including increased demands 
for rehabilitative and mental health services?
    Response. VA does have health care access standards in place which 
apply to all veterans. These standards are:

     96 percent of primary care appointments should be within 
30 days of the desired appointment date.
     93 percent of specialty care appointments should be within 
30 days of the desired appointment date.

    When these standards cannot be met, medical centers have the option 
of purchasing that care in the community. Appropriate legislative 
authority exists for these purchases.

                 DOD AND VA HEALTH INFORMATION SHARING

    Question 2. Shared health care information technology has been 
identified by Congressional and Presidential task forces for nearly a 
decade as a key enabler of transition for servicemembers from DOD to 
the VA. In spite of years of joint committees and joint programs, we 
continue to hear that when wounded soldiers transition from DOD to VA 
for their health care, they carry with them a conglomeration of health 
records on paper--often incomplete. Why are VA and DOD hospitals faxing 
important laboratory and inpatient data?
    Response. VA fully supports the most seriously ill and wounded 
servicemembers who are being transferred to VA polytrauma centers. 
Currently, much of DOD inpatient data is paper-based and not 
electronic. Therefore, VA social workers embedded in MTFs ensure that 
all pertinent inpatient records are copied and transferred with the 
patient. At key military treatment facilities (Walter Reed Army Medical 
Center, Bethesda National Naval Medical Center and Brooke Army Medical 
Center), DOD transmits scanned images of the paper records, along with 
radiology images, to VA clinicians at polytrauma centers for viewing. 
Images that are sent via this solution may then be made available for 
viewing from any VA facility where veterans' health information systems 
and technology architecture (VistA) Imaging is in use.

    Question 3. Why are medical records still being lost?
    Response. New technological and personnel initiatives are reducing 
the possibility that medical records will be lost. Technologically, VA 
recently deployed the Veterans Tracking Application (VTA), which brings 
data from three sources (DOD, VHA, and VBA) together for display on one 
platform creating the beginning of a truly veteran-centric patient 
tracking record. The starting point for the electronic transfer of 
clinical information from DOD to VA is in Afghanistan or Iraq. 
Information from that point on is entered in the joint patient tracking 
application (JPTA). When the patient is ready to be transferred to a VA 
medical center, VA staff working at the military hospital copy the 
record and fax it to the VA facility, which prepares to receive the 
patient. VA now has a version of JPTA called VTA. This contains all the 
information in JPTA except information deemed sensitive to military 
activities. DOD has begun to transform key portions of these records 
into electronic documents accessible through VTA. This reduces the 
number of documents that must be copied and faxed.
    The patient may ultimately be cared for at several VA and military 
facilities. VA is increasingly using VTA to track patients through each 
of these steps. VA also successfully implemented bidirectional 
capability at every VA medical facility, meaning that VA and DOD are 
able to exchange information directly from facility to facility. As of 
July 2007, bidirectional health information exchange (BHIE) data are 
now available for viewing at all VA and DOD facilities. These sites 
include the Walter Reed Army Medical Center and the Bethesda National 
Naval Medical Center, the Landstuhl Regional Medical Center in Germany 
and the Naval Medical Center, San Diego. VA is working closely with DOD 
to increase the scope of data available between DOD and VA.
    Throughout the remainder of the year and into 2008, the types of 
data shared bidirectionally will increase by adding domains such as 
progress notes and problem lists.
    In March 2007, VA added a personal touch to seamless transition by 
creating 100 new transition patient advocates (TPA). They are dedicated 
to assisting our most severely injured veterans and their families. The 
TPA's job is to ensure a smooth transition to VA health care facilities 
throughout the Nation and cut through red tape for other VA benefits. 
Recruitment to fill the TPA positions began in March, and to date VAMC 
hired 46 TPAs. Interviews are being conducted to fill the remaining 54 
positions. Until these positions are filled, each medical center with a 
vacant TPA position has detailed an employee to perform that function. 
We believe these new patient advocates will help VA assure that no 
severely injured Iraq or Afghanistan veteran falls through the cracks. 
VA will continue to adapt its health care system to meet the unique 
medical issues facing our newest generation of combat veterans while 
locating services closer to their homes. DOD and VA sharing electronic 
medical records facilitate this process.

    Question 4. Why are these still problems for our servicemembers?
    Response. Sharing electronic medical records between DOD and VA is 
a longstanding issue, which has been the subject of several Government 
Accountability Office (GAO) reviews. Developing an electronic interface 
to exchange computable data between disparate systems is a highly 
complex undertaking. VA is fully committed to ongoing collaboration 
with DOD and the development of interoperable electronic health 
records. While significant and demonstrable progress has been made in 
our pilots with DOD, work remains to bring this commitment to system-
wide fruition. VA is always mindful of the debt our Nation owes to its 
veterans, and our health care system is designed to fulfill that debt. 
To that end VA is committed to seeing through the successful 
development of interoperable electronic health records. One of the 
biggest obstacles is identifying and agreeing upon standard data fields 
for these records, since VA and DOD have different needs for their 
respective populations.
    DOD/VA Joint Executive Council (JEC), co-chaired by VA's Deputy 
Secretary and DOD's Under Secretary of Defense for Personnel and 
Readiness, continues its ongoing active executive oversight of 
collaborative activities, including health data sharing initiatives. VA 
and DOD have documented a Joint Strategic Plan (JSP) that is maintained 
by the JEC. The JSP contains the strategic goals, objectives and 
milestones for VA/DOD collaboration, including VA and DOD health data 
sharing activities. Under the leadership of the JEC, VA and DOD 
realized significant success in meeting JSP health data sharing 
milestones.
    VA and DOD also chartered DOD/VA Health Executive Council (HEC), 
co-chaired by VA's Under Secretary for Health and DOD's Assistant 
Secretary of Defense for Health Affairs. The HEC serves to ensure full 
cooperation and coordination for optimal health delivery to our 
veterans and military beneficiaries. Through the HEC Information 
Management and Information Technology Work Group (co-chaired by VHA 
chief officer, Health Information Technology Systems and the Mental 
Health Services chief information officer) HEC maintains management 
responsibility for the implementation of electronic health data sharing 
activities. These data sharing activities are largely governed by DOD/
VA joint electronic health records interoperability (JEHRI) plan, 
approved in 2002, which serves as the overarching strategy around which 
these data sharing activities are managed.
    There are a number of ongoing pilot programs that have developed 
into operational capabilities to share increased amounts and types of 
viewable data being exchanged between VA and DOD. After a successful 
pilot in El Paso, Texas, VA and DOD are now sharing digital images at 
this location. The same is true in the Puget Sound area, Hawaii and San 
Antonio, Texas where VA and DOD can now share narrative text documents, 
such as inpatient discharge summaries.

                PROJECTION OF FUTURE HEALTH CARE NEEDS 
                         BY AMERICA'S VETERANS

    Question 5. A column by Harvard researcher Linda Bilmes asserts 
that ``the seeds of the Walter Reed Army Medical Center scandal were 
sown in . . . a failure to foresee the sheer number and severity of 
casualties.'' Do you agree with that statement?
    Response. VA cannot comment on Ms. Bilmes' assertion. VA is 
committed to ensuring it meets the needs of our veterans, including 
those who serve in OEF/OIF. VA has made every effort to account for the 
needs of OEF/OIF veterans within the VA enrollee health care projection 
model. To identify OEF/OIF veterans, we started using a DOD personnel 
roster in Fiscal Year (FY) 2002 where the model develops projections 
based on the actual enrollment and usage patterns of OEFIOIF veterans. 
These projections are based on the development of separate enrollment, 
morbidity, and reliance assumptions for OEF/OIF veterans based on their 
actual enrollment and usage patterns. However, many unknowns influence 
the number and types of services that VA will need to provide OEF/OIF 
veterans, including the duration of the conflict, when OEF/OIF veterans 
are demobilized, and the impact of our enhanced outreach efforts. 
Therefore, we have included additional investments for OEF/OIF in the 
Fiscal Year 2008 budget to ensure that VA is able to care for all of 
the health care needs of our returning veterans.

    Question 6. What joint planning or analytical process exists today 
between DOD and the VA that did not exist in the past which will ensure 
a more complete understanding of the near- and long-term needs of our 
returning servicemembers?
    Response. VA and DOD are committed to increasing collaborative and 
sharing activities between the Departments. This commitment is embodied 
in the work of the three joint councils established to facilitate 
collaborative initiatives and the workgroups and task forces that have 
emerged from them. Additional efforts to enhance cooperation and 
collaboration between the Departments have been initiated by 6 
individual offices/interest groups. At the current time there are three 
primary joint councils:

    (1) VA/DOD JEC co-chaired by VA's Deputy Secretary and DOD's Under 
Secretary for Personnel and Readiness.
    (2) VA/DOD HEC, co-chaired by VA's Under Secretary for Health and 
DOD's Assistant Secretary for Health Affairs.
    (3) VA/DOD Benefits Executive Council (BEC), co-chaired by VA's 
Under Secretary for Benefits and DOD's Assistant Secretary for Force 
Management.

    In May 2007, VA and DOD collaborated on the formation of the Senior 
Oversight Committee (SOC) to focus on opportunities to directly support 
the seriously ill and wounded. The SOC is co-chaired by the Deputy 
Secretaries of each Department and is organized around business lines 
of action in clinical, administrative and personnel domain areas.
    In response to the Global War on Terror (GWOT) task force 
recommendations, DOD and VA have been actively engaged in the 
development of a systematic, integrated and coordinated approach to the 
delivery of clinical and non-clinical case management services to 
severely injured OEF/OIF servicemembers and veterans. This integrated 
approach includes the support of a single point of contact, such as a 
recovery coordinator, who will engage the right resources at the right 
time to meet the biopsychosocial needs of the severely injured person 
and his or her family. In addition, the individual will benefit from a 
``recovery plan'' based on the patient's identified needs. This plan 
will remain across the Departments and care settings.
    In partnership with DOD, VA has implemented a number of strategies 
to provide timely, appropriate, and seamless transition services to the 
most seriously injured OEF/OIF active duty servicemembers and veterans.
    VHA's work to create a seamless transition for men and women as 
they leave the service and take up the honored title of ``veteran'' 
begins early on. Our benefits delivery at discharge program enables 
active duty members to register for VA health care and to file for 
benefits prior to their separation from active service. Our outreach 
network ensures returning servicemembers receive full information about 
VA benefits and services. And each of our medical centers and benefits 
offices now has a nurse or social worker program manager assigned to 
work with veterans returning from OEF/OIF.
    VHA has coordinated the transfer of over 7,900 severely injured or 
ill active duty servicemembers and veterans from DOD to VA. Our highest 
priority is to ensure that those returning from OEF/OIF transition 
seamlessly from MTFs to VAMCs and continue to receive the best possible 
care available anywhere.
    VA social workers, benefits counselors, and outreach coordinators 
advise and explain the full array of VA services and benefits. These 
liaisons and coordinators assist active duty servicemembers as they 
transfer from MTFs to VA medical facilities. In addition, our social 
workers help newly wounded soldiers, sailors, airmen and Marines and 
their families plan a future course of treatment for their injuries 
after they return home. Currently, VA social workers and benefit 
liaisons are located at 10 MTFs, including Walter Reed Army Medical 
Center, the National Naval Medical Center Bethesda, the Naval Medical 
Center San Diego, and Womack Army Medical Center at Ft. Bragg. A 
national memorandum of understanding (MOU) has been signed between VA 
and DOD as directed by the GWOT task force, with memorandums of 
agreement (MOA) in place at each local facility.
    Since September 2006, a VA certified rehabilitation registered 
nurse (CRRN) has been assigned to Walter Reed to assess and provide 
regular updates to our polytrauma rehabilitation centers (PRC) 
regarding the medical condition of incoming patients. The CRRN assists 
families and prepares active duty servicemembers for transition to VA 
and the rehabilitation phase of their recovery. A second nurse liaison 
is being hired for national Naval Medical Center, Bethesda, and should 
be in place by September 2007.
    Another important aspect of coordination between DOD and VA prior 
to a patient's transfer to VA is access to clinical information. This 
includes a pre-transfer review of electronic medical information via 
remote access capabilities. The VA polytrauma centers have been granted 
direct access into inpatient clinical information systems from Walter 
Reed Army Medical Center and National Naval Medical Center. VA and DOD 
are currently working together to ensure that appropriate users are 
adequately trained and connectivity is working and exists for all four 
polytrauma centers. For those inpatient data that are not available in 
DOD's information systems, VA social workers embedded in the MTFs 
routinely ensure that the paper records are manually transferred to the 
receiving polytrauma centers.
    BHIE, a data exchange system allows VA and DOD clinicians to share 
text-based outpatient clinical data between VA and the 10 MTFs, 
including Walter Reed and Bethesda.
    VHA understands the critical importance of supporting families 
during the transition from DOD to VA. We established a Polytrauma Call 
Center in February 2006, to assist the families of our most seriously 
injured combat veterans and servicemembers. The Call Center operates 24 
hours-a-day, 7 days-a-week to answer clinical, administrative, and 
benefit inquiries from polytrauma patients and family members. The 
Center's value is threefold: it furnishes patients and their families 
with a one-stop source of information; it enhances overall coordination 
of care; and, very importantly, it immediately elevates any system 
problems to VA for resolution.
    VA's Office of Seamless Transition includes outreach coordinators 
who regularly visit seriously injured servicemembers at Walter Reed and 
Bethesda. Their visits enable them to establish a personal and trusted 
connection with patients and their families.
    These outreach coordinators help identify gaps in VA services by 
submitting and tracking follow-up recommendations. They encourage 
patients to consider participating in VA's national rehabilitation 
special events or to attend weekly dinners held in Washington, DC, for 
injured OEF/OIF returnees. In short, they are key to enhancing and 
advancing the successful transition of our service personnel from DOD 
to VA, and, in turn, to their homes and communities.
    In addition, VA has developed a vigorous outreach, education, and 
awareness program for the National Guard and Reserve. To ensure 
coordinated transition services and benefits, VA signed a MOA with the 
National Guard in 2005. Combined with VA/National Guard State 
coalitions in 54 States and territories, VA has significantly improved 
its opportunities to access returning troops and their families. We are 
continuing to partner with community organizations and other local 
resources to enhance the delivery of VA services.
    At the national level, MOAs are under development with both the 
United States Army Reserve and the United States Marine Corps. These 
new partnerships will increase awareness of, and access to, VA services 
and benefits during the de-mobilization process and as service 
personnel return to their local communities.
    VA is also reaching out to returning veterans whose wounds may be 
less apparent. VA is a participant in the DOD's PDHRA program. DOD 
conducts a health reassessment 90-180 days after return from deployment 
to identify health issues that can surface weeks or months after 
servicemembers return home.
    VA actively participates in the administration of PDHRA at Reserve 
and Guard locations in a number of ways. We provide information about 
VA care and benefits; enroll interested Reservists and Guardsmen in the 
VA health care system; and arrange appointments for referred 
servicemembers. As of June 30, 2007, an estimated 109,117 
servicemembers were screened, resulting in over 25,055 referrals to VA 
medical facilities and 12,624 referrals to Vet Centers. Of those 
referrals, 47.9 percent were for mental health and readjustment issues; 
the remaining 52.1 percent were for physical health issues.
    In April 2007, VA sponsored a conference to educate VA and DOD 
staff about services and programs for OEF/OIF veterans. Specialized 
educational tracts included mental health, polytrauma and Traumatic 
Brain Injury, diversity and women's health, pain management, seamless 
transition, and prosthetics and sensory aids. Each veterans integrated 
service network (VISN) developed an action plan for management of OEF/
OIF veterans.
    In May 2007, VA and DOD established a work group for seamless 
transition clinical case management to improve the delivery of safe, 
high-quality, and timely medical care to OEF/OIF wounded warriors and 
other similarly injured or ill servicemembers through the seamless 
provision of case management services in both DOD and VA systems. The 
work group will use a clinical case management model to address the 
transition issues of our servicemembers and veterans. It will identify 
and define policies, assist in the development of qualifications and 
functions and help identify potential gaps in tracking of the severely 
wounded warrior from agency to agency.

                 DOD AND VA HEALTH INFORMATION SHARING

    Question 7. According to DOD, health assessment data on separating 
servicemembers is being provided to the VA on a monthly and weekly 
basis. How does the VA use this data to support care of veterans today?
    Response. Beginning in October 2003, DOD Defense Manpower Data 
Center (DMDC) has sent VA's Office of Public Health and Environmental 
Hazards a periodically updated personnel roster of troops who 
participated in OEF/OIF and who had separated from active duty and 
become eligible for VA benefits. The latest DMDC file received in 
January 2007 indicates that there are a total of 686,306 OEF/OIF 
veterans who have been separated up to November 2006 from active duty 
following deployment to the Afghanistan and Iraq theaters of operation. 
For each veteran, their demographic (social security number, name, date 
of birth, gender, education, etc.) and military service specific data 
(branch, rank, unit component, deployment dates, etc.) are included in 
the record received from DOD.
    VA uses this roster to evaluate the VA health care use of OEF/OIF 
veterans. This analysis, which is based on the roster received from 
DOD, is very useful to plan allocation of VHA healthcare resources. The 
roster is checked against VA's inpatient and outpatient electronic 
patient records to determine which veterans have sought treatment in VA 
facilities as well as the International Classification of Disease (ICD-
9) diagnostic codes used to describe their diagnoses. These data 
indicate what types of health problems OEF/OIF veterans who have 
presented to VA have developed since deployment. The most recent report 
of OEF/OIF health care utilization is attached.
    In addition to VA health care utilization data, which is based on 
the troop roster supplied by DMDC, DOD performs health assessments of 
servicemembers just prior to deployments and at the time of return from 
deployments. The purpose of these assessments is to screen for health 
concerns that warrant further medical evaluation. Since September 2005, 
DOD has sent VA their electronic pre-deployment and post-deployment 
health assessments of servicemembers who have deactivated from active-
duty back to the Reserve and National Guard or who have separated 
entirely from service. This data transfer takes place monthly. More 
recently, beginning in 2005, DOD developed the PDHRA. The purpose of 
PDHRA is to screen for physical health and mental health concerns at 90 
to 180 days after return from deployments. In November 2006, DOD began 
monthly electronic transfers of PDHRA data to VA, and as of June 2007, 
VA has received over 1.7 million PPDHA and PDHRA assessments on more 
than 706,000 separated servicemembers and deactivated Reserve/National 
Guard members.
    DOD deployment health assessments are available to VA health care 
workers in the VHA electronic health record, which is accessed during 
each patient encounter. These health data are used by VA clinicians to 
aid in the diagnosis and care of OEF/O!F veterans.

    Question 8. Is the data useful for projecting future care needs, 
for example, for TBI, Post Traumatic Stress Disorder (PTSD), and 
prosthetic care? If not, are there joint efforts underway by the two 
departments to improve the ability to project future health care needs?
    Response. Data derived from DOD's PDHRA do not allow for projecting 
servicemembers' need for services for Traumatic Brain Injury (TBI) and 
prosthetics. Data are being analyzed within VA for both mental health 
and prosthetics to project mental health service needs based on recent 
workloads for mental health programs as well as workloads for 
prosthetic equipment, sensory aids and devices.
    As of the second quarter of Fiscal Year 2007, 35 percent (252,095) 
of veterans eligible for care came to VA for clinical services. Of 
these, 37.7 percent received provisional diagnoses of mental disorders 
including 45,330 with a provisional Post Traumatic Stress Disorder 
(PTSD) diagnosis. These are cumulative data, and not all these veterans 
are found to actually have a mental disorder or, if they do, the 
problem may be resolved with treatment.
    As of July 2007, an estimated 109,117 servicemembers were screened, 
resulting in more than 25,055 referrals to VA for follow-up health 
care. In addition to mental health, 52.1 percent of the referrals were 
for physical health issues.
    VHA's Prosthetics and Clinical Logistics provided prosthetics and 
other medical equipment and supplies to 22,910 OEF/OIF veterans in 
Fiscal Year 2006. As of Fiscal Year 2007 second quarter, 18,367 OEF/OIF 
veterans have received care in prosthetics. Based on the trend thus far 
this FY, VA anticipates a significant increase in the number of OEF/OIF 
veterans we will care for in Fiscal Year 2007. This data are based on 
matching unique NPPD (National Prosthetic Patient Database) patient 
identifications to the OEF/OIF roster obtained from the VHA support 
service center (VSSC). On a monthly basis, DOD provides VA with the 
latest amputee statistics from DOD's amputee patient care program-
clinical database. This allows VA to project the number of amputees 
that will eventually be discharged from MTFs and transitioned into VA 
care. Last, NPPD is currently being enhanced to alert staff and flag 
the patient's record when a consult for an OEF/OIF patient is initiated 
for a prosthetic appliance. This allows the medical facilities 
prosthetic departments to better prioritize requests for OEF/OIF 
veterans.
    In partnership with DOD, VA has implemented a number of strategies 
and innovative programs to provide timely, appropriate, and seamless 
services to the most seriously injured OEF/OIF active duty members and 
veterans. One such program enables active duty members to register for 
VA health care and initiate the process for benefits prior to 
separation from active service. The centerpiece program supporting the 
seamless transition of seriously injured servicemembers and veterans 
involves placement of VA social work liaisons, VA benefit counselors, 
and outreach coordinators at MTFs to educate servicemembers about VA 
services and benefits.
    VA and DOD continue to collaborate in the screening process for 
TBI. A TBI screening instrument was developed based on the experience 
of VA, MTFs and Defense and Veterans Brain Injury Center. As of April 
2, 2007, VA mandated administration of the TBI screen to all OEF/OIF 
veterans who receive medical care in the VA. Every possible reply in 
the TBI Screening reminder generates a unique ``health factor'' that is 
stored in the ``health factors file'' in the VA databases. This will 
further improve VA's ability to project healthcare needs of veterans 
with TBI.

              PRIVACY RULES AND THE SHARING OF DOD AND VA 
                          MEDICAL INFORMATION

    Question 9. Congress enacted the Health Insurance Portability and 
Accountability Act (HIPAA) of 1996 (Public Law 104-191) to prevent the 
disclosure of certain personal medical information, but permits DOD and 
VA to share information on individuals being treated in both systems. 
Yet HIPAA is often cited as a barrier to easy sharing of health data 
between DOD and VA. In 2003, a Presidential task force recommended that 
the two departments be declared a single health care system for the 
purposes of implementing HIPAA--in order to smooth transition of 
servicemembers from DOD to the VA, and to accelerate the development of 
shared health care information technology. What did the two departments 
do, if anything, in response to this recommendation?
    Response. As a rule, there are no HIPAA constraints on sharing 
electronic data between VA and DOD. In general, the HIPAA Privacy Final 
Rule prohibits covered entities--health care providers that conduct 
certain transactions electronically, health plans, and healthcare 
clearinghouses--from disclosing protected health information unless a 
specific permitted disclosure is applicable. One special exemption 
pertains to DOD's sharing data with VA. This permitted disclosure, 45 
CFR 164.512(k)(1)(ii), allows DOD to ``disclose to VA the protected 
health information on an individual who is a member of the Armed Forces 
upon separation or discharge of the individual from military service 
for the purpose of a determination by VA of the individual's 
eligibility for or entitlement to benefits under laws administered by 
the Secretary of Veterans Affairs.'' VA and DOD HIPAA, privacy and 
General Counsel staffs worked diligently to resolve any differences in 
interpretation of these authorities. In June 2005, DOD and VA 
implemented a data-sharing MOU that outlines these agreed-upon 
authorities.

    Question 10. Why is HIPAA still cited as a barrier to information 
sharing?
    Response. As a rule, there are no HIPAA constraints on sharing 
electronic data between VA and DOD. The HIPAA Privacy Rule has not 
impacted VA's health information exchange efforts as ample authority 
exists under this Rule for the exchange of health information both with 
DOD and private and public health care providers.
                                 ______
                                 
  Response to Written Questions Submitted by Hon. Saxby Chambliss to 
Gerald Cross, M.D., Acting Principal Deputy Under Secretary for Health, 
                     Department of Veterans Affairs

    Question 1. One suggestion I have heard regarding how to speed up 
the MEB/PEB process within DOD and make it more efficient and easier 
for our servicemembers is to embed more VA personnel within DOD to help 
with the transition process. Specifically, VA personnel could begin 
working with soldiers and possibly take charge of their paperwork and 
medical requirements once it is clear that a servicemember cannot be 
retained in the Service. Can you comment on how embedding VA personnel 
might affect the MEB/PEB process and if you think, from our 
servicemembers' perspective, that this would be a good idea?
    Response. Expanding VA and DOD's partnership to include 
coordination on the MEB/PEB process is an excellent idea. It is the 
logical next step in ensuring that servicemembers experience a smooth 
transition from military to civilian life. VA staff is participating in 
the Army's transformation initiative for the physical disability 
evaluation process (PDES) by participating in five process action teams 
(PATs) developing transformation strategies for five key components of 
the PDES as well as the council of colonels which is the group 
overseeing the initiative.
    In addition, VA staff is participating in the Army medical action 
plan (AMAP) and fully supports the concept of getting VA personnel 
involved as servicemembers enter the MEB/PEB process. As part of the 
VA/DOD Senior Oversight Committee (SOC), October 1, 2007, VA and DOD 
will initiate a pilot joint disability program at Walter Reed Army 
Medical Center, National Naval Medical Center, Bethesda and Malcom Grow 
Medical Center. The goal of the pilot program is to develop one 
comprehensive physical exam and a joint disability evaluation board. 
Most, if not all, of the initiatives can be accomplished through 
cooperation and partnership and do not require legislative authority.

                           TRICARE ACCEPTANCE

    Question 2. I was surprised to learn that VA hospitals do not 
necessarily accept TRICARE. Would ensuring that all VA hospitals 
accepted TRICARE be a way to improve the seamless transition of our 
veterans from DOD to the VA as well as ensuring that they have easy and 
quick access to the best health care they are entitled to?
    Response. VA and DOD signed a MOU on June 29, 1995 that allows VA 
health care facilities to provide care for TRICARE beneficiaries. Prior 
to the completion of the MOU, the Deputy Under Secretary for Health for 
Operations and Management directed all VA medical facilities to become 
TRICARE network providers in order to provide timely care to DOD 
beneficiaries, especially those returning from the GWOT theaters. As of 
May 2007, approximately 94 percent of VA medical facilities have signed 
TRICARE agreements with DOD's managed care support contractors. VA's 
goal is to have 100 percent of the VAMCs participating in TRICARE.

                   BUDGETING FOR ADDITIONAL PATIENTS

    Question 3. Over the past fiscal year, the Atlanta VA hospital has 
experienced an increase in the number of Operation Iraqi Freedom/
Operation Enduring Freedom unique patients of 75 percent. My guess is 
that the Atlanta VA hospital is not unique in the increase of Iraq and 
Afghanistan veterans that they are receiving. A few years ago, Congress 
had to add a significant amount of money to the VA health system's 
budget because the VA had not adequately predicted how much money they 
would need to take care of the patients in the VA health care system. 
Can you provide your assurances that the VA and specifically the VA 
health care system will correctly budget for the number of patients 
they will be required to serve in the coming years?
    Response. Yes, VA uses an enrollee health care projection model to 
develop budget estimates based on the actual enrollment rates, age, 
gender, morbidity, and reliance on VA health care services of the 
enrolled OEF/OIF population. OEF/OIF veterans have significantly 
different VA health care usage patterns than non-OEF/OIF enrollees, and 
this difference is reflected in the estimates from the enrollee health 
care projection model. For example, when modeling expected demand for 
PTSD residential rehab services for the OEF/OIF cohort, the model 
reflects the fact that they are expected to need three times the number 
of these services than non-OEF/OIF enrollees. The model also reflects 
their increased need for other health care services, including physical 
medicine, prosthetics, and outpatient psychiatric and substance abuse 
treatment. On the other hand, experience indicates that OEF/OIF 
enrollees seek about half as much inpatient acute medicine and surgery 
care from the VA as non-OEF/OIF enrollees.
    Many unknowns influence the number and types of services that VA 
will need to provide OEF/OIF veterans, including the duration of the 
conflict, when OEF/OIF veterans are demobilized, and the impact of our 
enhanced outreach efforts. VA has made every effort to account for the 
needs of OEF/OIF veterans within the actuarial model. Starting with the 
identification of OEF/OIF veterans from a roster provided by DOD the 
actuarial model develops projections based on the actual enrollment and 
usage patterns of OEF/OIF veterans since Fiscal Year 2002. These 
projections are based on the development of separate enrollment, 
morbidity, and reliance assumptions for OEF/OIF veterans based on their 
actual enrollment and utilization patterns. However, unknowns, such as 
the length of the conflict, will impact the services that VA will need 
to provide. Therefore, we have included additional investments for OEF/
OIF in the Fiscal Year 2008 budget to ensure that VA is able to care 
for all of the health care needs of our returning veterans.

    Chairman Levin. Thank you, Secretary Cooper.
    Secretary Geren?

    STATEMENT OF HON. PRESTON M. ``PETE'' GEREN III, ACTING 
          SECRETARY OF THE ARMY, DEPARTMENT OF DEFENSE

    Mr. Geren. Thank you, Mr. Chairman.
    Chairman Levin, Chairman Akaka, Senator McCain, Senator 
Craig, thank you for hosting this hearing. The fact that you 
all are meeting together jointly demonstrates that this is a 
problem that is not a DOD problem, not a DOD challenge, but it 
is a VA challenge. I think that as we study the problem 
further, as Secretary England alluded to, we are going to find 
that in order to address this issue effectively, we are going 
to have to reach even broader than these two Committees and 
partner with the entire Congress. Our Army Wounded Warrior 
Program is an example of that. In our Army Wounded Warrior 
Program, the Department of Labor, the Department of 
Transportation, and the Department of Homeland Security are 
also partners in that. So I commend these two Committees for 
the leadership you have shown on this.
    I would also, on a personal note, like to thank all of you. 
Every one of you here has met with our wounded servicemen and 
women. You have been to the hospitals. You have been to the 
facilities. That demonstrated commitment to those soldiers 
means so much to them, and thank you for taking your time to do 
that. That is greatly appreciated and it is something that 
resonates among the force. We need to thank you for doing that.
    I would like to offer my written statement for the record 
and summarize, if I could, Mr. Chairman.
    Chairman Levin. It will be made part of the record, and I 
have just been notified the vote is now scheduled for 10:45. It 
has been pushed back 15 minutes.
    Mr. Geren. I will finish before then. We have got numerous 
commissions and committees looking at this issue right now. We 
have the Dole-Shalala. Yesterday, we got the initial reports 
from West-Marsh. Secretary Nicholson is doing a report. General 
Scott's Commission is going to report out in October. They are 
all going to provide us with important new road maps, I am 
confident. But I am also confident that Omar Bradley, 50 years 
ago, probably got it right and the bottom line for all of these 
commissions is going to be a little different from what General 
Bradley said 50 years ago. The system needs a radical overhaul. 
The system doesn't work for soldiers and their families today.
    We are not, as an Army, though, stopping and waiting for 
these new commissions to report out before we start fixing the 
problem. We are working aggressively, not only at Walter Reed, 
but throughout the system. I would like to take a moment and 
just summarize some of the things that have happened to this 
system that not work well for our soldiers and the veterans, 
and try to make it work as best as it can, and we have got some 
extraordinary leadership doing a great job of making that 
happen.
    Many of you all have already met with the new leadership at 
Walter Reed, all the way from General Schoomaker down to the 
NCOs that are working out there. They are doing an outstanding 
job. General Gale Pollock, our Acting Surgeon General, who is a 
nurse, also has provided great leadership in this area and is 
making the system work.
    Our focus at Walter Reed is to make sure that the soldiers 
out there get the kind of individual care and attention that 
they have to have to make this system work for them. The acute 
care system works well. You have all met with wounded warriors 
who have come from the battlefield to Landstuhl to Walter Reed, 
and on the acute care side, we do an extraordinary job, first 
class, best in the world. Outpatient care has not been up to 
standard and we are working to make it so.
    At Walter Reed, we have built a triad of support for each 
wounded soldier. It has got a primary care physician that is 
assigned to that soldier, a nurse case manager, a ratio of 1:17 
that works with that soldier from the moment he gets to Walter 
Reed all the way to the transition into the VA system. And then 
we have got, I think most importantly, we have an NCO ratio of 
1:12, a squad leader, and the job of that NCO out there as part 
of this Warrior Transition Brigade is to make sure that he 
looks after those 12 soldiers. Just like that NCO would do out 
in the field, we are doing that same thing now at Walter Reed 
and that program will be fully operational by the first of next 
month.
    We put 130 soldiers, many of them the leaders are combat 
veterans, many of them also are veterans of the health care 
system, out there to work individually with these soldiers. We 
are also hiring ombudsmen. Many of these are initiatives that 
you all have addressed in your legislation, good ideas and we 
are already moving out on them.
    We have launched the Wounded Warrior and Family Hotline. 
Every one of you has a card at your desk. We are disseminating 
these broadly throughout the system. You see the example of the 
card on the board over there. The Wounded Warrior Hotline is 
working very well. We have had 700, 800 calls already, and 
those don't go into some remote call center somewhere. They go 
into the Army Operations Center. So if the system doesn't work, 
if these new advocates that we have in place to make sure they 
are representing the soldiers effectively aren't getting the 
job done, the issue gets elevated immediately with instructions 
to act on it, and then there is a team in place to make sure 
that the liaison officers, the case managers address the 
problems that are raised.
    We have made process improvements out there. We are also 
making physical infrastructure improvements. As you know, all 
the soldiers are out of Building 18. Building 18 is empty now. 
We have those soldiers in barracks on the Walter Reed campus.
    We welcome the results of Secretaries Marsh's and West's 
report from yesterday. We have worked with them over the last 
couple of months. Many of their initiatives, we have already 
put in place. We are building the soldier-centric system with a 
triad of support that I mentioned earlier. We are activating 
the Wounded Warrior Transition Brigade on April 25. And this 
might seem like a small gesture, but it is very important to 
the families. We are meeting the families at the airport, 
bringing them to the facility, providing them orientation, make 
sure that they understand what the situation of their loved one 
is, and also make sure that they understand how they can work 
through the system.
    One-stop shop, also a subject of your legislation. We have 
a Soldiers and Families Assistance Center, which brings 
together the agencies, the VA, the Army, other government 
agencies, as well as veterans' service organizations and the 
Red Cross. They work together with those soldiers and their 
families so they can meet their needs in one place instead of 
multiple places.
    We have a new Deputy Commanding General at Walter Reed. His 
job is a bureaucracy buster, and I am pleased to tell you that 
we have taken the number of forms that a soldier has to fill 
out from more than 40 down to ten. Now, you might ask, I did, 
why ten, but at least we are moving in the right direction.
    We are committed to providing a seamless transition of 
medical care. That is what the soldiers deserve. That is what 
they need. What they have now is confusing, it is time 
consuming, it is arbitrary in some cases, it is unquestionably 
bureaucratic, and we are going to learn more through these 
commissions how to make it better. But under the leadership 
that we have seen demonstrated over the last 6 weeks, we have 
tried to make the system work better and I believe we are.
    We also have some models out there that we can call on that 
I think will help us see the way into the future. We work best 
with the VA where we work closest with the VA. At Eisenhower 
Army Medical Center in Georgia, and at Tripler Army Medical 
Center in Honolulu, the Army and the VA work hand-in-hand. We 
have relationships at every medical facility, as does the VA at 
their facilities, but we do have some models that can show us 
the way ahead and I think those are two great examples of it.
    On the issue of BRAC that has been raised by many people, 
it is our position that with the closure of Walter Reed and the 
expedited construction of the facility at Bethesda and the new 
facility at Fort Belvoir, we can provide better care to our 
wounded warriors and their families in this region. We need to 
move ahead with that. It is important that we do that, and we 
are examining ways to advance the calendar on that and we look 
forward to working with the Congress to accomplish that.
    There is good news in our treatment of wounded warriors 
that also has posed extraordinary challenges for the system. In 
World War II, about 70 percent of the people who were wounded 
in battle survived. Now, over 90 percent. In some cases, it is 
from simple innovations like one-handed tourniquet and bandages 
that help the blood clot. There are all sorts of other 
remarkable medical miracles that our Army doctors have 
performed that make sure that we get the soldiers the absolute 
best when they need it.
    But this also poses a challenge for us. People are 
surviving that have never survived before. They are surviving 
with wounds that they would never survive with in private life, 
frankly, because of the immediate care that they get under the 
military health care system. That poses challenges in the near 
term. It poses challenges in the long term. The partnership 
between the DOD and VA has to work in order for us to meet our 
obligation to those soldiers and their families in the long 
term.
    We have got to do more. And as I said at the beginning, 
that obligation extends beyond just the Department of Defense 
and the Veterans' Affairs Committee. It is an obligation that 
we are going to have to take on as a government if we are going 
to make it work.
    This Senate and the House both have presented important 
pieces of legislation. We look forward to working with you. We 
don't have all the answers now. I can tell you, though, the 
Army is committed to take care of our soldiers. We share your 
commitment to those who have borne the battle, their widows and 
their orphans, and we are doing everything we can to redress 
the wrongs that came to light a couple of months ago and we 
look forward to working with you to make sure that we continue 
to improve the system.
    Thank you, Mr. Chairman.
    [The prepared statement of Mr. Geren follows:]

       Prepared Statement of Hon. Preston M. ``Pete'' Geren III, 
          Acting Secretary of the Army, Department of Defense

    Chairman Levin, Chairman Akaka, Senator McCain, Senator Craig, and 
distinguished Members of the Senate Armed Services Committee and the 
Senate Veterans' Affairs Committee, thank you for inviting me here 
today to speak about caring for our Soldiers and their families.
    There is no greater duty we have as a Nation than to ensure that 
those Soldiers who volunteer to defend our freedom are treated with not 
only the best medical and transitional care we can provide, but with 
the dignity and compassion they deserve. Whether wounded in war, 
injured in training, or taken ill, Soldiers deserve the very best that 
our Nation can offer to honor their service and their sacrifice.
    In some areas, regrettably, we have not lived up to that 
obligation. The superhuman work done by medics, fellow Soldiers, and 
military nurses and doctors to ensure that our Soldiers survive combat 
and receive quality care has been undermined by an outdated and 
bureaucratic system that leaves recovering Soldiers and their families 
frustrated and sometimes angry.
    Just this past Sunday, The Washington Post ran a column written by 
Sergeant David Yancey of the Mississippi Army National Guard, a patient 
at Walter Reed, detailing his struggles with a bureaucracy that simply 
failed him. Sergeant Yancey wrote, ``This is not supposed to be an 
adversarial system, but that's the way it feels--like another battle to 
fight.'' That is totally unacceptable, Soldiers who have been fighting 
or preparing to fight a war overseas should not have to fight a 
bureaucracy here at home, and I am committed to doing all I can and all 
the Army can to make the system more responsive, more dignified, and 
more accountable.
    To be sure, the Army cannot solve the system's many problems by 
itself. However, based on the progress we have made to date and the 
work we continue doing to identify specific remedies, I know that 
together, the Army, the Department of Defense (DOD), the Department of 
Veterans Affairs (VA), and the Congress can provide the compassionate, 
seamless, and robust healthcare system that our Soldiers and their 
families have earned and deserve.
    I'd like to begin by providing an update on the Army's progress in 
addressing issues at Walter Reed Army Medical Center. On March 15th, I 
testified before the Senate Armed Services Committee and vowed that the 
Army would work aggressively to identify and fix the problems at Walter 
Reed. I told the Committee that we would not wait for reports or 
recommendations, but that we ``would fix things as we go.'' Today I am 
pleased to report that we have made a great deal of progress in the 
areas of infrastructure, leadership, and process-related issues, as we 
work toward a Soldier-centric health care system that is supported by 
the triad of: a caring and energetic chain of command; a primary care 
physician; and a Registered Nurse case manager.
    The Army is committed to continuous infrastructure maintenance and 
improvements at Walter Reed. As you know, we no longer house Soldiers 
in Building 18 and are evaluating the long-term use of that facility. 
There is a facility assessment team onsite, contracted by the Baltimore 
District, U.S. Army Corps of Engineers, conducting a thorough 
evaluation of the installation's infrastructure.
    Meanwhile, immediate information technology upgrades to provide 
telephone, Internet, and cable television for Soldiers in all on-post 
lodging facilities have been completed.
    With regard to leadership issues, we believe we have the right 
people and the right mechanisms in place to make sure that all Soldiers 
who are in a transitional status are managed with care and compassion, 
and that they and their families are satisfied. For example, we now 
greet family members at the airport and escort them to the hospital, 
letting them know in word and deed that they and their Soldiers have a 
working support system.
    The Warrior Transition Brigade, to which our medical holdover 
Soldiers are assigned, will activate on April 25th 2007 and will be 
fully operational on June 7th. We are adding over 130 military 
positions to the leadership team that provides daily care and 
leadership for our medical holdover soldiers, and creating new 
leadership posts for company commanders, first sergeants, and squad 
leaders. This reduces the noncommissioned leader-to-led ratio at the 
platoon level from 1:55 to 1:12. Just like Soldiers in every unit in 
the Army, these Soldiers now have a full chain of command, starting at 
the squad leader level, to look after their health and welfare.
    A Clothing Issue Point recently began operations to replace items 
such as undergarments and uniforms, as appropriate, for Soldiers 
evacuated from theater to Walter Reed.
    We have enhanced access to the hospital dining facility and 
established special meal cards to prevent Soldiers from losing their 
basic allowance for subsistence.
    As many of you know, the Mologne House on the Walter Reed campus is 
home to many of our medical holdovers. There is now an emergency 
medical technician onsite at Mologne House 24 hours a day, 7 days a 
week, a change that has been well received by Soldiers and family 
members.
    We have also improved information dissemination and feedback 
mechanisms. A weekly Newcomer's Orientation informs Soldiers and 
families of all programs available to them at Walter Reed. Recently, we 
conducted two Town Hall meetings to make sure that we are aware of the 
issues most important to our Warriors and their families, and have 
incorporated that feedback into our plans and processes. The Town Hall 
meetings are a success and will continue.
    Soldiers and their families were given a Family Member Hero 
Handbook and 1-800 Hotline cards. The Hotline allows Soldiers and their 
families to gather information about medical care as well as suggest 
ways to improve our medical support systems. These cards are being 
distributed throughout the force, and so far the result has been very 
encouraging. By April 2nd, we had received 656 calls detailing 394 
distinct issues. Of these roughly 202 were medical issues and 132 were 
tasked to MEDCOM for research and resolution.
    In an effort to provide better service, we conducted a survey at 
Walter Reed to determine the Soldiers' view of their outpatient care 
experiences and have already implemented many of their suggestions. We 
will also continue to conduct monthly after-action reviews to assess 
what is working and what still needs improvement.
    On the issue of process, the Soldier and Family Assistance Center 
(SFAC) opened its doors on March 23rd, 2007. The SFAC brings together 
assistance coordinators, personnel and finance experts, and 
representatives from key support and advocacy groups such as the U.S. 
Army Wounded Warrior Program, the Red Cross, Army Community Services, 
Army Emergency Relief, and VA. Co-locating these organizations provides 
one-stop service to Soldiers.
    Also, we have begun a more efficient and thorough system for 
transferring our warriors in transition from inpatient to outpatient 
status. At Walter Reed, a complete review of our discharge management 
process resulted in a revision of standard operating procedures. We 
developed a discharge escort system whereby hospital staff, including 
the brigade leadership, comes to the Soldier to conduct discharge 
business, escort the Soldier to the brigade, and assist with luggage 
and transition into the unit. We instituted training to re-emphasize 
the importance of hospitality for our Soldiers and their families.
    The Physical Evaluation Board (PEB) process, which determines if a 
Soldier is fit to continue performing his or her duties, is one of the 
most daunting a Soldier can face. We have significantly increased the 
number of Physical Evaluation Board Liaison Officers (PEBLO) to help 
Soldiers navigate this process. (The ratio of PEBLO to Soldier has 
improved from 1:45 to 1:30.) Standardization of the case management 
process, coupled with increased case managers and PEBLOs, has 
significantly improved the level of service we provide to the Soldier. 
And importantly, we will soon see an improved ratio of case managers to 
patients, from 1:50 to 1:17, to permit better coordination of treatment 
and evaluation.
    The rest of the Army leadership and I also vowed to address similar 
issues around the country and in the medical system at large. For 
example, we are aggressively working to make improvements to the 
existing Physical Disability Evaluation System (PDES) to minimize the 
difficulties that Soldiers are facing. This system was developed half a 
century ago and has become overly bureaucratic and, too often, 
adversarial. The Army has undertaken corrective action and we are 
developing initiatives to overhaul or replace the current process. 
Indeed, rather than settle for yet another attempt to streamline 
current processes, our goal is to eliminate the bureaucratic morass 
altogether, and develop a more streamlined process to best serve our 
Soldiers.
    As we move forward to transform the PDES, there will be areas of 
policy, process, and administration requiring full collaboration and 
coordination involving both DOD and VA. We have worked together in the 
past, and it is imperative that we continue that partnership in order 
to identify the issues, fix the problems, and improve the process for 
our servicemen and women.
    Specific areas for improvement include: Soldier processing within 
Medical Evaluation Boards (MEB) and Physical Evaluation Boards (PEB); 
training of physicians, adjudicators, administrators, and legal 
advisors; establishing standard counseling packages and procedures; and 
ensuring that the automation systems supporting the PDES are 
interconnected.
    Currently, the Army is determining the manpower and funding 
requirements for each initiative and it is our intention to implement 
them within the next 60 days. For example, we are reducing the number 
of forms Soldiers have to complete, and transmitting documents 
electronically rather than through the mail.
    Warriors in medical transition status have been frustrated by 
inconsistent processing of their orders. We have issued a military 
personnel message that clarifies how orders for Soldiers should be 
processed.
    We continue to address concerns that caseworkers are ill-prepared 
to carry out their duties. We have conducted training for our PEBLOs 
via Video Teleconference and in May we will hold a PEBLO Training 
Conference on solving problems for Soldiers in Medical Hold and Medical 
Holdover status.
    The transition of our Warrior medical care from DOD to VA should be 
seamless; right now, it is not, leaving soldiers and their families 
confused and frustrated.
    The bottom line is that the process can't be seamless if the edges 
don't touch. In this case, the ``edges'' between DOD and VA are the 
administrative hand-off in medical management and the disability 
determination. We continue to work with VA to ensure timely access to 
health records for VA providers. Bidirectional health information 
exchange is now operational at all DVA healthcare facilities and at 
over 200 DOD facilities. DVA and DOD, in coordination with the American 
Health Information Community, are working to implement the system 
consistent with the President's health information technology 
initiative. And the VA/DOD Joint Executive Council continues to pursue 
a variety of other efforts to achieve seamlessness on the health 
information technology front. We must work together to minimize the 
number of physical examinations and repeat diagnostic testing that our 
warriors in transition must undergo, and as much as possible, collocate 
our facilities and share resources. Again, these long-term solutions 
will be the result of a collaborative effort between the services, DOD, 
VA, other State and Federal agencies, and the Congress.
    These are just a few of the actions that we have taken to address 
these serious issues. We have yet to receive and/or fully digest the 
reports of other groups that are looking into these same problems, but 
we look forward to reviewing their recommendations.
    On April 3rd, the Army's Tiger Team concluded an exhaustive study 
of the Army's 11 key Medical Treatment Facilities at Forts Bragg, 
Gordon, Stewart, Campbell, Knox, Sam Houston, Hood, Bliss, Lewis, and 
Drum, and Schofield Barracks. Throughout the month of April, the Tiger 
Team will present its findings and recommendations to the senior Army 
leadership, which we anticipate will generate healthy discussion.
    This month, we will also receive the report of an independent 
review group, co-led by former Army Secretaries Jack Marsh and Togo 
West. The Army will carefully study its findings and recommendations 
and will keep you informed as we move through the appropriate 
corrective actions.
    Finally, the Nicholson Task Force and the Dole-Shalala Commission 
findings are forthcoming and will be valuable as we work together to 
define further and address the challenges we face.
    To lead the effort to fix what is wrong are two senior Army leaders 
in whom I have great confidence: Maj. Gen. Gale Pollock, our Army's 
acting Surgeon General, and Brig. Gen. Mike Tucker, our ``bureaucracy 
buster'' who is busy ``knocking down walls,'' so that we can improve 
the Army's system of caring for our wounded, injured, or sick Soldiers 
and establish long-term solutions to the challenges of providing a 
lifetime of care to them and their families.
    We are under no illusions that the work ahead will be easy or quick 
. . . or cheap; we have a lot to do to get this right. Mending the 
seams and fixing the myriad issues we have recently uncovered will take 
energy, patience, determination and above all, political will.
    Soldiers are the centerpiece of the Army and the focus of our 
efforts. Soldiers should not return from the battlefield to fight an 
antiquated bureaucracy.
    Wounded, injured, and ill servicemembers and their families expect 
and deserve quality treatment and support as they return to their units 
or their communities. I know full well that the President, Secretary 
Gates, the Congress and the American public are committed to this 
effort as the cornerstone of everything we are doing. I would simply 
ask for your continued support as we strive to provide the best care 
for those who give so much to protect us all.
    With your help, and the help of all the agencies involved, I know 
that we can match the medical care Soldiers receive at the point of 
injury or illness, whether on the battlefield or during training, with 
simple, compassionate and expeditious service that ensures every 
Soldier knows the Army and the Nation are indeed grateful.
    Thank you again for inviting me to testify. I look forward to your 
questions.
                                 ______
                                 
  Response to Written Questions Submitted by Hon. Daniel K. Akaka to 
   Hon. Preston M. ``Pete'' Geren III, Acting Secretary of the Army, 
                         Department of Defense

    Question 1. I understand that many members of the National Guard 
who are seeking VA disability ratings may have to wait an additional 2 
to 3 months for their claim to be processed pending authorization for 
their National Guard unit to release their records. What can be done to 
resolve this problem?
    Response. Your understanding is correct. There are cases in which 
members of the National Guard who are seeking disability rating from 
the Department of Veterans Affairs have waited two months or more for 
their claim to be processed pending authorization for the release of 
their military health records. There was a misunderstanding of the 
Health Insurance Portability and Accountability Act of 1996 by some 
states. Two actions are being taken to correct this situation. First, 
we are issuing a policy letter to all states and territories clarifying 
the release of health information to the Department of Veterans 
Affairs. Second, the National Guard Bureau has appointed a Protected 
Health Information (PHI) Officer who will be responsible for providing 
policy and compliance for the National Guard related to PHI. We are 
committed to supporting our Guard members and we will move quickly to 
rectify this situation.

    Question 2. The Center for the Intrepid is, by all accounts, a 
truly impressive, state-of-the-art facility for the treatment of 
individuals with major amputations. As you know, it is now run by the 
Army. Do you anticipate that the Army will still be operating this 
facility in ten years? In twenty years?
    Response. We anticipate that the Army will be operating the Center 
for the Intrepid in conjunction with the Department of Veterans Affairs 
as a VA/DOD joint venture for the foreseeable future.
                                 ______
                                 
   Response to Written Questions Submitted by Hon. Larry E. Craig to 
   Hon. Preston M. ``Pete'' Geren III, Acting Secretary of the Army, 
                         Department of Defense

    Question 1. It is my understanding that the Army's Physical 
Evaluation Boards only rate conditions that are ``independently 
unfitting.'' But many severely wounded servicemembers have complex 
injuries involving multiple body systems that, in concert, may cause a 
severe disability. Can you explain the basis for this policy and how it 
would affect those soldiers? Does this policy contribute to the 
relatively low percentage of Army members who receive a 30 percent 
rating or more through the Physical Evaluation Board process?
    Response. The basis for the Army only rating independently 
unfitting conditions can be found in DOD Instruction 1332.39. The PEB 
evaluates each condition independently, determining whether that 
condition prevents the Soldier from performing required duties. Many 
wounded Soldiers are found unfit for multiple conditions, each of which 
is rated, and the ratings are combined to produce an overall rating for 
the Soldier. Individual conditions that are not determined to be 
unfitting are not rated by the Army, although they may be rated by the 
VA. The fact that the military only rates unfitting conditions does 
result in lower military disability ratings than would be the case if 
all conditions were rated.

    Question 2. According to testimony provided at the hearing, the 
Army assigned 0 percent ratings to 27 percent of the soldiers who were 
found to be unfit for duty over the past 6 years. Can you explain how a 
condition could be ``unfitting'' by the Army's standards but at the 
same time be rated as non-disabling under the Department of Veterans 
Affairs (VA) rating criteria? Do these statistics suggest that the VA 
rating criteria do not accurately reflect the impact of some 
disabilities?
    Response. A Soldier is found unfit when he is unable to perform 
appropriate duties in his or her primary military occupational 
specialty. This does not necessarily mean he or she would be unable to 
perform gainful employment in a general civilian job market. 
Generalized pain in knees, back, shoulders, neck, or other regions, 
even without significant medical findings, may nevertheless result in a 
finding of unfitness for Soldiers who must be able to wear helmets, 
body armor, carry heavy rucksacks, walk long distances, etc. A Soldier 
is rated at 0 percent when his medical condition qualifies for a zero 
percent rating in the VA Rating Schedule or does not meet the minimum 
criteria for a 10 percent rating. It should be noted that a 0, 10, or 
20 percent rating all result in the same compensation package for a 
separating Soldier.

    Question 3. Army regulations require that when a patient transfers 
to a military treatment facility or a VA Medical Center, a copy of the 
Inpatient Treatment Record is to accompany the patient. Yet, the Army 
Inspector General recently reported that this is not happening in all 
cases. What steps do you plan to take to address this situation?
    Response. A message has gone out to all military treatment 
facilities (MTFs) to emphasize compliance with the appropriate Army 
regulations. The MTFs will ensure that local procedures for patient 
transfer comply with Army regulations. The Army Surgeon General will 
ensure that quality control measures are established to ensure 
appropriate records accompany all patients being transferred from other 
military treatment facilities or to VA medical centers.

    Question 4. It is my understanding that only outpatient records are 
accessible via the Armed Forces Health Longitudinal Technology 
Application or ``AHLTA,'' what DOD calls its ``comprehensive lifelong, 
computer-based patient record for every Soldier, sailor, airman, and 
marine.'' So, military treatment facilities and VA providers would not 
be able to gain access to a servicemember's inpatient records this way, 
either. What is your plan for making the inpatient treatment record a 
part of the Electronic Health Record?
    Response. Unifying electronic inpatient treatment records within 
the longitudinal medical record (AHLTA) is a stepwise process. Current 
plans call for electronic inpatient records from theater to start 
flowing through the Theater Medical Data Server into AHLTA, where they 
will be visible to AHLTA users in July 2007. They will also be 
accessible to Department of Veterans Affairs (VA) and theater users via 
the Bidirectional Health Information Exchange (BHIE) and BHIE-Theater 
interfaces, with a timeline currently estimated at September 2007. For 
Military Health System facilities which utilize an inpatient electronic 
record (the Clinical Information System or CIS), efforts to transfer 
those records to the AHLTA Clinical Data Repository are also underway. 
A pilot project making some CIS records visible to VA users via BHIE 
was recently completed successfully. As the last and most comprehensive 
step, VA and DOD both seek to acquire an updated inpatient electronic 
record; a feasibility study for this joint acquisition is underway. 
This record would be fully integrated into both AHLTA and VistA, the 
VA's electronic medical record.

    Question 5. If we were to start from scratch and design a new 
system of compensation for those who are severely injured in service, 
what should that system look like?
    Response. The Army is reviewing several courses of action that 
would update and or revamp the current compensation program for our 
Wounded Warriors. However, before recommending a particular course of 
action, it is important for us to consider the findings and 
recommendations of the various healthcare-related commissions. One key 
tenet for our consideration is whether a redesigned compensation system 
should include different compensation options to afford Wounded 
Warriors with choices that might better fit their situation.

    Question 6. What do you think should be the purpose of a modern 
compensation program and how would we regularly determine whether the 
program, as designed, is meeting its intended purpose?
    Response. The Army is reviewing several courses of action that 
would update and or revamp the current compensation program for our 
Wounded Warriors. However, before recommending a particular course of 
action, it is important for us to consider the findings and 
recommendations of the various healthcare-related commissions. One key 
tenet for our consideration is whether a redesigned compensation system 
should include different compensation options to afford Wounded 
Warriors with choices that might better fit their situation.
                                 ______
                                 
    Response to Written Questions Submitted by Hon. John McCain to 
   Hon. Preston M. ``Pete'' Geren III, Acting Secretary of the Army, 
                         Department of Defense

                   MEDICAL HOLD AT WALTER REED ARMY 
                      MEDICAL CENTER--THEN AND NOW

    Question 1. On February 16, 2007, the former Commander of Walter 
Reed Army Medical Center, MG Weightman, reported the medical hold 
census was 654--those housed in or near Walter Reed Army Medical Center 
awaiting medical disability determinations and outpatient care. He 
reported that the average length of stay in medical hold was 297 days 
for Active Duty and 317 days for members of the Reserve. Today, 
according to the Army, the total number is 644. My expectation was that 
the Army would be establishing new boards or augmenting existing boards 
in order to reduce the number of wounded who are retained at Walter 
Reed Army Medical Center. Am I mistaken on this?
    Response. The challenge is as much one of new patients arriving as 
it is a matter of throughput. Each Warrior must first be afforded the 
maximum benefit from medical care before the Medical Evaluation Board 
(MEB)/Physical Evaluation Board (PEB) process can begin. This recovery 
and rehabilitation phase is often the longest part of the process.
    We have seen decreases in the number of individuals in the MEB/PEB 
process. The number of individuals in the MEB/PEB phase was 55 as of 
April 3, 2007. This was down from 95 a month earlier. The total number 
of Warriors in Transition was about 640 during both periods. While the 
aggregate number of Warriors in Transition remained constant, the 
transition of patients was offset by new patients arriving.
    Significant changes are occurring that will affect the aggregate 
number in a positive direction and attend to the needs of the Warrior 
in Transition and his or her Family. The Warrior Transition Brigade is 
operational. At end-state, the brigade will consist of four companies. 
The 18 squad leaders within each company will assist the Warrior in 
medical case review, financial issues and assistance through the 
treatment and medical evaluation system. We have established reception 
procedures for Warriors and Families as well as opening of a Soldier 
Family Assistance Center. We have added 40 trained, clinical case 
managers to achieve a 1:17 case manager to Warrior ratio at Walter Reed 
based on that facility's uniquely complex patient population. We are 
also in the process of establishing a Primary Care Physician program. 
Our Physical Evaluation Board Liaison Officer (PEBLO) staff has 
undergone change as well. We have instituted a new structure with teams 
and designated MEB physicians and increased physical capacity and 
remodeled PEBLO offices. The number of PEBLO counselors has been 
doubled to 20. We have also increased salary levels to attract and 
maintain more qualified counselors. We also sent our counselors to 2 
weeks of specialized training and to the 1 week worldwide PEBLO 
conference.

    Question 2. Have you established metrics for soldiers in medical 
hold status to which you will hold the new leaders accountable? If so, 
what are they, and do they include reducing the number of soldiers who 
remain in a medical hold status as well as reducing the time for 
completed processing?
    Response. The Army has experienced significant success in tracking 
the status of Reserve Component Medical Holdover Soldiers utilizing a 
tracking module developed as part of the Medical Operational Data 
System (MODS). Moving forward, both Medical Holdover Soldiers and 
Active Component Medical Hold Soldiers (collectively referred to as 
Warriors in Transition) will be tracked utilizing this capability. The 
MODS module provides the ability to track and evaluate status and 
length of time as a Warrior in Transition.
    The Army Medical Action Plan currently being developed for 
deployment on June 15, 2007, establishes Warrior Transition Units. 
Established as distinct units with their own command and control 
structure and reporting to the local MTF commander, the appropriate 
Regional Medical Command, and ultimately the U.S. Army Medical Command, 
these Warrior Transition units are organized as companies and 
battalions with dedicated Primary Care Manager, Nurse Case Manager, and 
Squad Leader cells (referred to as the care triad) to provide focused 
management of Warriors in Transition to optimize the provision of care, 
progression through the U.S. Army Physical Disability Evaluation 
System, and seamless transition to civilian status and Department of 
Veteran's Affairs care and services.
    The Army Medical Action Plan establishes access to care standards 
for Warriors in Transition designed to ensure priority scheduling and 
delivery of medical care. The combined capabilities being rolled out as 
part of the Army Medical Action Plan provide effective monitoring of 
Warrior in Transition progress, focused care management, efficient 
medical and physical evaluation and disposition, comprehensive Family 
support, and efficient transition to civilian status and Department of 
Veteran's Affairs services.
    I am confident that implementation over the next weeks and months 
of the numerous improvements contained in the Army Medical Action Plan 
will provide our brave Soldiers with an unsurpassed and effective 
program to efficiently move them from point of injury through recovery, 
return to duty, or transition to civilian life. I look forward to 
reporting to you in the future the many successes this thorough and 
insightful plan both has and will continue to accomplish.

    Question 3. Has the Army convened additional medical evaluation 
boards (MEBs) and PEBs to assist in completing pending evaluations and 
appeals? If so, how many? If not, why not?
    Response. The Army is making significant changes to the MEB and PEB 
system. We are establishing Warrior Transition Units across the Army to 
better care for Warriors and their families. We are creating dedicated 
MEB physicians whose sole job is to manage the medical evaluation 
boards. The Army's Physical Disability Agency has more than doubled the 
number of adjudicators at each of its three PEBs since October 2001 and 
has increased administrative support capacity a commensurate amount. We 
also added a mobile PEB in 2004 to augment capability to conduct formal 
boards at our three fixed sites. In addition, we are taking steps to 
further increase our PEB manning to ensure all Soldiers continue to 
receive prompt disability processing.

           CONDITIONS EXISTING PRIOR TO ENTRY ON ACTIVE DUTY

    Question 4. Under existing law, members with less than 8 years of 
Active Duty service get zero disability compensation if it is 
determined that their disabling condition ``existed prior to entry.'' 
This has resulted in soldiers, marines, and others--volunteers all--who 
have served one, two, or maybe even three tours of duty in Iraq 
receiving nothing when they suddenly are unfit for continued service. 
Do you think this 8-year rule is fair or should it be eliminated?
    Response. We think that this rule prevents us from compensating 
Soldiers who we believe are deserving of disability benefits and who 
have served the Army and their country proudly and well. The law 
currently provides that the disabling condition must be incurred or 
aggravated as a result of military service, and we think that 
requirement is appropriate for Soldiers on their initial term of 
service. However, once a Soldier has served beyond a 2-year minimum we 
would like to see this requirement lifted, and we are in the process of 
proposing legislation that would change the 8-year rule to a 2-year 
rule.
                                 ______
                                 
    Response to Written Questions Submitted by Hon. Barack Obama to 
   Hon. Preston M. ``Pete'' Geren III, Acting Secretary of the Army, 
                         Department of Defense

    Question 1. Has the Army better engaged some of our Veterans 
Service Organizations (VSOs) in its recent efforts to make military 
health facilities like Walter Reed more responsive? Are there plans to 
include these groups more systematically in your new outreach and 
support efforts for families and servicemembers?
    Response. The Army has better engaged VSOs in an effort to provide 
outreach and support to Soldiers and their Family members. The Walter 
Reed Army Medical Center's (WRAMC) Soldier and Family Assistance Center 
(SFAC) assists Soldiers who have been evacuated from a theater of 
operation to WRAMC and their Family members. SFAC provides VSO points 
of contact and services information to Soldiers and Family members. 
Currently two SFACs are in operation: one at WRAMC and one at Brooke 
Army Medical Center, Fort Sam Houston, Texas. The standard operating 
procedure manual for these two SFACs and others soon to be operational 
will address VSOs, the importance of VSO representation within the 
SFACs and the importance of making VSO services available to Soldiers 
and their Family members.
    The Disabled American Veterans (DAV) has an office and a veteran 
service officer located within WRAMC. DAV also has veteran service 
officers available for Soldier representation at the Physical 
Evaluation Board (PEB) sites.
    VSO information is found in several different Army-related and 
veteran Internet sites and in written resources accessible by Soldiers 
and Family members. Multiple sites pop up when ``Veteran Service 
Organizations'' is typed into the Army Knowledge Online search engine. 
The U.S. Army War College Military Family Program has published a 
Directory of Veterans Services and contains a link to a Veterans 
Affairs web site that provides a listing of VSOs. Several different 
free military handbooks include VSO information (i.e., 2007 Veterans 
Health Care Benefits). Our Hero Handbook, A Guide for Families of 
Wounded Soldiers is a comprehensive guide to assist families in 
understanding and navigating the military medical system. The handbook 
also has a section listing VSOs with descriptions of services, 
telephone numbers and web site addresses.

    Question 2. We've heard from you today that many problems are being 
fixed at Walter Reed and important new casework pilot programs are just 
getting off the ground: should we turn around and rush to shut this 
down? Do you think it's wise to waive an environmental impact study of 
this expansion?
    Response. The Department is committed to improving how we care for 
our wounded warriors as outpatients. This commitment and the 
improvements already in place will follow as we move care to Bethesda 
and Fort Belvoir. The Army's Environmental Impact Statement (EIS) at 
Fort Belvoir is well along. There is no reason to waive this important 
analysis at this point. The Navy is overseeing the EIS at Bethesda. I 
know of no Navy effort to waive the EIS at Bethesda.

    Question 3. We saw reports today of a DOD recommendation to speed 
the process of closing Walter Reed under BRAC, despite the fact that 
ground hasn't been broken to expand the Bethesda facility. What is your 
view on this recommendation? Do you think it sends the right signal to 
servicemembers and care providers at Walter Reed?
    Response. The Department supports the Independent Review Group's 
recommendation to accelerate the construction of new facilities at 
Bethesda National Naval Medical Center in Maryland and at Fort Belvoir, 
Virginia, and relocate healthcare from Walter Reed as soon as the new 
facilities are ready. We believe this sends the strongest possible 
message to servicemembers, Families, and care providers--that they 
should have first-rate facilities befitting of their service. Should 
Congress not provide additional funds, the Department recommends using 
the Medical Military Construction process to implement unfunded 
requirements.
                                 ______
                                 
   Response to Written Questions Submitted by Hon. Johnny Isakson to 
   Hon. Preston M. ``Pete'' Geren III, Acting Secretary of the Army, 
                         Department of Defense

    Question 1. How will the Army guarantee completion of the Post-
Deployment Health Reassessment by soldiers as discussed in Mr. William 
Thresher's memorandum of March 7, 2006 for commanders of MEDCOM 
Regional Medical Commands?
    Response. The Army's Post-Deployment Health Reassessment (PDHRA) 
program was implemented as a commander's program and as such, 
commanders are held responsible for ensuring that the Soldiers under 
their command are in compliance. In order to assist commanders in 
identifying Soldiers that require the screening, and for reporting 
compliance, each Soldier's status is tracked and maintained in an 
electronic database. Additionally, various resources have been 
allocated to ensure that Soldiers are screened in accordance with the 
Army's PDHRA policy. For the Active Component, the Army has already 
implemented walk-in screening capabilities at Army Medical Treatment 
Facilities and also schedules Soldier Readiness Processing (SRP) 
screening events for returning units as part of the Deployment Cycle 
Support (DCS) Program. For the Reserve Component, the Army continues to 
utilize deployable onsite contract screening teams and a 24x7 PDHRA 
Call Center. The Army expects 100 percent compliance for this mandatory 
program. The Army tracks PDHRA program compliance down to the 
individual Soldier level to ensure that all Soldiers complete the 
screen and have access to appropriate health care resources as needed. 
Program compliance is reported weekly at the Department of the Army 
level.

    Question 2. Does the Army have adequate funds for execution and 
enforcement of the Post-Deployment Health Reassessment?
    Response. The Army has adequate funds for execution and enforcement 
of the PDHRA.
                                 ______
                                 
  Response to Written Questions Submitted by Hon. Saxby Chambliss to 
   Hon. Preston M. ``Pete'' Geren III, Acting Secretary of the Army, 
                         Department of Defense

                       MEDICAL HOLDOVER PERSONNEL

    Question 1. One key to effectively handling medical holdover 
personnel is by having active and engaged case managers. The Army has 
three medical holdover units in Georgia, at Fort Gordon, Fort Benning, 
and Fort Stewart. The Fort Benning medical holdover unit relies in part 
on contract case managers. I am not fundamentally opposed to 
contractors performing this function, but I do think it can put the 
mission at risk if the contract expires and new case managers cannot be 
recruited and hired in time to replace the old ones. Do you think there 
should be a regulation requiring a certain percentage of case managers 
to be DOD civilians or military personnel?
    Response. No. A regulation requiring a certain percentage of case 
managers to be DOD civilians or military personnel would be too 
prescriptive. Commanders should have the flexibility to use military 
nurse case managers, hire civil service or contract for nurse case 
managers based on geographic location (availability/cost) and a stable 
and/or fluctuating Warrior in Transition population.

    Question 2. In the event that contractors are utilized, what are 
you doing to ensure the medical holdover mission is not compromised and 
that our soldiers receive the necessary advocacy when they are in a 
medical holdover unit?
    Response. Contract nurse case managers are utilized and have been 
since the beginning of the medical holdover program. There are several 
mechanisms in place to ensure the medical holdover mission is not 
compromised and Soldiers receive necessary advocacy. Military 
installations are visited periodically by higher headquarters to review 
the medical holdover program. These visits include records review, 
sensing sessions with Soldiers, cadre and nurse case managers. The 
chain of command--commanders, platoon sergeants and now squad leaders, 
the local Inspector General's office, ombudsman, and hotlines, as well 
as the nurse case manager, are available to serve as advocates for 
Soldiers.

                     SHORTAGE OF MEDICAL PERSONNEL

    Question 3. My staff traveled across the State of Georgia last week 
and visited three DOD hospitals, and one comment that surfaced at every 
installation related to the Army's inability to offer attractive enough 
incentives to hire the doctors and nurses they need to execute their 
mission, as well as an overly burdensome bureaucratic hiring and 
contracting process that prevents military bases from getting the 
military, civilian, and contract health care providers that they need 
when they need them. I think you will agree that this is a problem 
across DOD. In my mind, we ought to be able to do whatever we need to 
streamline this process and give you the authorities you need to get 
the personnel you need in this area because it is one of the most 
critical areas facing our military. What, in your opinion, needs to be 
done here and how can Congress help?
    Response. There are a number of initiatives underway within to Army 
to streamline this process and make a career in military medicine, 
whether as a civilian or in uniform, more attractive. Congress has 
provided the Department with broad authority to offer financial 
incentives for health professionals to join the military and to remain 
in the military beyond their service obligation. Reducing the eight-
year mandatory service obligation for health professions is needed. For 
several years Congress has authorized the Department to allow hospital 
commanders to hire health professionals directly, bypassing many of the 
civilian personnel requirements. Making this Direct Hire Authority 
permanent and expanding it from 12 to 45 healthcare occupations is also 
important.
    The National Security Personnel System provides flexibility to 
increase the salaries of certain health professionals' compensation 
beyond what current statutory authority allows. This tool is extremely 
important to attracting and retaining civilian health professionals. 
Some remedial actions can be done without legislation. The Department 
should consider implementing Title 38 provisions in the Delegated 
Agreement with the Office of Personnel Management, which allows the use 
of Title 38 locality pay, qualifications and classification standards 
for nurses.

                   POST-DEPLOYMENT HEALTH ASSESSMENT

    Question 4. I understand that the Army requires each soldier who 
redeploys from theater to undergo a post-deployment health reassessment 
90 to 180 days after their return. This is obviously a good idea since 
many conditions may not show up until several months after a 
deployment. However, I understand that these health assessments are not 
always done in person but can be done over the phone and by contractors 
versus military personnel. In my mind this is not ideal and allows for 
many conditions to be overlooked and go unreported which might then 
surface months or years later. Specifically, related to some of the 
most common conditions such as PTSD and TBI, I believe that it would be 
particularly hard if not impossible to diagnose these conditions over 
the phone. Regarding the post-deployment health assessment process, do 
you believe it would be wise for DOD and the Army to require these 
assessments to be conducted in person by military personnel?
    Response. Soldiers routinely receive health care from either a 
civilian or military medical provider depending upon the circumstances 
and the availability of providers. Many of our post-deployment health 
reassessment (PPDHRA) events are conducted by trained military 
personnel; however, because of availability, we sometimes rely on 
licensed health care providers that are Army civilians or trained 
personnel under contract for the specific purpose of conducting a PDHRA 
screening to DOD standard. It is mandatory that each PDHRA include an 
interview with a qualified health care provider. This one-on-one 
interview is a key component of the PDHRA screen. The provider reviews 
each Soldier's responses, asks additional questions, and then decides 
whether to make a referral for an evaluation. The PDHRA is a screening 
assessment only and does not provide a diagnosis. The provider, 
however, makes a decision in each case whether to refer a Soldier for a 
follow-on evaluation appointment. In the majority of cases, the 
provider interviews are conducted face-to-face, but there is also a 
Call Center option available for those Soldiers located in remote 
locations who would not be able to attend an onsite PDHRA event. We 
have dispatched face-to-face screening teams to Guam, the Virgin 
Islands, and other remote locations. For those Soldiers that receive a 
referral for a behavioral health reason, any subsequent diagnosis of 
PTSD, or a related condition, would be made during a medical 
appointment by a qualified health care provider and never during the 
PDHRA screen.

    Question 5. How do DOD and the Army ensure that soldiers actually 
complete these health assessments?
    Response. The post-deployment health assessment (PDHA) is conducted 
prior to Soldiers leaving the theater of operations and is a 
requirement for redeployment. For both the PDHA and the PDHRA, the Army 
tracks compliance through the use of an electronic database. This 
database keeps track of all Soldiers and identifies which Soldiers have 
deployed and their individual eligibility and compliance status with 
each program. Commanders at all levels are held accountable for the 
compliance of all Soldiers under their command for both programs.

    Chairman Levin. Thank you, Secretary Geren.
    Dr. Cross, we understand you do not have a statement.
    Dr. Cross. No, Mr. Chairman.
    Chairman Levin. Thank you. General Scott?

   STATEMENT OF LIEUTENANT GENERAL JAMES TERRY SCOTT (RET.), 
            CHAIRMAN, VETERANS' DISABILITY BENEFITS 
                           COMMISSION

    General Scott. Chairman Levin, Chairman Akaka, Members of 
the Committees, it is my pleasure to appear before you on 
behalf of the Veterans' Disability Benefits Commission. Mr. 
Chairman, I request to submit my written statement for the 
record.
    Chairman Levin. It will be made part of the record.
    General Scott. And I also would comment that my name tag 
should read Lieutenant General, Retired. The military should no 
longer be required to bear the burden of my words and actions.
    [Laughter.]
    Chairman Levin. We will also note that for the record and 
we will correct that as quickly as humanly possible, which 
means the next hearing.
    [Laughter.]
    General Scott. Sir, the Commission was established by the 
National Defense Authorization Act of 2004. That law charged 
the Commission with studying the benefits available for 
disabilities and deaths related to military service, more 
specifically the appropriateness of the level of the benefits, 
and how a decision is made whether to compensate a veteran.
    We are in the process of doing an in-depth study of 
disability benefits and my written statement contains the 
information on the range of issues being addressed. The 
Commission has not completed its work and is not scheduled to 
present its report until October 1, 2007. We have not reached 
conclusions at this time. I must emphasize that my comments 
today are my own and not necessarily those of the Commission. 
However, I believe my fellow Commissioners are in agreement 
that significant improvement is needed in the processes and 
procedures that affect the transition from military to veteran 
status, particularly when it involves the transition of sick 
and injured servicemembers.
    I am aware of your interest in the comparison the 
Commission is conducting between disability ratings made by DOD 
and those made by the VA. We asked our contractor, the Center 
for Naval Analysis, to conduct a study to determine, based on 
accurate data provided by the DOD, whether there are, in fact, 
significant differences in the ratings assigned by DOD and VA 
to the same individuals.
    Some 83,000 records were provided by DOD of servicemembers 
who were found unfit for military duty during the period 2000 
through 2006. Eighty-one percent of these people were rated 
less than 30 percent disabled and discharged, most with only 
severance pay. Perhaps the greatest importance to the 
servicemember is that he or she is not then eligible for family 
health care coverage. VA will provide health care for the 
service-disabled veteran, but not for the family unless the 
veteran is rated 100 percent disabled.
    Over 13,000 Army soldiers were found unfit for military 
duty yet rated zero percent. Navy, Marine, and Air Force 
assigned zero percent yet unfit ratings to about 400 
individuals each. We discussed this with Army and the 
explanation is that these soldiers were found unfit by with 
symptoms whose severity did not qualify for a compensable 
rating of at least 10 percent. For these Army soldiers rated at 
zero percent by DOD, the average VA rating was 56 percent.
    The DOD records were matched with VA records on 2.6 million 
veterans receiving disability compensation. The combined VA 
rating for these individuals was generally higher than the DOD 
rating. To cite an example, those rated 0, 10, or 20 percent by 
DOD were rated in the 30 to 100 percent range by VA more than 
half of the time.
    We believe the difference in the overall combined ratings 
is mostly caused by DOD rating fewer disabilities. The number 
of conditions rated by DOD is much lower than VA. DOD rated 
only one condition 83 percent of the time. VA rated 2.6 to 3.3 
more disabilities per person than DOD. It is our understanding 
that DOD policy, not statutory requirements, instructs the 
services to rate only the disabilities found to be unfitting.
    I believe that the inconsistency between the DOD ratings 
and the VA ratings can be largely explained by two factors. DOD 
rates only the condition or conditions that DOD finds 
unfitting, and DOD does not use the VA's schedule for rating 
disabilities in the same way that VA does. Variance among the 
service's missions also contributes. It is also apparent that 
DOD has a strong incentive to rate less than 30 percent so that 
only severance pay is awarded.
    I believe that the issue of consistency of ratings should 
be considered in the context of a broader goal of improving the 
transition from active duty military member to veteran status. 
The goal should be to transition the person in a way that 
respects his or her service to our country while providing 
appropriate continuity of health care, financial stability, and 
dependent and family care. I recommend four short-term actions 
and a long-term realignment of function.
    First, the current DOD process should be restructured to 
streamline the Medical Evaluation Board and Physical Evaluation 
Board responsibilities and procedures.
    Second, DOD should immediately begin to medically evaluate 
and rate all disabilities that are identified as part of a 
comprehensive medical examination.
    Third, VA and DOD should immediately conduct a joint 
analysis of the DOD and service instructions on rating and 
compare those instructions with the VA's schedule for rating 
disabilities and the VA's policies. This analysis should 
consider the soon-to-be-released study by the Institute of 
Medicine on the VA rating schedule that is being conducted for 
the Commission.
    Fourth, remove the statutory requirement that prevents 
veterans from being paid any compensation for the partial month 
in which discharge occurs and delays the second month's payment 
until the first day of the following month. The current 
requirement results in the veteran having no source of income 
for up to 2 months.
    Turning to the long term, I recommend a major realignment 
of the decisionmaking processes used to decide whether a 
servicemember is unfit for duty and eligible for either 
military disability retirement or separation with severance pay 
and VA disability compensation. The primary features of such a 
realignment should be: The service determines fitness for duty. 
This is the most important issue for the service and it is 
rightly their responsibility. If found unfit, all 
servicemembers should be referred to the VA for rating prior to 
discharge. VA would assign the rating for all service-connected 
disabilities that are found in a comprehensive medical 
examination.
    I am aware, as are the Members of these Committees, of the 
often confusing situation and status regarding compatible VA 
and DOD computer systems. From information made available by 
the two departments, it is very difficult to understand the 
current level of compatibility and the direction for the 
future. Goals, objectives, and milestones are vague and not 
well defined.
    The Commission has found that the two departments do not 
currently use compatible systems, regardless of assertions to 
the contrary. For example, the DOD system does not have the 
capability, as VA's does, to digitally store inpatient 
discharge summaries and images from CAT scans, MRIs, and X-
rays. I believe that compatible IT systems may well be one of 
the most important steps that can be taken to improve 
transition, and parenthetically, it should also help improve 
the timeliness of VA claims processing.
    Finally, transition must address the needs of the families 
of the disabled, especially the severely disabled. DOD has 
considerable latitude to assist with transportation expenses 
and lodging. VA is very limited by its statutory authority. 
Generally, VA can provide only milage compensation for the 
veteran to travel for medical treatment.
    Concerning long-term assistance for the severely disabled, 
VA is also limited to aide and attendants and house-bound 
stipends that may not be adequate to maintain a level of 
independent living. Additional benefits should be considered to 
support the families who are bearing the heavy burden of caring 
for severely injured veterans. We cannot depend on every 
severely injured veteran having a stable, supportive family, 
particularly as parents age and pass away.
    In conclusion, improving the transition of wounded 
servicemembers in a manner that assures continuity of health 
care, financial stability, and family care is of the utmost 
importance. I hope the data that the Commission has provided 
you today on the comparison of VA and DOD ratings and my 
suggestions for addressing the existing shortcomings in the 
transition of wounded and injured servicemembers are useful in 
your deliberations. As you know, the Commission is analyzing a 
wide range of issues and we look forward to submitting our 
report in the fall that will provide recommendations to you and 
the two departments. In the meantime, the Commission is 
available to assist you in your deliberations.
    Thank you for the opportunity to speak with you today.
    [The prepared statement of General Scott follows:]

  Prepared Statement of Lieutenant General James Terry Scott (Ret.), 
           Chairman, Veterans' Disability Benefits Commission

    Chairman Levin, Chairman Akaka, Ranking Member McCain, Ranking 
Member Craig, and Members of the Committees:
    It is my distinct pleasure to appear before you on behalf of the 
Veterans' Disability Benefits Commission (the Commission). As you may 
recall, the Commission was established by the National Defense 
Authorization Act of 2004. The law charged the Commission with studying 
benefits available for disabilities and deaths related to military 
service, specifically:

     The appropriateness of the benefits,
     The appropriateness of the level of benefits, and
     The appropriate standards for determining whether the 
disability or death of a veteran should be compensated.

    We are committed to meeting that charge for the betterment of all 
of our Nation's veterans. Many of us, who are combat veterans 
ourselves, have watched a new generation return from the battlefield to 
face the challenges of severe wounds/illnesses, unemployment, family 
adjustments, and mental health issues. We are ever-mindful of these 
challenges as we carry out our study of the benefits under the laws of 
the United States that compensate and assist veterans and their 
survivors for disabilities and deaths attributable to military service.
    We have identified thirty-one research questions for further 
analysis, which are enclosed for the record. Commission staff, aided by 
the Institute of Medicine (IOM) and the Center for Naval Analyses 
(CNA), is in the process of methodically addressing these questions. 
Additionally, we have conducted a series of eight site visits 
throughout the country, held monthly open public meetings, and have 
heard from the Department of Veterans Affairs, the Department of 
Defense and the Services, the Department of Labor, the Social Security 
Administration, Veterans Service Organizations, The Military Coalition, 
Professional Associations, Congressional staffers, and individual 
veterans and family members.
    The Commission has not completed its work, is not scheduled to 
present its report until October 1, 2007, and has not reached 
conclusions at this time.
    I must emphasize that my comments today are my own and do not 
represent the views of the other members of the Commission. However, I 
believe my fellow Commissioners are in agreement that a great deal of 
improvement is needed in the overall processes and procedures that 
affect the transition from military to veteran status, and most 
emphatically when it involves the transition of our sick and injured 
servicemembers.
    The recent media attention on Walter Reed Army Medical Center and 
more generally on the treatment and disability evaluation of soldiers, 
sailors, marines, and airmen have led to several Congressional 
hearings, both in the House and Senate. I believe that this intense 
scrutiny is appropriate and necessary.
    Your Committees are specifically interested in the comparative 
analysis that the Commission is undertaking to assess the level of 
consistency between disability ratings assigned by DOD and VA. This 
analysis is continuing but preliminary results are available and should 
contribute to the dialogue on the issue.
    The Commission became concerned with the consistency of DOD and VA 
disability ratings because of anecdotal allegations presented by 
individuals to the Commission, a 2002 RAND study, and the 2006 GAO 
report assessing the DOD Disability Evaluation System.
    You may not be aware that the 1956 Bradley Commission also analyzed 
this issue and interestingly found that at that time the military was 
more generous in its ratings than VA.
    In order to assess consistency of ratings between DOD and VA, the 
Commission asked its contractor, the Center for Naval Analyses (CNA) to 
compare DOD rating decisions with VA ratings. The Commission requested 
data in the Fall of 2006 from the Army, Navy, and Air Force on all 
disability separations and disability retirements from 2000 to 2006. 
The Navy Physical Evaluation Board handles both Navy and Marine Corps 
disability decisions, but we separated the data for the two Services. 
As a result, 65,087 records were provided initially. The data was 
compared with data from VA and preliminary results were presented by 
CNA to the Commission at its March 22-23, 2007, public meeting. These 
results were posted to the Commission's Web site and shared with Senate 
staff.
    Subsequently, on April 2, 2007, in a meeting with DOD, Commission 
staff was informed that the data provided by Army and Navy was not 
accurate in that it omitted records for individuals initially placed on 
TDRL for a period of stabilization and later permanently rated. Revised 
data was provided by Army and Navy to CNA on April 4, 2007. The revised 
data included a total of 83,004 records and significantly affected the 
analysis. The revised data was quickly analyzed and preliminary results 
are provided in this statement. I emphasize that these are preliminary 
results with more complete analysis to follow.
    The disability ratings shown in Table 1 are the combined or overall 
ratings assigned by DOD. Those found unfit for military duty who have 
less than 20 years of service and are rated less than 30 percent 
disabled receive a severance payment but no continuing retirement 
payment, are not eligible for health care coverage for themselves or 
their families, and no other benefits from DOD. As can be seen, overall 
19 percent of those rated by DOD are in the 30-100 percent range. The 
percentage rated 30 percent or higher ranges from 13 percent for the 
Army to 36 percent for the Navy. The individuals rated 30 percent or 
higher will receive continuing military disability retirement, health 
care coverage for themselves and their families, and many other 
military retirement benefits.

                            Table 1. Veterans With DOD Disability Ratings (2000-2006)
----------------------------------------------------------------------------------------------------------------
             Combined disability rating                  Army        Navy       Marines    Air Force     Total
----------------------------------------------------------------------------------------------------------------
0-20%...............................................      44,307       8,603       7,769       6,862      67,541
                                                           (87%)       (64%)       (82%)       (73%)       (81%)
30-100%.............................................       6,369       4,849       1,748       2,497      15,463
                                                           (13%)       (36%)       (18%)       (27%)       (19%)
                                                     -----------------------------------------------------------
    Total...........................................      50,676      13,452       9,517       9,359      83,004
----------------------------------------------------------------------------------------------------------------


    The Army data contained 13,646 records (27 percent) out of the 
total of 50,676 soldiers who were found unfit for duty yet assigned 
zero percent ratings. Navy, Marine Corps, and Air Force assigned zero 
percent ratings to about 400 individuals or less each. We discussed 
this with the Army and their explanation is that these soldiers were 
found unfit but with symptoms whose severity did not qualify for a 
compensable rating of at least 10 percent. We note, however, that 
whether the DOD rating is zero, ten, or twenty percent, the severance 
payment from DOD is the same. Of the Army zero percent ratings that 
matched with VA records, the average VA disability rating was 56 
percent for those with 20 or more years of service and the average was 
28 percent for those with less than 20 years of service and receiving 
severance. I suggest that an in-depth analysis of these zero percent 
ratings be conducted to ascertain the reasons for these ratings.
    It is important to note that DOD only rates the condition or 
conditions that DOD finds makes the individual unfit for duty. To our 
knowledge, this policy is set forth in DOD directives and is not set by 
statute. VA rates all claimed conditions and determines whether or not 
each condition is service connected. For veterans rated by both 
agencies, DOD rated only one condition 83 percent of the time. For 
cases in which DOD rated one condition, VA rated an average of 3.7 
conditions.
    CNA compared the DOD records to data requested by the Commission 
from VA on all 2.6 million service-disabled veterans as of December 1, 
2005. Records on service personnel separated or retired after 2004 
would generally not be found in the VA data because their claims would 
not have been processed. Focusing on the individuals receiving DOD 
disability ratings from 2000 to 2004, 78 percent had also received 
ratings from VA by December 2005. We have requested current data from 
VA which will be used to update the comparison in the coming months.
    Looking at the differences among the Services, Figure 1 shows that 
the ratings by the Navy, and to a lesser extent the Air Force are 
significantly different than those of the Marines and Army in the 
proportion of ratings in the 30-100 percent range.
    Figure 1. Distribution of Veterans by DOD disability rating

    [GRAPHIC] [TIFF OMITTED] T5997.001
    
    Comparing the combined ratings by DOD to the combined ratings by 
VA, Figure 2 shows that VA ratings (represented by the bars) are higher 
on average than DOD ratings (shown on the horizontal scale and the 
diagonal line) at almost all levels. The green bars to the left 
represent those with less than 30 percent ratings and less than 20 
years of service; these were provided severance pay only. For example, 
the green bar at the far left shows that for those assigned a zero 
percent rating by DOD, VA rated them an average of 29 percent. 
Likewise, the red bar 4th from the left shows that for those rated 30 
percent by DOD, VA rated them an average of 56 percent. The difference 
is more pronounced for those rated less than 30 percent but eligible 
for retirement with 20 or more years of service as represented by the 
first three red bars to the left.
    Figure 2. Comparison of Average VA Rating with DOD Ratings (N = 
52,573)
[GRAPHIC] [TIFF OMITTED] T5997.002

    Of all of those rated by DOD as zero, ten, or twenty percent, VA 
rated them at 30 percent or higher 59 percent of the time.
    The number of conditions rated is very different between VA and 
DOD, as can be seen in Table 2, and we believe that this difference 
accounts for the largest portion of the difference in the overall 
ratings by DOD and VA. In general, VA rated 2.4 to 3.3 more 
disabilities than DOD.

                  Table 2. Average Number of VA Disabilities vs. the Number of DOD Disabilities
----------------------------------------------------------------------------------------------------------------
                                                                               Average Number
                 Service                    Number of DOD      Number  of           of VA          Difference
                                            Disabilities        Veterans        Disabilities
----------------------------------------------------------------------------------------------------------------
Total                                                    1            42,922               3.7               2.7
                                                         2             7,557               5.2               3.2
                                                         3             1,660               6.1               3.1
                                                        4+               434               6.8               2.8
                                         -----------------------------------------------------------------------

Army                                                     1            25,696               3.6               2.6
                                                         2             4,583               5.2               3.2
                                                         3               902               6.3               3.3
                                                         4               239               7.0               3.0
                                         -----------------------------------------------------------------------

Navy                                                     1             8,013               3.8               2.8
                                                         2             1,250               5.3               3.3
                                                         3               336               6.1               3.1
                                                        4+               139               6.4               2.4
                                         -----------------------------------------------------------------------

USMC                                                     1             5,375               3.6               2.6
                                                         2               614               5.3               3.3
                                                         3               124               6.0               3.0
                                                        4+                56               6.9               2.9
                                         -----------------------------------------------------------------------

USAF                                                     1             3,840               4.2               3.2
                                                         2             1,110               4.8               2.8
                                                         3               298               5.7               2.7
----------------------------------------------------------------------------------------------------------------
Note: the Army data caps the number of disabilities at 4 and the Air Force cap is 3. The Air Force data only
  contains a single, combined percentage rating so records with more than one disability could not be considered
  in the analysis of individual disabilities.

    Because of the difference in the number of conditions rated, it is 
important to analyze the ratings assigned by DOD and VA to the same 
diagnosis experienced by the same individual.
    CNA found 26,447 matches of individual diagnoses and analyzed the 
seven most frequent diagnoses:

     Lumbosacral or Cervical Strain
     Arthritis
     Intervertebral Disc Syndrome
     Asthma
     Diabetes
     Knee Impairment
     PTSD

    Six other diagnoses among the 20 most frequent diagnoses were also 
selected:

     Traumatic Brain Injury
     Migraine
     Seizure Disorder
     Bipolar
     Major Depressive Disorder
     Sleep Apnea
    Together, these thirteen diagnoses comprise 16,169, or 61 percent, 
of the individual diagnoses matched.

    CNA found that overall 73 percent of those diagnoses rated 0-20 
percent by DOD were also rated 0-20 percent by VA showing general 
agreement between VA and DOD from the individual diagnosis perspective. 
In some cases the VA rating was lower, but more often VA was higher. 
However, for individual veterans with a combined rating of 0-20 percent 
from DOD, only 41percent were also rated 0-20 percent by VA. This shows 
the propensity for VA to give higher ratings overall due to rating more 
conditions.
    However, for eight of the thirteen diagnoses, where DOD rated cases 
at 0-20 percent, VA rated cases from 30-100 percent. These include:


------------------------------------------------------------------------

------------------------------------------------------------------------
1. Sleep Apnea...............  100 percent of the time VA rated 30-100
                                percent
2. Seizure disorder..........  39 percent of the time VA rated 30-100
                                percent
3. PTSD......................  87 percent of the time VA rated 30-100
                                percent
                               55 percent of the time VA rated 50-100
                                percent
4. Asthma....................  58 percent of the time VA rated 30-100
                                percent
5. Traumatic Brain Injury....  40 percent of the time VA rated 30-100
                                percent
6. Bipolar...................  71 percent of the time VA rated 30-100
                                percent
7. Major depressive disorder.  73 percent of the time VA rated 30-100
                                percent
8. Migraine..................  73 percent of the time VA rated 30-50
                                percent
------------------------------------------------------------------------


    CNA found that DOD rated 107 of 123 cases of sleep apnea as zero 
percent disabling, yet unfit. VA rated all 107 cases in the 30-100 
percent range with 98 rated at 50 percent and one at 100 percent. 105 
of the 123 cases were Army. The DOD directive provides instructions for 
using the VA Rating Schedule that, in effect, changes the criteria for 
many conditions. DOD instructions regarding sleep apnea profoundly 
change the criteria. For some conditions such as knee impairment, the 
DOD criteria is more specific and more measurable than the VA criteria, 
while for other conditions such as sleep apnea, the DOD criteria is 
less specific and less measurable.
    Of the thirteen individual diagnoses analyzed, the VA ratings were 
statistically significantly higher than all of the Services for 8 
diagnoses: lumbosacral, intervertebral disc syndrome, asthma, sleep 
apnea, diabetes, migraine, seizure disorder, PTSD, bipolar, and major 
depressive disorder. The difference was significant for 12 of 13 
diagnoses for Army; the only exception being the knee. The Air Force 
was significantly different for 11 of the 13 diagnoses, the Navy was 
significant for 10 of 13 diagnoses, and Marines were significantly 
different for 8 of the 13 diagnoses.

        Table 3. Statistical Significance of Individual Diagnoses
------------------------------------------------------------------------
                                   Difference between VA and DOD  is
                                      statistically significant*
          Diagnosis          -------------------------------------------
                                 Army       USAF       USMC       Navy
------------------------------------------------------------------------
Arthritis...................         x
Lumbosacral or Cervical              x          x          x          x
 Strain.....................
Intervertebral Disc Syndrome         x          x          x          x
Knee Condition..............
Asthma......................         x          x          x          x
Sleep Apnea.................         x          x                     x
Diabetes....................         x          x                     x
Traumatic Brain Injury (TBI)         x          x
Migraine Headaches..........         x          x          x          x
Seizure Disorder............         x          x          x          x
PTSD........................         x          x          x          x
Bipolar Disorder............         x          x          x          x
Major Depressive Disorder...         x          x          x          x
------------------------------------------------------------------------
*``x'' marks indicate that the mean VA rating is statistically higher
  than DOD's rating at the 5-percent level.

    Graphic presentations of these thirteen individual diagnoses are 
enclosed for the record.
    Inconsistency in ratings between VA and DOD can largely be 
explained by two factors. One, DOD only rates the disability or 
disabilities that DOD determines makes the servicemember unfit. Second, 
DOD does not use the VA Rating Schedule in the same way that VA does. 
Variance in ratings among the Services and between VA and the Services 
can also be partially explained by the differences in mission between 
the Services and the disability determination standards they set. It is 
also apparent that DOD has strong incentive to assign ratings less than 
30 percent so that only separation pay is required and continuing 
family health care is not provided.
    DOD issues DODI 1332.38, which describes the Physical Disability 
Evaluation, and DODI 1332.39, Application of the Veterans 
Administration Schedule for Rating Disabilities. Army, Navy, and Air 
Force each provide their own directives to the field on how to 
implement title 10 U.S.C. and the DOD Instructions based upon the 
unique needs and missions of their Services. Army issues AR 600-60, 
Physical Performance Evaluation System and AR 635-40, Physical 
Evaluation for Retention, Retirement or Separation. Navy issues SECNAV 
1850.4E, Department of the Navy Disability Evaluation Manual. Air Force 
issues the Physical Evaluation for Retention, Retirement or Separation 
or AFI 36-3212.
    The 2006 GAO study found that DOD delegates to the Services and 
does not maintain accountability or monitor compliance over the 
Disability Evaluation System. The Services are allowed to establish 
different time frames for line of duty determinations, Medical 
Evaluation Board (MEB) referrals, MEB compositions, MEB appeals, 
Physical Exam Board (PEB) responsibilities and compositions, and 
training. RAND (2002) ``identified 43 issues regarding variability in 
policy application across or within the military departments' . . . 
that affect the performance of the DES.''
    GAO also found that there is no common DOD database that tracks 
disabled servicemembers and each Service's database is different. This 
lack of a common database complicated the CNA comparison of DOD and VA 
ratings considerably. GAO also found that there is no consistency in 
MEB/PEB training, or in the use of counselors.
    While DOD asserts that it follows the VA Schedule for Rating 
Disabilities, the instructions issued by DOD and the Services, in 
effect, change the criteria contained the Rating Schedule and how the 
Rating Schedule is applied.
    After discharge, the former servicemember must file a claim for 
disability with VA. A servicemember can either go through a Benefits 
Delivery at Discharge (BDD) process in which they file their claims 
while still on active duty, or they must file a claim at one of VA's 57 
regional offices after discharge. Either way, the VA process largely 
duplicates the process the veteran faced before discharge. As mentioned 
before, almost 80 percent of those discharged by DOD as unfit for duty 
subsequently file disability claims with VA. To the veteran, this means 
another round of applications, examinations, determinations, and time. 
Currently, the VA is experiencing a backlog of approximately 400,000 
cases and takes an average of 177 days to rate a claim. When a panel of 
disabled servicemembers appeared before the Commission, they told us 
that even 1 to 2 months without financial support creates a hardship 
upon them and their families. Waiting up to 6 months certainly would 
put these disabled servicemembers at a socio-economic disadvantage that 
could lead to other complications.
    The Commission is also aware that there are variances in how those 
57 VA regional offices rate claims. This was reported by the VA Office 
of the Inspector General in May 2005. VA has since contracted with the 
Institute for Defense Analysis to conduct an analysis of the reasons 
for variations in ratings among VA Regional Offices. We understand that 
this study will be completed shortly and the Commission has requested a 
briefing on the results. In addition, the Commission contracted with 
the Institute of Medicine (IOM) to evaluate the VA Schedule for Rating 
Disabilities (VASRD) and make suggestions for improvement. The IOM 
report should give us a better understanding of the best way to 
evaluate veterans' disabilities and compensate for them.
    Training and certification for medical examiners and raters were 
also essential issues brought to the attention of the Commission. It is 
evident that VA is making a concerted effort to improve the examination 
process by improving training, developing templates for use by the 
examining physicians and routinely assessing the quality of exams. Yet, 
to date the templates are not mandatory and certification is not 
required.
    Thus, both VA and DOD face challenges to improve rating veterans 
and servicemembers for disability. The CNA comparison of ratings is 
continuing but even at this preliminary stage, it is apparent that 
servicemembers are not well served by the current process to evaluate 
disabilities and award benefits. I believe that both short-term and 
long-term changes are needed to ensure equity.
    For the short term, I would immediately require DOD to evaluate and 
rate all disabilities that are identified as part of a comprehensive 
medical examination. It is unfair to discharge servicemembers with 
ratings that reflect only one disability when often other disabilities 
are present and identified. This is particularly true since Army rates 
so many soldiers as unfit but at zero percent rating. In addition, I 
recommend that a thorough joint VA/DOD analysis of the DOD and Service 
instructions in comparison with the VA Rating Schedule be undertaken. 
This analysis should carefully consider the soon to be released 
analysis of the VA Rating Schedule by the Institute of Medicine.
    Another short-term action could greatly improve a servicemember's 
financial stability during transition. An obstacle to an effective f, 
inancial transition is the current statutory requirement that 
disability compensation payments cannot be paid from the effective date 
of entitlement but are required to be delayed until the first day of 
the second month after they are entitled. This is true even for those 
filing a claim within 1 year of discharge whose entitlement date is the 
day after the date of discharge. This requirement was enacted as a 
budget saving provision in the Omnibus Budget Reconciliation Act of 
1982 \1\. While this restriction might seem reasonable from a cost 
savings standpoint, it means that servicemembers do not receive any 
disability benefits for up to 2 months after discharge. For example, a 
veteran discharged on August 2, 2006, could not be paid disability 
benefits for the partial month of August and could not be paid 
September benefits until October 1. Before this statutory change, the 
veteran would have received payment from the effective date which was 
August 3. Veterans still have to provide for themselves and their 
families, especially those who are unable to work. I would recommend 
that Congress consider changing this requirement.
---------------------------------------------------------------------------
    \1\ Public Law 97-253, Sec. 401, 96 Stat. 763, 801, now U.S.C. 
Sec. 5111.
---------------------------------------------------------------------------
    For the long term, beyond disability ratings, there are other 
issues that should be addressed in the context of the broader goal of 
improving the transition from active duty military member to veteran 
status. In general, the goal should be to transition the person in a 
way that respects his or her service to our country and provides 
appropriate continuity of health care, financial payments, and care for 
dependents and family members.
    I would recommend that serious consideration be given to a major 
realignment of the decisionmaking process used to decide if 
servicemembers are unfit for duty and eligible for military disability 
retirement or separation with severance pay and for VA disability 
compensation.
    The major features of such a realignment should be:

    1. The Services determine fitness for duty.
    2. If a servicemember is found unfit, the servicemember's case 
should be referred to VA before discharge.
    3. VA would rate and assign the percentage of disability of all 
service-connected disabilities found on exam.
    4. VA/DOD would share the cost of the exam process.
    5. VA/DOD must utilize a common, electronic patient and personnel 
record system while maintaining quality control over existing paper 
records.

    I believe that fitness for duty is the primary and most important 
issue for the Services. They each have their own unique needs for 
manpower to meet their missions. A servicemember's ability to perform 
their Military Occupational Specialty (MOS) based on their office, 
grade, rank or rating should be evaluated against the good of the 
service. That should continue. Currently, the Medical Evaluation Board 
(MEB) determines fitness for duty. The Services can find someone fit 
and return them to full duty, or issue a ``profile'' that limits duty. 
If a servicemember is found unfit under the current process, a Physical 
Evaluation Board (PEB) assigns a disability rating.
    I suggest that the responsibility for assigning a disability rating 
be turned over to VA and that the DOD MEB/PEB structure be streamlined. 
This would provide the servicemember with a single, objective rating 
that would apply to both military disability retirement or severance 
pay and to VA disability compensation. In essence, this would expand 
the Benefits Delivery at Discharge process that VA has implemented and 
relieve DOD of the burden of making the rating decision. The disability 
rating should be completed prior to discharge in order to provide 
continuity of financial and healthcare support.
    Key to this realignment would be the development and implementation 
of a single, comprehensive medical examination protocol that would be 
used by both DOD and VA. This protocol would require examining all 
conditions that were found on exam, and not be restricted to the 
``unfitting'' conditions. Servicemembers would not be subjected to 
multiple examinations. At some locations, it may be appropriate for the 
examinations to be conducted by VA medical staff and at other locations 
DOD staff could conduct them. Training and certification of all 
examiners will be essential for consistent, high quality examinations.
    I realize that funding of both program administration and 
disability benefits are of concern for both DOD and VA. Budgetary 
considerations are very important. But neither the taxpayer nor the 
servicemember being discharged for disability cares whether the costs 
are covered by the DOD budget or the VA budget or some combination of 
the two. They care that the person disabled in the service of our 
country is provided with prompt and appropriate compensation, health 
care, and other 
benefits.
    In order for transition from military to veteran status to be 
seamless, effective, and efficient, VA and DOD absolutely must develop 
and use a common electronic system for both medical records and 
military personnel records. Extensive discussion of common IT systems 
has occurred over the years but this remains an illusive goal, not a 
reality. You are well aware of the problems. Our Commission has found 
it very difficult to fully understand the current status of 
compatibility between VA and DOD systems. It has also been difficult to 
assess the future plans of the two departments. Goals, objectives, and 
milestones are often vague and not well defined. I understand that the 
Congress has struggled with conflicting information about many of these 
same issues. Despite claims to the contrary, VA and DOD do not 
currently use compatible systems. Too much attention may be focused on 
developing the perfect system so that interim, short-term solutions are 
ignored. The DOD ALTHA system may provide a more modern platform than 
VA's VISTA, but in the meantime significant capability residing in the 
older VA system is not available to DOD users. For example, inpatient 
discharge summaries and digital images from CAT scans, MRIs, and X-rays 
have been included in VA's VISTA for many years but are not yet 
available in DOD's ALTHA. This means that those records and images 
cannot be transferred to VA upon discharge. Quick fixes are needed now 
to solve this problem.
    If DOD and VA were required to use compatible IT systems that 
allowed for the immediate electronic transfer of all medical records 
and military personnel records, then processing new disability claims 
would be expedited. This may well be one of the most important steps 
that can be taken to speed up claims processing for those leaving the 
military.
    An effective transition demands caring for the families of the 
disabled, especially in the event of severe or catastrophic disability. 
Currently, DOD has considerable latitude to provide the families of the 
severely injured with transportation, expenses, and lodging. VA is 
currently severely limited in what it is statutorily authorized to 
provide for families. This should be corrected as soon as possible. I 
was heartened to learn of legislation recently passed by the House of 
Representatives that would increase the mileage rate paid to veterans 
for Beneficiary Travel but this does not solve the problem for those 
severely wounded and disabled or their 
families.
    DOD has an array of programs that assist with reunion and 
reintegration and can authorize Individual Travel Orders and per-diem 
to non-medical attendants. However, there is no statutory authority for 
VA to provide any level of support to these same families when the 
servicemember leaves the military and transfers to a VA Medical Center. 
VA is able to provide very limited long-term financial support in the 
form of Aid and Attendance or Housebound stipends for veterans rated 
100 percent only. The amount may not be sufficient for the severely 
disabled to maintain independent living. And even these VA benefits are 
reduced during prolonged periods of hospitalization.
    In conclusion, I hope that the issues and recommended solutions 
outlined here today will be beneficial to your Committees. The 
Commission is analyzing these issues and its other research questions 
in depth. When the analysis is completed in October we will provide you 
with a comprehensive report that includes recommendations that you, and 
the two departments can act upon. I look forward to sharing the full 
report with your distinguished Committees in the Fall. In the meantime, 
the Commission is available to assist you in any of your deliberations.

                              Enclosure 1

               VETERANS' DISABILITY BENEFITS COMMISSION, 
            LIST OF RESEARCH QUESTIONS, VERSION 2 (10-4-05)

    1. How well do benefits provided to disabled veterans meet 
Congressional intent of replacing average impairment in earnings 
capacity?
    2. How well do benefits provided to disabled veterans meet implied 
Congressional intent to compensate for impairment in quality of life 
due to service-connected disabilities?
    3. How well do benefits provided to survivors meet implied 
Congressional intent to compensate for the loss of the veterans/
servicemembers' earning capacity and for the impairment in quality of 
life due to service-connected death?
    4. How well do benefits provided to disabled veterans and survivors 
meet implied Congressional intent to provide incentive value for 
recruitment and retention?
    5. Should the benefit package be modified?

    a. Would the results be more appropriate if reduced quality of life 
and lost earnings were separately rated and compensated?
    b. Would the results be more appropriate if the level of payment 
was higher before some normal ``retirement age'' and lower thereafter?
    c. Are there negative unintended consequences resulting from the 
current benefit structure? Does the receipt of certain levels of 
compensation provide a disincentive to work or undergo therapy?
    d. To what extent should VA modify its compensation policies if 
data from certain categories of service-connected veterans demonstrate 
little or no measurable loss of earning capacity and/or quality of 
life?

    6. How well do the medical criteria in the VA Rating Schedule and 
VA rating regulations enable assessment and adjudication of the proper 
levels of disability to compensate for both the impact on quality of 
life and impairment in earnings capacity?
    7. How does the adequacy of disability benefits provided for 
members of the Armed Forces compare with disability benefits provided 
to employees of Federal, State, and local governments, and commercial 
and private-sector benefit plans?
    8. How do the operations of disability benefits programs compare?

    a. The role of clinicians in the claims and appeals processes, and 
the required number of staff for this function.
    b. The role of attorneys and legal staff in the claims and appeals 
processes, and the required number of staff for this function.
    c. Compensation Claims Process
    d. Appeals Process
    e. Training and certification of staff and client representatives
    f. Quality Assurance/Control Program

    9. Pertinent law and regulations require that disability 
compensation be based on average impairment of earnings capacity, not 
on loss of individual earnings capacity.

    a. Would the results be more appropriate if factors such as the 
individual's military rank, military specialty, pre-service occupation, 
education, and skill level were taken into consideration in determining 
benefits?
    b. Would the results be more appropriate if the effect of the 
veteran's medical condition on his or her occupation were taken into 
consideration in determining benefits?

    10. Should lump sum payments be made for certain disabilities or 
level of severity of disabilities? Should such lump sum payments be 
elective or mandatory? Consider the merits under different 
circumstances such as where the impairment is to quality of life and 
not to earnings capacity.
    11. Should universal medical diagnostic codes be adopted by VA for 
disability and medical conditions rather than using a unique system? 
Should the VA Schedule for Rating Disabilities be replaced with the 
American Medical Association Guides to the Evaluation of Permanent 
Impairment?
    12. Are benefits available to service disabled veterans at an 
appropriate level if not indexed to cost of living and/or locality? 
Should the various benefits that are presently fixed be automatically 
adjusted for inflation?
    13. Should VA's definition for ``line of duty'' change? If so, how?
    14. To what extent, if any, should VA policies relating to 
presumptive conditions be changed?
    15. Should certain rating principles related to service connection 
be modified? (See questions below:)

    a. To what extent, if any, should ``age'' factor into determining 
entitlement to service connected compensation?
    b. To what extent should the benefit of the doubt rule be 
reconsidered or redefined?
    c. To what extent should service connection on a ``secondary'' 
basis be redefined?
    d. To what extent should service connection on an ``aggravation'' 
basis be redefined?

    16. Do changes need to be recommended for the Individual 
Unemployability (IU) benefit?
    17. Because Vocational Rehabilitation and Employment (VR&E) 
benefits are an integral part of the compensation package for many 
service connected veterans, what changes, if any, are needed in this 
program?
    18. Should there be a time limit for filing an original claim for 
service connection? (does not include claims for service connection on 
a presumptive basis)
    19. Currently, a pending claim terminates at the time of the 
veteran's death even when dependents remain. To what extent, if any, 
should this law be changed?
    20. Certain criteria and/or levels of disability are required for 
entitlement to ancillary and special purpose benefits. To what extent, 
if any, do the required thresholds need to change?
    21. What recommendations, if any, should the Commission make in 
regards to Concurrent Receipt policies?
    22. Should the Commission explore and recommend changes to the 
``duty to assist'' law? If so, how?
    23. Should the Commission explore the Character of Discharge 
Standard?
    24. Should compensation payments be protected from apportionments 
and garnishments?
    25. In regards to Post Traumatic Stress Disorder (PTSD), what 
policy changes, if any, need to be recommended?
    26. To what extent is the coordination between the Department of 
Veterans Affairs (VA) and the Department of Defense (DOD) adequate to 
meet the needs of servicemembers/veterans, particularly the needs of 
service-connected disabled veterans?
    27. To what extent is the coordination for seriously injured and 
disabled servicemembers/veterans adequate within VA between the 
Veterans Health Administration (VHA) and the Veterans Benefits 
Administration (VBA) and internally within each of the Administrations? 
What are the internal and external impediments, challenges and gaps, 
and how might these barriers be overcome?
    28. To what extent is the coordination adequate within DOD between 
the Office of the Secretary of Defense for Personnel and Readiness, 
Health Affairs and Force Management Policy, and the branches of 
Service. What are the internal and external impediments, challenges and 
gaps and how might these barriers be overcome?
    29. To what extent do DOD and VA provide disabled members/veterans 
the means and the opportunity to succeed in their transition to 
civilian life? What are the adequacy, quality, and timeliness of the 
benefits provided by each agency?
    30. What policy and cultural shifts must be made to produce a 
common, shared, bidirectional data exchange of information and access 
to medical and personnel records between VA and DOD and within VA 
between VBA and VHA?
    31. To what extent are the training, education and outreach 
programs (of DOD, VA, and DOL) adequate to ensure that the greatest 
number of active duty, Guard and Reserve personnel are informed of the 
full range of Federal Government veteran benefits and services and 
provided tools such as a statement of education and military 
occupational specialties experiences adaptable to civilian job 
searches?

    [Graphic presentations of the 13 individual diagnoses follow:]

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  Response to Written Questions Submitted by Hon. Daniel K. Akaka to 
   Lieutenant General James Terry Scott (Ret.), Chairman, Veterans' 
                     Disability Benefits Commission

    Question 1. I realize you cannot speak for the Commission, but in 
your personal view, based on your work as the Commission Chairman, do 
you have any thoughts on what is needed to improve the cooperation and 
coordination between DOD and VA?
    Response. The Commission recognized early in its deliberations that 
cooperation and coordination between DOD and VA are key to the 
successful and ``seamless'' transition of servicemembers to veteran 
status, especially for those seriously ill or injured with service-
connected disabilities. Three of the Commission's 31 approved research 
questions (RQs), attached for the record to my written statement, 
address aspects of this question [RQs 26, 29, and 30]. The Commission's 
final report will provide additional illumination and recommendations 
for areas of short-term and long-term improvement in the cooperation 
and coordination between the two departments.
    My personal views are that VA and DOD absolutely must develop and 
use compatible electronic system(s) for both medical records and 
military personnel records. I understand that there have been extensive 
collaborative efforts toward compatible information technology (IT) 
systems between VA and DOD over the years. At a minimum, the different 
systems, irrespective of legacies or architecture should be able to 
exchange relevant data bidirectionally, in a ``seamless'' manner that 
is transparent to servicemembers/veterans. We recently learned that 
VA's IT budget was reduced by $400 million in Fiscal Year 2006 because 
of IT management concerns expressed by the House Committee on Veterans' 
Affairs on IT management. Such funding reductions may have unintended 
consequences for the very programs that need to be given priority and 
the service-connected disabilities.
    In my personal view, VA and DOD should be required to have all 
medical and relevant personnel records in electronic format and allow 
those records to be exchanged electronically prior to a servicemember's 
separation from service. Further, the information should be provided to 
servicemembers on various Federal benefit programs from VA, Department 
of Labor (DOL) and Social Security Administration (SSA) early in their 
military service and periodically throughout their careers. All 
servicemembers should have a comprehensive physical examination prior 
to separation from the military that is suitable for VA rating 
purposes. A single separation examination would reduce redundancies and 
streamline the transition of servicemembers.

    Question 2. Have you observed any best practices among the services 
in their disability ratings systems that should be adapted DOD-wide to 
reform the system?
    Response. During calendar year 2006, the Commission conducted fact-
finding visits to eight cities located across the country. In addition 
to touring VA facilities such as regional offices, medical facilities 
and Vet Centers, the Commission also visited DOD facilities and 
National Guard and Reserve units, where appropriate.
    While in San Antonio, the Air Force briefed us that a Veteran 
Service Officer is available to assist all Air Force members going 
through their physical evaluation board (PEB) process. At the Brooke 
(Texas), Madigan (Washington) and Eisenhower (Georgia) Army hospitals, 
we learned that there are Army and VA counselors available to wounded 
soldiers to help with their military and VA disability claim processes. 
The Army and VA counselors worked together on records transfer and 
medical appointments, whether to a military or VA medical facility or 
regional office nearest the servicemember's duty station or home. 
MacDill Air Force Base medical facility (Florida) set up space for VA 
Compensation and Pension (C&P) contracted examinations to take place 
for separating servicemembers and military retirees on weekends in 
their facility. The Army placed a fulltime liaison at the Tampa VA 
Polytrauma Rehabilitation Center.
    The Commission found that focused efforts to maintain ongoing 
communications between the local VA and DOD leadership and staff, 
supported by integrated services and assigned personnel working in 
tandem at each other's facilities produced best practices and improved 
disability benefits delivery to separating servicemembers.
                                 ______
                                 
   Response to Written Questions Submitted by Hon. Larry E. Craig to 
   Lieutenant General James Terry Scott (Ret.), Chairman, Veterans' 
                     Disability Benefits Commission

    Question 1. If we were to start from scratch and design a new 
system of compensation for those who are severely injured in service, 
what should that system look like?
    Response. While a great deal of improvement is needed in the 
overall processes and procedures that affect the transition of the 
severely injured into the VA disability system and the operation of the 
current disability system, I believe it would be impractical to design 
an entirely new system of compensation built from scratch. As I stated 
in testimony before the Committees, I believe that the military 
services should make the determination whether a servicemember is fit 
or unfit for military duty. If the Servicemember is found unfit, the 
overall disability rating should include all disabilities identified in 
a comprehensive examination and should be made by VA using the VA 
Schedule for Rating Disabilities (VASRD). All records, medical and 
personnel, should be electronic and bidirectional between VA and DOD.
    Another short-term action suggested in my statement to greatly 
improve a servicemember's financial stability during transition would 
be to alter the commencement date of disability compensation payments. 
Current law prohibits the commencement of disability compensation 
payments from the effective date of entitlement. Instead, payments are 
required to be delayed until the first day of the second month after 
the disabled servicemember is first entitled to receive payments as a 
disabled veteran. This is true even for those filing a claim within one 
year of discharge whose entitlement date is the day after the date of 
discharge. This requirement was enacted as a budget saving provision in 
the Omnibus Budget Reconciliation Act of 1982. \1\ While this 
restriction might seem reasonable from a cost savings standpoint, it 
means that servicemembers do not receive any disability benefits for up 
to 2 months after discharge. For example, a veteran discharged on 
August 2, 2006, could not be paid disability benefits for the partial 
month of August and could not be paid September benefits until October 
1. Before this statutory change, the veteran would have received 
payment from the effective date which was August 3. Veterans still have 
to provide for themselves and their families, especially those who are 
unable to work. I would recommend that Congress consider changing this 
requirement.
---------------------------------------------------------------------------
    \1\ Public Law 97-253, Sec. 401, 96 Stat. 763, 801, now U.S.C. 
Sec. 5111.

    Question 2. What do you think should be the purpose of a modern 
compensation program and how should we regularly determine whether the 
program, as designed, is meeting its intended purpose?
    Response. The purpose of a modern compensation program is, and 
should continue to be, to compensate the injured servicemember for 
average loss of earning power and for loss of quality of life. In 1956, 
the Bradley Commission concluded that reintegration of servicemembers 
into civilian society was of paramount importance. I agree that 
reintegration through benefits such as medical care, education, 
vocational training and rehabilitation services are most critical.
    Determining the effectiveness of the compensation programs might 
include recurring independent assessments on a frequent, systematic 
basis--certainly more frequently than every 50 years--by a group of 
individuals who are knowledgeable, but not employed by VA or DOD. A 
standing (or periodic) assessment team, board or Commission reporting 
directly to Congress with access to VA and DOD staff in Washington and 
field sites would be essential. Our report will describe in detail the 
methodology and recommendations aligned with answering this important 
question.
                                 ______
                                 
     Response to Written Question Submitted by Hon. John McCain to 
   Lieutenant General James Terry Scott (Ret.), Chairman, Veterans' 
                     Disability Benefits Commission

    Question. Under existing law, members with less than 8 years of 
Active Duty service get zero disability compensation if it is 
determined that their disabling condition ``existing prior to entry.'' 
This has resulted in soldiers, marines, and others--volunteers all--who 
have served one, two, or maybe even three tours of duty in Iraq 
receiving nothing when they suddenly are unfit for continued service. 
Do you think this 8-year rule is fair or should it be eliminated?
    Response. The Commission did not request or receive data from the 
Services regarding pre-existing conditions. As we understand from 
current VA policy, VA considers aggravation of pre-existing conditions 
as a result of military service in its disability ratings, but we have 
not addressed the 8-year rule, as described in your question. To 
credibly answer your question requires further research.
    In my personal view, should a disabling condition become apparent 
within a reasonable period of time after entry into service, separation 
due to failing to meet entry requirements makes sense and honors the 
contract between the Service and the member. Eight years after the 
fact, especially if those years include tour(s) in a combat zone, 
exceed a reasonable time period, in my opinion, and should not be used 
as a sole basis for declaring unfitness for continued service based on 
preexisting conditions alone.
    Perhaps DOD should consider the type, conditions, length and 
locations of service and how these and other service-connected factors 
may have permanently aggravated or increased the severity of a non-
disabling pre-existing conditions. It is my understanding that VA does 
consider these factors in its disabilities ratings, if provided 
supporting documentation (including statements from friends and 
family).
                                 ______
                                 
    Response to Written Question Submitted by Hon. Mark L. Pryor to 
   Lieutenant General James Terry Scott (Ret.), Chairman, Veterans' 
                     Disability Benefits Commission

    Question. In your prepared statement on Department of Defense 
disability ratings, you point out that of approximately 50,676 records, 
13,646 of them contain data showing soldiers who were found unfit for 
duty yet assigned a zero percent rating. What circumstances warrant 
this determination and what is your opinion on how the rating system 
can be more effective?
    Response. Your question merits further investigation. As noted in 
my written statement, DOD only rates the condition or conditions that 
DOD determines to render the individual unfit for duty. By contrast, VA 
determines whether or not each identified condition is service-
connected and rates all conditions found to be serviceconnected. For 
veterans rated by both agencies, DOD rated only one condition 83 
percent of the time. For cases in which DOD rated one condition, VA 
rated an average of 3.7 conditions.
    Particularly noteworthy (as your question suggests) are the number 
of Army soldiers rated zero percent and when matched to VA's records, 
are subsequently rated with substantially higher disability ratings. I 
suggested in my testimony and reiterate here, that an in-depth analysis 
of these zero percent ratings should be conducted to ascertain the 
reasons behind these ratings. The Commission's research produced the 
data, but we do not have the time to delve deeper into these 
anomalies.
    In my opinion, the existing rating systems could be improved by 
requiring VA and DOD to use a single, comprehensive medical examination 
protocol. This would include a requirement to examine and rate all 
conditions that are found during the exam, and would not be restricted 
only to the ``unfitting'' condition(s). Training and certification of 
all examiners would also be essential for consistent, high quality 
examinations.
    I also suggest that serious consideration be given to a major 
realignment of the decisionmaking process used to decide if 
servicemembers are unfit for duty and eligible for military disability 
retirement (>30 percent rating) or separation with severance pay <30 
percent rating) and for VA disability compensation. Please refer to my 
written statement for further details on the major features of my 
realignment 
proposal.
    As a separate but related issue, I offer some background 
perspective and the following suggestions related to S. 1252, the bill 
introduced by Chairman Akaka on April 30, 2007, after the joint hearing 
on April 12th. The stated purpose of S. 1252 is to amend title 10, 
United States Code, to provide for uniformity in the awarding of 
disability ratings for wounds or injuries incurred by members of the 
Armed Forces, and for other purposes.
    As part of the Commission's analysis of disability ratings by VA 
and DOD, we found that prior to 1986, DOD instructions required that 
all service connected disabilities be rated regardless of whether or 
not the condition(s) contributed to an unfit determination, with the 
exception of hysterectomies. Based on a DOD General Counsel opinion, 
dated March 25, 1985, this policy changed. Now when determining the 
compensable disability rating, the Services are no longer required to 
consider or rate a physical condition if that condition does not render 
the servicemember unfit for military duty. Using this revised DOD 
policy, from 2000 to 2006 DOD determined that only one condition was 
disqualifying for 83 percent of all instances in which a servicemember 
was found unfit and discharged.
    In order to ensure that DOD rates all disabilities identified 
during a comprehensive examination, the following amended wording of S. 
1252 is (highlighted) suggested for your consideration [emphasis 
added]:
    ``(b) Consideration of All Applicable Medical Conditions--The 
Secretary of Defense shall prescribe in regulations requirements that, 
in making the determination of a rating of disability of a member of 
the armed forces for purposes of this chapter, the Secretary concerned 
shall identify, take into account, and evaluate all medical conditions 
incurred by the member while entitled to basic pay or while absent as 
described in section 1201(c)(3) of this title. Each identified medical 
condition shall be assigned a percentage of disability utilizing the 
standard schedule for rating disabilities referred to in subsection (c) 
along with a finding of fitness to perform the duties of the member's 
office, grade, rank, or rating. If the member is found unfit by reason 
of any medical condition or conditions, a combined rating of disability 
shall be determined for the member based on all identified medical 
conditions utilizing the standard schedule for rating disabilities 
referred to in subsection (c).''
                                 ______
                                 
   Response to Written Question Submitted by Hon. Saxby Chambliss to 
   Lieutenant General James Terry Scott (Ret.), Chairman, Veterans' 
                     Disability Benefits Commission

                           TRICARE ACCEPTANCE

    Question. I was surprised to learn that VA hospitals do not 
necessarily accept TRICARE. Would ensuring that all VA hospitals 
accepted TRICARE be a way to improve the seamless transition of our 
veterans from DOD to the VA as well as ensuring that they have easy and 
quick access to the best health care they are entitled to?
    Response. Under the Veterans' Disability Benefits Commission 
charter, health care is considered an ancillary benefit of particular 
importance to our service-connected disabled veterans. Timely access to 
quality health care for veterans with service-connected disabilities 
is, in my opinion, a top priority. The Commission has not addressed the 
issue of VA medical facilities being accepted as TRICARE providers, so 
I defer to VA for explanation.

    Chairman Levin. General, thank you. That is extremely 
helpful data that you have presented to us.
    Let me start, then, with Secretary England. We have heard 
now a suggestion from General Scott, speaking for himself but 
obviously in a very important position with the review that he 
is leading, that the fitness for duty determination be made by 
the DOD, and then there be one comprehensive physical 
examination by the VA and they determine the rating. That 
suggestion, I think, has been made previously by Secretary Chu, 
although I am not positive of that. Something similar to that 
has been recommended.
    Secretary England, why not do that? Just end these really 
incredibly diverse, disparate treatments when you go through 
the DOD system, then the VA system? These numbers are pretty 
stunning numbers here that General Scott has given to us this 
morning. I don't know if you are familiar with those numbers, 
but it is a pretty compelling case that there is a very major 
gap here between the determination by the DOD as to the level 
of disability and that which is reached by the VA. Why not 
follow that recommendation? It has been made before. That 
specific recommendation.
    Mr. England. Mr. Chairman, I actually don't disagree. I am 
not sure I know enough to agree, but I was very impressed with 
General Scott. That is the first time I have heard at least his 
views of what the Commission is doing. It is in line with my 
thinking. I mean, there is no question. My comment was we have 
these two disparate systems. We actually evaluate people on the 
basis of fitness to serve and that determines our rating. Then 
they go to VA and VA looks at not just that but other factors 
that could affect employability, and so it is two different 
rating systems. It certainly seems evident to me that we need 
to get down to some sort of a consistent process because it is 
confusing, and it is particularly confusing for the people who 
use the system, so----
    Chairman Levin. It is not confusing, I think it is just 
unfair. It is unjust. The figures I heard of, 13,000 Army who 
got a zero disability rating, rated unfit for duty, and then 
when the VA gave them a rating, if I heard the numbers 
correctly, they were given an average rating of 56 percent. 
Those 13,000, as I understand it, General, is that correct?
    General Scott. Yes, sir.
    Chairman Levin. Those same 13,000 who were rated zero had 
an average VA disability of 56 percent, which means that they 
would have been retired medically. Their families would have 
been given health care and all the other benefits that go with 
it.
    Now, we are going to need you to get us a response on this 
quickly because there is just a compelling argument here which 
needs to be addressed. I don't know what the incentive is that 
General Scott made reference, I think it was you, General, who 
made reference to a strong incentive that the DOD has to rate 
below 30 percent. I don't know what that incentive is other 
than saving money, and that is not acceptable. But the VA, if 
that incentive applied to the DOD, would presumably have the 
same unacceptable incentive about saving money.
    But in any event, let me just ask Secretary England, will 
you get to these Committees, our two Committees, the DOD 
response to that specific recommendation within the next couple 
of weeks?
    Mr. England. Yes, we will, Senator.
    Chairman Levin. Thank you. Again, we are on a four-minute 
time line here. Regarding electronic transfer of medical 
records, I believe in General Scott's written testimony, 
perhaps I missed it in his oral testimony, said that it has 
been difficult to understand the current status of 
compatibility between the two systems, the VA and the DOD, and 
to assess future plans of the Department. In other words, it is 
difficult to even grasp the plans and the current status. From 
everything we understand, there is a real problem here in terms 
of electronic transfer of medical records and that it just 
isn't happening in some places.
    Perhaps there are some experiments going on.
    But, Secretary England, this has been going on for a long 
time. Can you tell us what has been done to finally achieve 
this electronic transfer and what is the time line for doing 
it?
    Mr. England. Mr. Chairman, I can. I am going to turn it 
over to David Chu, who is more intimately familiar. I do know 
we are building bridge systems between while we have a more 
comprehensive integrated IT system, but David, if you would 
address in more detail.
    Dr. Chu. Delighted, sir. The systems the two institutions 
used were, of course, designed some years ago. They are 
separate. Starting in 2004, we began a Bidirectional Health 
Information Exchange that allows the VA, using the same system 
it uses, to look at records from one VA hospital to another, to 
look at the electronic records that DOD possesses for so-called 
shared patients. That is 2.2 million personnel. The major DOD 
installations can do the same thing currently through a Web 
site.
    Now, General Scott is right. Not everything is currently on 
that system, but it has been specifically discussed and 
somebody mentioned that is scheduled to occur later this year. 
This has been a response to the task force that was appointed 
by the President earlier in this Administration.
    For the future, I do think it is very clear, Secretary 
Leavitt of HHS has celebrated this plan--the two institutions 
have committed, subject to various technical reviews, 
obviously, to a common future inpatient electronic system that 
will ultimately make it unnecessary to have the current bridge 
arrangement that we have deployed. I should add, the Department 
does send its electronic records on all discharged personnel 
when they are discharged to the VA. We transferred just under 
four million such records. We perhaps haven't been good enough 
at explaining what we are doing and what we plan to do, but 
there is significant accomplishment already. Further 
accomplishment will be achieved by the end of this year.
    Chairman Levin. Would you get us for the record your time 
line to achieve your future transition of these electronic 
records?
    Dr. Chu. Delighted, sir. I will furnish a much larger 
diagram of the electronic information----
    Just as an example, when someone enlists in the military, 
on a daily basis, we send a record to the VA so that they can 
open a file. So it begins when you start in the military.
    Chairman Levin. If you can just get us the time line and 
very clearly stated what not just your plans are, but what is 
the time line to achieve those plans.
    Senator Akaka?
    Chairman Akaka. Thank you, Mr. Chairman.
    Secretary England, what is DOD doing with the services to 
promote consistency in their respective disability rating 
systems?
    Mr. England. Senator, I have had a number of discussions 
this week on that topic and so let me tell you what I know 
about it. Again, maybe somebody here can give you something a 
little more precise.
    Each of the services evaluates fitness to serve based on 
their particular service. So it is perhaps not surprising that 
maybe Air Force is different than Marine Corps because of the 
nature of what military people do. So there is what appears to 
be, I would expect, some inconsistency just because of the 
fitness evaluation for the military, you know, for the job they 
have in their particular service, so you would expect some 
inconsistency in terms of just based on those facts.
    On the other hand, there was a study, I understand, 2 years 
ago by the GAO and that conclusion was there was reasonable 
consistency between the services based, I guess, on all the 
factors that went into that.
    So I will tell you, it is unclear to me, frankly, what that 
answer is. I mean, I can understand that they are different 
because of service differences. We do have the GAO Report. On 
the other hand, there are a lot of reports of inconsistency 
between the services. So this is something I believe, frankly, 
for myself, needs to be looked at in more detail to really 
understand this. I cannot tell you today how big that problem 
is, what the problem is and how big it is, and that is 
something we are just going to have to get into. Perhaps, Dave, 
you know more on that subject, but that is at least where I am 
on this particular subject.
    Dr. Chu. I might add that one source of apparent 
inconsistency in aggregate data is the fact that there are 
several major populations all being evaluated by the disability 
evaluation system. You have the wounded. That is, as the 
Secretary notes, a distinct minority of the total. You have 
those who are retiring at 20 or more years of service, so it is 
a whole different population, different set of issues involved. 
In fact, there is a presumption of fitness to serve because up 
until the day of retirement, you have been good to go in your 
military specialty, in general. Then you have the trainees and 
they present a different set of issues. That is where some of 
the zero percent disability ratings occur, particularly in the 
Army, and Mr. Geren may want to speak to that issue.
    So I do think we need to disaggregate these overall data 
before we reach a hasty conclusion that the differences are 
troubling.
    Chairman Akaka. Thank you very much for that response. This 
is how we see it, also, that there are these inconsistencies 
within DOD, as you pointed out, each service has a distinct and 
different system within DOD.
    Secretary Geren, in your efforts to reform the Army's 
disability rating system, what guidance are you receiving from 
DOD?
    Mr. Geren. I beg your pardon? What----
    Chairman Akaka. What guidance----
    Mr. Geren. Oh, what guidance----
    Chairman Akaka [continuing].--are you receiving from DOD?
    Mr. Geren. We are working directly--well, Secretary Gates 
is taking a very strong personal role in working this issue. 
From the moment he became aware of the challenges in this 
issue, he has been personally involved. We have had regular 
meetings with him as with Dr. Chu and Secretary England on this 
subject. Their guidance has been strong encouragement to take 
this problem on, to work it from our service's perspective, and 
he has been very supportive every step of the way. Some of 
these issues, as you all have noted, extend well beyond our 
service and we are working with the other services. The Walter 
Reed move to Bethesda is an example of a joint service effort.
    So the OSD and the services are working hand-in-hand in 
this. Some of the solutions are service-centric, but the 
comprehensive long-term solutions are all DOD-wide, and in some 
cases governmentwide. But we have worked very closely with Dr. 
Gates and the Secretary of Defense's Office in moving ahead on 
this.
    Chairman Akaka. General Scott first, and then anyone else 
on the panel who wants to comment on this question, have you, 
General Scott, observed any best practices among the services 
and their disability rating systems that should be adapted to 
DOD-wide to reform the system?
    General Scott. Not specifically in terms of best practices 
at this time. As I mentioned, Mr. Chairman, we are looking at a 
lot of data that is coming in right now, and what I presented 
to you today was largely preliminary in nature, but I will take 
that and supply it either with our final report or if we get 
something useful in the interim to you. But the answer would be 
no at this time, sir.
    Chairman Akaka. Thank you very much. We look forward to 
that, Mr. Chairman. My time has expired.
    Chairman Levin. Under the early bird rule, as our staff has 
explained to us, I was going to call on the two Ranking 
Members. They are not here, so I am going to call on two 
Republicans, but from that point on, we are going to go one and 
one on the early bird rule, which I understand for some reason 
that is new to me goes by seniority. So the order would then 
be, after McCain on the Armed Services Committee, Warner, 
Inhofe, Collins, Chambliss, Dole, Cornyn, Sessions, Thune, 
Martinez. On the Democratic side, on the Armed Services 
Committee would be Lieberman, Reed, Bill Nelson, Ben Nelson, 
Senator Clinton, Senator McCaskill, Senator Bayh. On the 
Veterans' Affairs Committee, it would be on the Democratic side 
Akaka, Murray, Sanders, Webb, Brown. For Republicans, Craig, 
Specter, Ensign, Burr. Don't ask me why, I am just following 
instructions here, but I hope it is adequate and fair.
    Senator Warner?

                STATEMENT OF HON. JOHN WARNER, 
                   U.S. SENATOR FROM VIRGINIA

    Senator Warner. Welcome to the Chairmanship, Mr. Levin.
    [Laughter.]
    Senator Warner. Two questions for Secretary England.
    Secretary England, the Base Closure and Realignment 
Commission concurred on closing Walter Reed. The Department 
envisioned transferring the important functions from that 
historic institution to the National Medical Center at Bethesda 
and a new construction facility at Fort Belvoir.
    I strongly supported in the aftermath of this tragic 
situation at Walter Reed that we accelerate the funding profile 
to move forward very smoothly and quickly for a phasing out of 
Walter Reed and the transfer of functions to Bethesda and the 
new facility at Fort Belvoir. I note this morning the Acting 
Secretary of the Army gave a very strong endorsement to that 
proposal.
    Added to that, we have now this morning the report from the 
panel that you empowered with Secretary Gates. They said as 
follows--that is the Jack Marsh panel--``Walter Reed Army 
Medical Center should be closed as soon as possible and 
construction of a larger Army hospital at Fort Belvoir should 
be expedited.'' As sort of the chief operating officer of the 
Department of Defense, do you concur in that recommendation and 
are you prepared to support the Secretary of the Army as he 
moves forward?
    Mr. England. I am prepared to support the Secretary of the 
Army to move forward, and Senator, I do concur it is in the 
best interests of our men and women to get a facility built at 
Bethesda, to move out of Walter Reed into Bethesda. It would 
then be a teaching hospital, which is very important. That is 
where we train all of our doctors. We also have the National 
Institutes of Health in that same area so that we have research 
in that area. Our vision is that we would have a very expert 
facility, a research teaching hospital which would be----
    Senator Warner. My 4 minutes are clicking on.
    Mr. England. OK.
    Senator Warner. I know exactly all of what you are saying. 
I just want to know if you concur in it and what steps are you 
now taking to accelerate the funding profile to initiate an 
earlier start at these two institutions.
    Mr. England. Well, we have asked to identify what specific 
steps we could take to accelerate and what that would cost. I 
do not have that on my desk yet, but we have asked that 
question and whatever is appropriate to do, we will do, 
Senator. If we don't have the funding early enough in the BRAC 
account, we will definitely ask for that. But it is 
beneficial--will be beneficial if we can accelerate whatever 
aspects we can at Bethesda and we will do that.
    Senator Warner. I thank you very much, and that also 
applies to Fort Belvoir?
    Mr. England. Yes, sir.
    Senator Warner. Fine. And I ask you to inform both 
Committees at your earliest convenience of your proposals and 
the funding 
profile.
    Mr. England. Senator, we will.
    Senator Warner. Thank you. My second question to you, Mr. 
Secretary, is as follows. With modesty, I draw on my own career 
in your Department, and at that time, in the middle 1970s, we 
envisioned going to an all-volunteer force and the concept was 
beginning to develop when I was Secretary of the Navy. As you 
know, it came into being and it was a major, major gamble by 
the United States military and our whole concept of defense of 
this Nation. It has worked beyond all expectations. It has 
worked magnificently, such that we have today--I think at no 
time in our history have we ever had a finer, more dedicated 
group of men and women serving in the Armed Forces of the 
United States.
    Throughout this period of its development, some 30-plus 
years now, Congress at every juncture has stepped forward and 
responsive to successive Secretaries of Defense and Presidents 
to shore up the necessary infrastructure, medical care, 
educational care, all types of things to make that all-
volunteer force work.
    Yesterday, Secretary Gates addressed the Nation with regard 
to the new Army policy--I understand, the Marine Corps and the 
Guard and Reserves are separate--but the Army to go to a 15-
month tour for overseas and guaranteed one year at home. What 
studies did you undertake as a Department to assess the impact 
on the viability of the all-volunteer force and its 
continuation?
    Mr. England. Senator, I understand that the Secretary made 
that decision based on the recommendation of the Acting 
Secretary of the Army and the Chief of Staff of the Army based 
on the fact that on their knowledge, at least, it would bring 
predictability to our men and women in uniform, which is the 
most important thing, I think, for all the families, is to have 
the predictability to know those times rather than being 
extended piecemeal. So this was an Army recommendation in 
response to prior actions, I believe, where we did just extend 
people and not always have the 12 months. So I think this was 
an understood problem and the way to address these issues.
    Senator Warner. What have you put to place--I address to 
you and the Acting Secretary of the Army--what benchmarks, 
monitoring system do you have in place, because I tell you 
without any reservation, this all-volunteer force is a national 
treasure. I do not, in any way, believe that the Congress would 
step forward and institute a draft, not under the present 
circumstances, and consequently, we have got to continue to 
make this all-volunteer force strong and able to serve this 
Nation. What benchmarks, what check points do you have in place 
to monitor, on a weekly basis, the viability of that force in 
the light of this very dramatic order that was enunciated 
yesterday?
    Mr. England. Well, of course, the Army monitors this 
regularly and we also have, of course, our retention and our 
recruiting numbers, which at the end of the day are very, very 
important, and so far, they have held very strong across the 
Army with our Guard and with our Reserves. So our retention 
number remain high and our recruiting numbers, we continue to 
meet even an expanded Army. So our recruiting has actually gone 
up during this period.
    So I will tell you, my view is they are the strongest 
metrics in terms of the strength of our system, is how we do in 
terms of recruiting and retention across all the services. 
Senator, that is very strong.
    Senator Warner. Was this dramatic change in policy 
envisioned at the time the President announced on January 10 
the surge operation into Baghdad which necessitated, I judge, 
this policy change?
    Mr. England. Senator, I guess I am not certain of that. I 
would have to ask Secretary Gates that. But my understanding is 
that this is prudent to do at this time because it does provide 
options for the country. So this does give us an option to 
extend the 20 brigade combat teams that we now have deployed in 
Iraq if we need to. This is a process that will allow us to do 
that and do it in a predictable manner.
    Senator Warner. Could Secretary Geren add any facts he 
wishes to this, Mr. Chairman? My time is then up.
    Mr. Geren. Sir, the recommendation from the Army that 
Secretary Gates acted upon is one that we have developed over 
the last couple of weeks. To my knowledge, it was not in the 
mind of the Administration at the time of the announcement of 
the surge. It certainly wasn't from the Army perspective. But 
the national treasure that is our all-volunteer force, I could 
not agree with you more.
    Secretary England talked about the retention rates, the 
recruiting rates. Those certainly are indicators. But probably 
the most important indicator comes up through our NCOs and 
through our officers that work with that Army every day and it 
was based on their feedback, feedback that said being able to 
have predictable time home, being able to tell a soldier and 
that soldier's family that you are going to be home no less 
than 12 months, that was a more important factor in the 
family's consideration and the soldier's consideration in this 
policy than the impact of the additional 3 months on the tour. 
It is a judgment call, but it is based on the feedback and 
input from soldiers, from NCOs right up to the top leaders in 
the Army.
    But we do have to watch it every single day. There are many 
indicators we look at. As you well know----
    Senator Warner. I thank the gentleman. That is very 
reassuring.
    Chairman Levin. Thank you, Senator Warner.
    Senator Inhofe?

              STATEMENT OF HON. JAMES M. INHOFE, 
                   U.S. SENATOR FROM OKLAHOMA

    Senator Inhofe. Thank you, Mr. Chairman. Let me just say to 
Senator Warner, I was a product of the draft and I was one of 
the last ones to believe that the all-volunteer force could be 
as good as it is, but I just recently made my 13th trip over to 
the AOR and I am just in shock. These guys are so good, and 
gals, and I am so proud of them.
    Let me say one thing, because it hasn't been said yet, 
about the great job our medical practitioners are doing, the 
doctors and the nurses. The figure that I used in the last 
hearing was that 30 percent of the injured troops died in World 
War II, 24 percent in Vietnam, and only 9 percent now, and I 
think we need to talk about what a good job they are doing.
    Senator Levin talked about the process and I will confine 
my questions to the Army, since that is what it was. We at this 
table deal with cases all the time. I had an Army Reservist in 
my State of Oklahoma that lost his leg and they diagnosed it as 
a fast-
growing cancer and the review board granted this soldier a 
disability rating. Then when it arrived in Washington, they 
reversed this decision and said that it was not service-
connected. Now, it turned out to be all right, but it does 
point out that, you know, this was the Army, and I am really 
concerned, I will say to Secretary Geren and perhaps Secretary 
Chu, when the Army is granting permanent disability to less 
than 4 percent of the cases and the Marines, 30 percent, and 
the Air Force, 24 percent, there has got to be something wrong.
    I asked this question of General Schoomaker when he was in 
a couple of weeks ago and he didn't have an answer, and it 
would be a very difficult thing for someone to answer. What is 
the reason for that? Have you analyzed that and is this going 
to be corrected in some way? Are the Army doctors applying 
stricter standards than Navy or Air Force?
    Mr. Geren. The numbers that you cite, the 4 percent versus 
the Air Force and Navy numbers, which are in the '20s and in 
the '30s, that was, unfortunately, incorrectly reported and 
communicated to the Congress. The Army number is really right 
at 20 percent. The 4 percent is our permanent retirement and 
there is another 15 percent that falls in the temporary 
category. So when you look at the Navy and the Air Force 
numbers, those include both the temporary and the permanent. 
So----
    Senator Inhofe. Well, I am glad for that clarification, 
because I hadn't heard that----
    Mr. Geren [continuing].--but we are still below the others.
    Senator Inhofe. I had not heard that before.
    Mr. Geren. Yes, sir.
    Senator Inhofe. In another similar question, I was kind of 
surprised when my staff told me, and I told them they must have 
misread it, about General Scott's testimony talking about the 
differences between the Department of Defense and the Veterans 
and having to do with additional severance pay and 
servicemembers' pay. In other words, pay is the determining 
factor. I didn't believe my staff until he showed me the 
testimony, and I will just read this sentence. ``It is also 
apparent that DOD has strong incentive to assign ratings less 
than 30 percent so that only separation pay is required and 
continuing family health care is not provided.'' I have to ask 
Secretary England, how do you respond to his assertion that DOD 
reduces disability ratings as a cost-savings device?
    Mr. England. I can tell you there is no incentive to do 
that, Senator. I mean, maybe that is read into it, but I can 
tell you at least at the Secretary level, my level, senior 
leadership, and I think the services also, we try to treat 
people fairly and accurately and so there is certainly no 
incentive. I mean, frankly----
    Senator Inhofe. General Scott, is my interpretation of your 
remarks accurate?
    General Scott. The data would indicate that is one of the 
rationales for an assessment of less than 30 percent. Now, I 
can't say either from my own experience of 32 years in the 
military or from my experience on this Commission exactly what 
the motivations inside the DOD or the services might be in that 
regard. I do not mean to infer necessarily that that is the 
rationale by which these disability decisions are made. But it 
is a fact that they are made----
    Senator Inhofe. Well, it is a factor. In fact, your 
statement had there, and that was the third time that you 
mentioned it. But the fact that it is even a factor is 
something that I think is disturbing. Secretary Geren, what are 
your thoughts on this?
    Mr. Geren. The people who are on the PD boards, that factor 
should not influence their decision at all. I guess I am trying 
to make some sense out of this finding of General Scott's 
Commission. When the Army or when a military department gives 
somebody a rating that puts them above 30 percent, there is a 
cost to the Army because the person is able to stay in the 
TRICARE health system. The same is true in the VA. Those rating 
boards, the higher rating they give, it is going to cost them 
more. So, I mean, any government program, the more people who 
avail themselves of the benefits of that program, it is going 
to cause that program to cost more, but I don't think there is 
any evidence to show that the people who make the decision on 
these evaluation boards are influenced by that at all.
    Senator Inhofe. Well, you might check it out. My time is 
expired, but I think it is worth looking into.
    Mr. Geren. They are charged as professionals to make the 
best decision, but like, again, any government program that 
gives out benefits, you know, you could conclude that that 
program has an incentive not to give out that benefit. But we 
have found no evidence that the officers and the soldiers, and 
civilians who are on those boards have been influenced by that, 
but it is certainly something we should look into. But their 
job and the job of managing the budget are very separate. We 
have not found evidence to that, but it is certainly worth 
exploring.
    Chairman Levin. Thank you. Senator Lieberman?

            STATEMENT OF HON. JOSEPH I. LIEBERMAN, 
                 U.S. SENATOR FROM CONNECTICUT

    Senator Lieberman. Thanks, Mr. Chairman, for an excellent 
hearing with some real concrete proposals and direct 
confrontation of the problems that we are all concerned about 
with the treatment of our veterans.
    I do want to thank all of you who are before us for the 
extraordinarily high level of medical care given to our 
veterans on the average, and it is more than on the average, it 
is in most cases. We have talked about the tremendous advances 
in battlefield medicine and treatment of injured soldiers. I 
will tell you that in my opinion, in speaking to independent 
medical experts, the national system of Veterans' 
Administration hospitals is one of the best things going in our 
country. I can tell you that the two in Connecticut, at West 
Haven and Newington, have a very high level of veteran 
satisfaction and appreciation. So as we go into the 
shortcomings of the system, I do feel that we ought to thank 
you and feel good about the things that we are doing right to 
take care of our veterans.
    This hearing was focused appropriately on two kinds of 
shortcomings, particularly the differences in disability 
ratings between the DOD and VA, and I think you have handled 
that well. We are going to monitor it, and Secretary England, I 
will be particularly interested in your earlier response to 
what General Scott has recommended today, which certainly seems 
to me, I am hearing, to be a very common sense and effective 
way to deal with the gaps in disability ratings that we are 
hearing about and are upset about.
    Second is the large number of pending claims by veterans--
this is in the VA--and I know you are taking steps to deal with 
that. I just really urge you, I appeal to you to be as clear 
with us as necessary to tell us what you need, including 
spending more money to hire more people or improve your systems 
to break this delay in dealing with claims, which can be as 
long as 2 years, as we have heard.
    But I want to focus for a moment in my one question to go 
back to treatment. We are seeing a rising demand for mental 
health services and brain injury-related services. One study I 
have seen said that it predicts that one in six returning 
servicemembers will be diagnosed with Post Traumatic Stress 
Disorder and that at least one in ten will return with 
traumatic brain injuries. Senator Boxer and I have been working 
together on some of this. There is a mental health task force 
report due out in May. I know we have written to Secretary 
Gates saying we hope that General Kiley's departure will not 
delay that report because it is so critically important.
    I want to ask both Secretary Cooper and Secretary England 
what both Departments are doing to deal with what seems to me 
and the experts to be a rising need for treating veterans who 
come home with PTSD and TBI.
    Mr. England. It is a rising need and it is a concern to us 
because, frankly, Senator, we learn more about this every day. 
I mean, this is something as we learn more about, literally, 
the brain and how it operates and reactions, I mean, we are 
learning more about this. In the past, World War II, people 
were, ``shell-shocked,'' right? Now, we actually understand 
that this is a Traumatic Brain Injury and we also understand it 
doesn't show up for some period of time. So we do have research 
into this issue to better understand it, but I agree with you 
here. This is an area where we need to be able to follow up 
with people, because otherwise we can't just let people go and 
then have this occur at a later date but it be too late to deal 
with.
    I am not sure we have all those programs in place, because, 
frankly, we are still trying to understand and deal with this. 
But there is an understanding that this is a significant issue 
for the Department and we do have people literally studying and 
working this and researching to understand how we deal with 
this on a long-term basis. So I wish I had a definitive answer. 
I am just not sure we have enough knowledge to have a 
definitive answer, but I can tell you we will deal with it 
effectively and we will deal with it correctly as we gather 
knowledge to do so.
    Senator Lieberman. Secretary Cooper, how about the VA?
    Mr. Cooper. Senator Lieberman, I certainly appreciate, or 
we appreciate your comments on the medical capability within 
VHA. They have done very well.
    To answer your question professionally, I would like to ask 
Dr. Cross, who is from VHA and can handle that specifically.
    Senator Lieberman. Fine.
    Dr. Cross. Sir, in order to answer your question, VA has 
been a leader in PTSD for decades. With our National Center for 
PTSD, we lead the way in research and understanding how best to 
treat this complex condition. But we are not new to TBI, 
either. Fifteen years ago, we created our special centers for 
TBI, four of them, and now we have built them and supplemented 
them into a multi-
disciplinary approach which we now call our Polytrauma Centers. 
We have promoted TBI education for our clinicians in a special 
course starting several years ago. As of 2 weeks ago, I checked 
how many we have trained in this supplemental training course. 
Sixty-one thousand of our clinical staff have been trained 
specifically, supplemental training on TBI.
    But now we are doing something that I think is very 
creative, screening all OIF and OEF for TBI. Everyone that 
comes in, a new patient, we want to put them through a screen 
and perhaps do so periodically to assess, because we can 
recognize--
    Senator Lieberman. You mean everyone coming in claiming 
PTSD, or anyone coming into the system?
    Dr. Cross. We already have a screen, sir, for PTSD and we 
have been doing that for some time.
    Senator Lieberman. Right.
    Dr. Cross. We have added on the TBI, and what we are trying 
to do is make sure that we recognize the mild to moderate 
cases.
    Senator Lieberman. Right. Well, I appreciate that.
    My time is up, but the challenge is to have the VA system 
be prepared to deal with this increasing number of veterans who 
will come back with both of these. I know you have been leaders 
and I do want to say that Senator Boxer and I and others are 
going to be introducing legislation to establish what we are 
calling Centers of Excellence within the DOD, Department of 
Defense, to develop and support a Department-wide strategy to 
provide care for combat-related mental health and brain injury 
conditions. As soon as we get a draft of it, Secretary England 
and Secretary Chu, I look forward to sharing it with you and 
getting your response.
    Mr. England. Thank you. We do, Senator, if I can comment, I 
have met several times with Secretary Nicholson on this whole 
subject, particularly TBI, and like the Doctor said, there are 
four centers of excellence now in VA where our people go. I 
think the question, sort of the worrisome question is not how 
we deal with people with TBI but with people we do not know 
have TBI and may show up later----
    Senator Lieberman. Absolutely.
    Mr. England.--and so that is really sort of my focus. I 
believe where we know we have an issue, it is being dealt with 
and we have experts, but I do think, because of a lack of 
knowledge in this area, we need to be able to monitor this over 
a period of time.
    Senator Lieberman. Thank you. Thanks, Mr. Chairman.
    Chairman Levin. As I said before, the best way I can figure 
out how to do this is to have one Democrat, then one 
Republican, and switch back and forth and that is what we will 
continue to do. However, we are going to have to, under the 
early bird rule, recognize Senators who were here when the 
gavel hit first before those who came later. It is even more 
complicated than that, but I have simplified this for 
everybody, and under that interpretation, Senator Collins would 
be next.

              STATEMENT OF HON. SUSAN M. COLLINS, 
                    U.S. SENATOR FROM MAINE

    Senator Collins. Thank you. I was getting worried where you 
were going, Mr. Chairman, with that because I was here on time.
    Chairman Levin. Well, it showed, I am afraid.
    Senator Collins. Secretary England, I want to echo the 
concerns that Senator Lieberman just enunciated about Traumatic 
Brain Injury. Senator Clinton and I recently introduced a bill 
also on this issue. My concern grew exponentially after talking 
to a neurologist from Maine who diagnosed a soldier who had 
served in Iraq with TBI and he had been misdiagnosed as having 
post-traumatic stress syndrome. This neurologist has attempted 
to teach me quite a bit about TBI. He calls it a silent killer 
and he believes that our Armed Forces need to do a far better 
job of screening our soldiers, marines, airmen, sailors, anyone 
who has served in Iraq or Afghanistan, when they come back 
State-side as part of a post-deployment medical examination. Is 
that being done? Is there a specific screening for Traumatic 
Brain Injury?
    Mr. England. David, would you address that for me?
    Dr. Chu. Yes, ma'am. Here is what is being done.
    First, we have promulgated and disseminated to the field 
and are requiring that in any incident where they believe that 
there has been a concussion that should be evaluated that there 
is a standard set of questions asked so we can record right 
away what we think happened and is this person someone to be 
flagged for this condition.
    Second, we are in the process, just as you suggest, ma'am, 
of revising our post-deployment health assessment and the post-
deployment health reassessment to deal with this issue.
    And third, of course, as VA has testified, they are now 
evaluating every veteran who comes through, regardless of 
whatever the presenting condition is, for Traumatic Brain 
Injury.
    So I think we have put in train a series of steps that are 
going to deal with the issue.
    Senator Collins. Thank you. General Scott, I want to turn 
to your testimony and the analysis that was done by the Center 
for Naval Analysis for your Commission. It seems to me that you 
have identified some very interesting issues for this Committee 
to pursue. Not only is there a big difference between how the 
DOD rates for disability versus the Veterans Administration, 
but there also appears to be an extraordinary difference among 
the services, with the Navy and the Air Force granting 
disability ratings that are far higher than either the Army or 
the Marines.
    My question to you is, based on the preliminary analysis 
that you have done, what do you think is the cause for the 
disparity within DOD among the four services? I must say that 
the disparity seems too pronounced to be attributable simply to 
the different missions of the various services. Do you have any 
preliminary judgments on that issue that you could share with 
us?
    General Scott. Thank you for the question, Senator.
    My opinion would be that there is really several things 
involved in it. One of them is, as you state, that there is a 
difference in what members of the services do. There is also 
probably some significant variation among how the instructions 
to the boards are applied. I believe I mentioned in my 
testimony that, to the best of our ability to determine at this 
point, the DOD has pretty well delegated to the services the 
implementation of the determination of disability. In other 
words, the services determine the disability based on their 
interpretation of the criteria, and one of the recommendations 
that I made was that there be a joint study actually between 
DOD and VA to look at the instructions that each of the 
services use and see if there is enough variation there to 
account for some of this difference, and then maybe to come out 
with some DOD guidance, if necessary, and then compare that 
with how the VA interprets and translates their disability 
assessments.
    I would also add that one of our contractors, the Institute 
for Medicine, which you required us to use in the authorizing 
legislation, quite rightly so, they are doing a study of what 
the VA calls the entire rating schedule of how ratings are 
conducted based on body systems, and we expect to get some 
information out of that that VA and DOD may find useful .
    Those are two of the reasons, and beyond that, ma'am, I am 
not sure that we have all the data in. As I mentioned early on 
in this, I am dealing with largely preliminary-type data, but I 
will be happy to furnish you an analysis of the differences as 
we see them as we get a little bit more data.
    Senator Collins. Thank you.
    Chairman Levin. Thank you, Senator Collins.
    In his capacity as a Member of the Veterans' Affairs 
Committee, I now call on Senator Webb.

                  STATEMENT OF HON. JIM WEBB, 
                   U.S. SENATOR FROM VIRGINIA

    Senator Webb. Thank you, Mr. Chairman. I might ask if you 
could give me 8 minutes given that I am on both Committees?
    Chairman Levin. Nice try.
    [Laughter.]
    Senator Webb. First, I would like to say, Secretary 
England, I would like to associate myself with the comments 
that the senior Senator from Virginia made with respect to this 
new policy that was announced yesterday and give you my utmost 
concern about this extension policy that has been put into 
place. I am stunned, quite frankly. I think it is one thing to 
say that we are putting predictability into the system and it 
is another when predictability is uniformly negative. In my 
view, the strategy doesn't justify this continuing abuse of 
people who have put their lives literally into the hands of our 
leadership. I think there are limits to human endurance and 
there are limits to what families can put up with.
    You made a comment about retention numbers, and we are 
going to be watching those very closely. Retention numbers that 
I saw just 2 days ago, I don't know if you have seen them or 
not, with respect to West Point graduates are pretty 
disturbing. The West Point Class of 2000, I think, has 54 
percent of that class have left the military already. The Class 
of 2001, I believe the number was 46 percent left pretty much 
as soon as their obligation was over. We have not seen that 
slide since the mid-1970s. I can't remember a slide like that 
since the Naval Academy Class of 1966, whose time expired right 
in the middle of Cambodia and Kent State and all of the rest of 
that during the Vietnam War.
    So I think there is, on the one hand, serious concerns 
about how these policies are affecting the willingness of very 
fine people to stay in, and on the other, I just don't see the 
strategy justifying it. I think 15 months for a 12-month 
turnaround here is a bad trade. Senator Hagel and I put a bill 
in to adjust that and I hope my colleagues will look at that 
bill.
    With respect to the issues on the table here, I have spent 
a good bit of my life dealing with these issues, as many people 
here know, having first of all grown up and served in the 
military, but I also spent 5 years at the Pentagon, 1 year as a 
Marine, and I spent 4 years of my life as a staff counsel on 
the Veterans' Committee dealing with these issues every day, 
and they are enormously complex issues. I hope my colleagues 
and other people will understand that.
    There is almost a quadrant here when we are talking about 
how disability systems go into place, and what I mean by the 
quadrant is the military itself basically looks at who is fit 
for duty and who is not. The VA system is not designed simply 
to do that. The VA system is designed to examine people who 
were injured or have some level of disability on active duty 
and to track that disability as you go through the rest of your 
life. So they are not something that you can meld together. You 
have other systems, such as PTSD and TBI, which may not 
manifest themselves when you are on active duty completely, so 
they kind of cross the line.
    But the other quadrant, and I think it was kind of 
interesting that in your comments, Secretary England, you 
mentioned that--first of all, you said you want to focus on the 
wounded, and I hope you mean the wounded and the injured, 
because somebody who rolls over in a Jeep is not technically 
wounded, but they have an immediate injury that should require 
this sort of attention.
    But the other statistics that kind of blew me away is that 
89 percent of servicemembers who are being evaluated are those 
transitioning to retirement, according to your number, and that 
is, from my understanding, it wasn't the original intention of 
the system, that so many people who move toward retirement on 
longevity, as Dr. Chu mentioned, should be part of this medical 
disability system. The assumption is that normal wear and tear 
wasn't going to go into the disability system.
    The one question I am going to be able to ask in this short 
period of time, I actually want to address it to Secretary 
Cooper and it follows onto the testimony that you gave in the 
Veterans Committee the last time that you and I were together 
there, and that is that when we were talking about the need for 
an analytical matrix to actually solve these problems. I 
contacted the Department of Veterans Affairs and I asked the 
question of how many claims adjudicators are actually on the 
ground, and that number came back to me is as of March 31, 
there were 5,409 claims adjudicators actually on the ground and 
that they are put on the ground on an assumption that they can 
turn out 109 claims a year.
    Now, if we do the math on that, with a backlog that has 
been estimated anywhere from 400,000 to 600,000, depending on 
who we are listening to, they can do about 600,000 claims a 
year, but this isn't a static situation. As you know, we have 
got claims coming in all the time. So what would you need? What 
would you need so that we can actually get rid of this backlog?
    Mr. Cooper. I think the primary thing that I need at this 
time is more people, as you pointed out. The budget for 2006 
asked for an increase of about 450-plus individuals and the 
problem is, of course, that with the very complicated system 
that we have addressed here today, particularly the fact that 
we have to look at all issues on an individual veteran and we 
have to rate them by 10 percent increments, it takes a long 
time to train people. After bringing people on board, the next 
problem I have is training them, and we essentially figure that 
to get to the point of being productive, they need to have at 
least 1\1/2\ to 2 years of training.
    We have made many changes over the last 4 or 5 years, done 
everything to try to make us more efficient, to consolidate 
where we think it is feasible, and to increase our efficiency. 
But I think, quite frankly, it is a very people-oriented 
problem and therefore it is people that I need.
    Senator Webb. Well, I would suggest, and my time has 
expired, that we really need to get to the number, that we can 
say analytically that we will fix this problem and make it one 
of the highest funding priorities in the Department of Veterans 
Affairs. We can't continue to do this not only to the Iraq and 
Afghanistan veterans, but to the Vietnam-era veterans who are 
aging out of their normal work, their career and wanting to get 
assistance in the system. We need to get to a number, and I 
want to work with you on that.
    Mr. Cooper. Yes, sir.
    Senator Webb. Thank you.
    Mr. Cooper. Speaking of the older veterans, by the way, you 
know, 54 percent of all claims we get are, in fact, second, 
third, and fourth claims coming back because of the aging 
process or deterioration in the particular condition for which 
they are evaluated.
    Senator Webb. I understand that. Thank you very much.
    Thank you, Mr. Chairman.
    Chairman Levin. Well, we have got a dilemma, unless Senator 
Specter sits down. The only early birds we have left who were 
here when the gavel hit are on this side. So now my question 
is, do I go back and forth or do I take care of the early birds 
according to the rule? So I am going to flip a coin and call on 
Senator Cornyn.
    Senator Cornyn. I was just going to say, Mr. Chairman, I am 
sure you would do justice in your determination, and I didn't 
know you were going to call on me next, but thank you very 
much.
    Chairman Levin. Well, that is my dilemma, folks. If you are 
all understanding, I will do the early birds first on this 
side.
    Senator Cornyn. I think that is fair.
    Chairman Levin. Thank you. I appreciate that a great deal.

           STATEMENT OF HON. HILLARY RODHAM CLINTON, 
                   U.S. SENATOR FROM NEW YORK

    Senator Clinton. Thank you very much, Mr. Chairman, and 
thank you, gentlemen. Before I address the issues that brought 
us here today, I want to associate myself with the comments of 
both of the Senators from Virginia. Senator Warner and Senator 
Webb speak from a great deal of experience, and Secretary 
England, the announcement yesterday by Secretary Gates that 
deployments for active duty will be extended raises serious 
questions, both about the over-stretched nature of the Army, 
which I think is getting to a crisis point, but also about how 
we are going to continue to take care of those people as we put 
them in harm's way for longer and longer periods of time.
    Our system, despite the best efforts of a lot of well-
meaning people, is not working to commensurate with what we owe 
those who have served. I think looking at these problems that 
we are addressing today in the context of this longer 
deployment just makes the urgency even greater. I hope that the 
suggestions that have been talked about today from General 
Scott's Commission and others will be put on the fastest of 
tracks and work with the Congress to please get some answers to 
these problems.
    I spent Tuesday at the VA in Syracuse, New York, and also 
up at Fort Drum, where I met with more than 40 returning active 
duty soldiers. They had been wounded and injured in both Iraq 
and Afghanistan, and I had a very frank discussion with them 
and I asked them what their situation was and here is what I 
heard.
    Loss of their medical records was a constant refrain, 
something that I have heard continually. One young soldier who 
was wounded by an IED in Baghdad said that as he was being 
rolled out on his gurney to get on the plane to go back to 
Landstuhl, a nurse put a packet on his chest and said, ``These 
are your medical records. Don't lose them.'' He said, ``You 
know, ma'am, I didn't get to Landstuhl with my medical 
records.'' I hear that over and over again.
    Physical Evaluation Board liaison officers who lack 
training or are just too busy, or no caseworker at all. Lack of 
legal assistance for the appeals process. Unfair 
determinations, at least in the minds of many of the soldiers 
and certainly on a basis of comparability due to the 
administrative and bureaucratic burdens placed on 
soldiers.
    We have talked a lot today about the disability system, but 
I don't think it accurately reflects TBI or PTSD, amputations, 
hearing loss, and diseases that since the First Gulf War we 
have seen in some increasing numbers as military members have 
returned.
    And then one issue which has not been mentioned and I want 
to put on the table is the Traumatic Servicemembers' Group Life 
Insurance, which has been the subject of just anguished reports 
to me. As you know, this is an insurance policy that many of 
our soldiers sign up for, and as of August 2006, over 41 
percent of the claims had been denied. What I heard at Fort 
Drum was that it is almost a joke. They call numbers. Nobody 
answers. They get hung up on. They are basically told, here is 
the way it works. We turn you down, and if you have the energy 
to come back, maybe we will do something for you.
    This is a disgrace and it is something that one sergeant 
told me just made him laugh instead of cry. His convoy had been 
hit by an IED. He had severe injuries. The life insurance 
representative told him that he would have to prove that he had 
been injured when he had his commanders, his doctors, and 
everybody else already having made that case. I think this 
needs to be looked at seriously and I hope, Mr. Chairman, we 
take a look at it, as well, because from what I am hearing, it 
is not performing the way it should.
    I also heard there is not a single neurosurgeon deployed to 
Afghanistan, and one of the problems we are having with head 
injuries is that people are sent directly from Afghanistan to 
Landstuhl. That is a long trip under often stressful 
circumstances. At the very least, I hope, Secretary England, we 
can get a neurosurgical team to Bagram so that we have the 
facilities and the personnel there ready to take care of our 
young men and women.
    I also was distressed to learn that Fort Drum does not have 
a caseworker assigned to assist wounded soldiers navigating 
through the disability process. A few months ago, the only 
caseworker assigned to the post was reassigned to an 
administrative position, and I heard from soldier after soldier 
that if it had not been for this particular caseworker, they 
would have really been lost.
    When I asked the commanders, they told me they are not 
authorized to spend budget dollars from operating and 
maintenance accounts to hire caseworkers because they are paid 
from a separate medical personnel fund which is not under the 
control of the base commanders. Again, I think we need to look 
at that. One thing that these soldiers need is somebody to help 
them navigate through this process and for them to feel like 
they have someone on their side.
    To follow up on Senator Webb's question, perhaps we could 
consider asking retired personnel to volunteer to assist us in 
reducing this backlog. I think we need to put as much energy 
and urgency into this as possible.
    And finally, with respect to the electronic medical 
records, you know, the VA system gets very high marks, not just 
within the VA system itself but by external independent 
assessments, and yet I hear the DOD electronic medical records 
system is plagued by failure to comply problems. People just 
don't want to do it, and apparently they are not ordered to do 
it. Lots of slips with the information getting from the 
battlefield into the system.
    I just think it would be a smart, efficient approach to 
look at taking the VistA system in VA, which is an already 
functioning, effective system that has a proven track record, 
and extending it to DOD. Instead of trying to figure out how to 
merge and create a new system, let us go with what works, 
because I think there are too many records that are being lost 
and people are literally falling through the cracks.
    Mr. Chairman, I have a series of questions related to TBI 
and the legislation that I, and Senator Collins and I and 
Senator Bayh have introduced, and I would like to submit those 
for the record.
    Chairman Levin. They will be made part of the record and we 
will keep the record open for the usual length of time for 
questions from any of the Members to be answered.
    Thank you very much, Senator Clinton.
    Now it will be Senator Specter.

               STATEMENT OF HON. ARLEN SPECTER, 
                 U.S. SENATOR FROM PENNSYLVANIA

    Senator Specter. Thank you, Mr. Chairman. When the recent 
disclosures were made about Walter Reed, I took another trip 
out there. I have been there on many occasions and have 
observed the returning troops from Iraq in the course of the 
past several years with the extraordinary injuries which they 
have. I was candidly surprised to see some with artificial 
limbs going back to active duty with tremendous composure and 
tremendous determination to continue to serve. We have had a 
wave of very serious brain injuries which are very 
debilitating. Now with the modern procedures, lives can be 
saved, but there is a lifetime of disability and those young 
men and women are returned to their families. There are real 
questions to the adequacy of their compensation as they are 
being cared for. They are in their '20s. Projecting ahead, they 
have 40, 50 years of disability.
    One concern which I have, having been Chairman of the 
Veterans' Committee for some 6 years, is the adequacy of the 
compensation. Some of it comes from the Department of Defense, 
some of it comes from the Department of Veterans Affairs, but 
when these evaluations are made, I think inevitably, because of 
budget constraints, there are pressures on the evaluating 
personnel to hold back at least a little.
    The question that I have, which could be directed at any 
one of the witnesses who are here today, but particularly 
Deputy Secretary of Defense England as the ranking DOD officer 
here, and at the outset thank him for his distinguished 
service, and to the ranking Veterans Affairs officer here, 
Under Secretary Cooper, has any consideration been given to a 
total top-to-bottom reevaluation as to the adequacy of the 
funds, say, in the Department of Defense--you have a big 
budget, you have got a lot of things you have to do with it--to 
evaluate whether or not the funding available for wounded 
returning veterans is adequate, and the same as it applies to 
the Department of Veterans Affairs, whether the funds are 
adequate.
    If there is one area of obligation which ought not to be 
shortchanged, it is to see to it that these men and women who 
come back injured are properly cared for in all respects. The 
study should take into account the modern techniques to save 
lives but leaving people with terrible brain disabilities, and 
similarly when they come into the veterans' hospitals. We in 
the Congress make it a practice to visit our veterans' 
facilities and the efforts made there are very substantial, but 
there are very frequent difficulties because of inadequate 
funding.
    Secretary England, you first. Do you think it would be a 
good idea to undertake such a comprehensive top-to-bottom study 
to see if funding is adequate for the responsibilities DOD has?
    Mr. England. Senator, I agree. I do think it is a good 
idea. I will tell you this. While I agree with it, I mean, my 
view of this, sitting where I sit, is that there is no budget 
constraint in this area. I mean, if people run short of money, 
we will reprogram money and refill those coffers. So my view 
where I sit is, there is no money constraint to take care of 
our wounded and there absolutely should 
not be.
    That said, I will tell you I am periodically surprised with 
what happens in this very, very large and complex organization, 
so yes, it is probably appropriate to step back and make 
absolutely certain that that is the case, that we are not 
unduly constraining the system because of funding, and I would 
be pleased to do that. I will do it. I will direct that look 
just to be sure because we don't want that to happen. I mean, 
we do not build a limitation into this area of our enterprise. 
This is the most important thing we do and so we will step back 
and make sure we are doing it right. I appreciate the 
suggestion.
    Senator Specter. Thank you, Secretary. I know my time has 
expired. Might we have a response, Mr. Chairman, from Secretary 
Cooper?
    Chairman Levin. Yes.
    Mr. Cooper. First, Senator, you discussed compensation, and 
in my particular part of the budget, all of the benefits that I 
have are mandatorily funded. There is no reason for us not to 
give exactly what we can, give the benefit of the doubt to the 
veteran, because I have two sets of money. One is the money I 
use to pay my people to do the work. For the money that goes to 
the veteran, all I have to do is say they are entitled to it 
and that money is available. So each year, there is mandatory 
money set aside for the compensation part.
    For the medical side, I am of the opinion that we have 
sufficient money to do what is required. I would like to ask 
Dr. Cross to comment further on that.
    Senator Specter. Dr. Cross?
    Dr. Cross. Yes, sir. We have the money that we need to 
carry out our existing mission. Our budget has increased 83 
percent over this Administration. Of course, we reevaluate 
continually, and I want to tell you and reassure you of one 
particular point. OIF and OEF and the medical care that they 
need, the medical care that they deserve is an absolute 
priority. We will find a way to make that happen no matter 
what.
    Senator Specter. Thank you very much. Thank you, Mr. 
Chairman.
    Chairman Levin. Thank you very much, Senator Specter.
    Senator McCaskill?

              STATEMENT OF HON. CLAIRE McCASKILL, 
                   U.S. SENATOR FROM MISSOURI

    Senator McCaskill. Thank you, Mr. Chairman.
    I also would like to express similar sentiments to the two 
Senators from Virginia and the Senator from New York concerning 
the policy that was announced yesterday in terms of extending 
the deployment of these incredibly brave men and women who have 
given so much. I particularly think of their families and what 
kind of impact this is having on them, and I would like to 
particularly talk a little bit today about the Guard and 
Reserves. This policy affects them and their situation is 
slightly different than the active military in terms of what 
impact it has on their families. The irony, the Catch-22 of 
their situation is that when they come back, they have this 
time period during which they have got to make sure they do the 
right things or they lose certain benefits that they are 
entitled to.
    You learn so much talking to the men and women who have 
come home. With all due respect to all of you who know so much, 
I have learned so much more in one-on-one conversations with 
men and women who have served than I have ever learned in this 
room because they tell me what really happens to them as they 
come back. And I was stunned to find out when I talked to a 
number of very brave men and women who served in the Missouri 
National Guard who have been to Iraq a number of times about 
this 2-year time frame they have, that they have got to do the 
right thing within these 2 years or they may not get everything 
that they are entitled to get. There is a limited amount of 
time that they are entitled to TRICARE when they get home, and 
then there is a limited amount of time that they have to access 
VA medical when they get home.
    Has there been any consideration, since we are going to 
extend the amount of time they are serving over there, has 
anyone had a conversation as to whether or not we should extend 
the time during which these men and women can access benefits 
that I think most Americans think that they shouldn't have to 
dance a bureaucratic dance in order to benefit from them? 
Secretary England?
    Mr. England. I will let Dr. Chu talk about the specifics of 
time, but on the larger issue, my understanding, Senator, is it 
does not apply to the Guard and Reserves. The 15-and-12 is 
active and the Guard and Reserves will maintain the current 
objective, which is one-and-five. So I don't believe--there are 
some Guard there and they were already being extended earlier, 
but otherwise, I don't believe they are in this queue, but 
Pete, is that a----
    Secretary Geren?
    Mr. Geren. That is accurate.
    Senator McCaskill. The overall point is that when most of 
these men and women signed up for the Guard and Reserve, many 
of them, I mean, we have traditionally had a strategic Reserve 
and the Guard was not seen as an operational force in our 
active military and it is a very important component of a 
voluntary military, obviously. And I look at the way--I had a 
young man tell me that he didn't realize until 6 months into 
his 2-year ticking time clock that he was even entitled to 
these benefits.
    Now, I know what someone would tell me is, well, they are 
told when they are dismissed that they can get all these 
things, but think about what they are going through at the 
moment that they are dismissed. Is that the moment in time that 
they want another packet of paper? Is that the moment in time 
that they are going to be best equipped to absorb the 
information about what they need to do to access full benefits? 
I think common sense would tell us it is not the best moment in 
time. They don't want to hear any more about what they need to 
do and where they need to go. They want to get home.
    Mr. England. Can we address that, please, Dr. Chu?
    Senator McCaskill. Sure.
    Dr. Chu. We agree, ma'am. We brief before they go. That is 
a better time and a place. But we are also standing up what we 
call Turbo TAP, Transition Assistance Program, Senator, to put 
on the Web, put on the Internet the kind of information that 
you are referring to so they can do it at their leisure, and it 
is particularly oriented toward the Guard and Reserve for just 
that reason.
    I will let the Veterans Affairs Department personnel 
comment on the 2-year window, but let me say, early during this 
Administration we extended TRICARE eligibility to be 90 days 
before mobilization, as long as you are holding orders, and 6 
months thereafter at the government's expense. In addition, 
Congress has made TRICARE available to Reservists at very 
beneficial rates if they wish to continue service beyond that 
point in time. So people do have coverage if they wish.
    The two-year window, if I recall correctly, and I defer to 
the VA, refers to the fact that they don't have to have a hard 
preexisting condition finding during that period of time to 
present themselves at a VA treatment facility and say, look, I 
think this is connected. But if it is service-connected, you 
have a lifetime entitlement to care from the Veterans 
Department, right?
    Mr. Cooper. Yes, sir, that is correct. The 2-year time 
frame was set up, I think, by Congress to have that done, but 
the fact is, prior to that, to get into the VA system, a person 
had to have a disability. So to preclude that problem, they set 
up the 2 years that they could do that.
    Now, a couple other things that we have done. We have had 
National Guard representatives come in from each State, and 
there is a representative that works with the Adjutant General 
in each State for National Guard in particular, and we have 
worked with them to train them to understand what they can do 
to help the Reserves and National Guard. Also, about 3 years 
ago, the Secretary set up a system whereby everybody--active 
duty, Reserve, National Guard--when they depart from active 
duty get a letter from the Secretary which delineates all of 
the benefits to which they are entitled. They get the same 
letter 6 months later because we understand there are certain 
veterans, like the seriously wounded, who are not ready 
immediately to understand all the benefits that are available, 
and so we have tried to set up systems that give them 
continuous information.
    Senator McCaskill. Would it be possible for somebody to 
call them?
    Mr. Cooper. It would certainly be possible, absolutely.
    Senator McCaskill. I just think, and Senator Clinton made 
the point, and what I have learned is so many of these men and 
women feel confused and they are almost paralyzed by the 
overwhelming nature of not only reintegrating with their 
families and their communities and finding work or returning to 
work, but then what they face in terms of learning how to--as 
one told me, you have got to learn how to game the system. You 
have got to learn how to use the system to your best advantage, 
and frankly, he said, it takes more time than I have right now. 
It is very clear to me that we are not getting these men and 
women the assistance they need in terms of navigating the 
system and I hope that we continue to make that a focus of our 
efforts.
    Mr. Cooper. It is a very strong focus. We also talk to 
families as these men or women are deployed and talk to them 
during the time they are deployed. So we are reaching out in 
many different ways in many forms to try to help them as best 
we can.
    Senator McCaskill. My time has expired, but I think we 
still have a lot of work to do in talking to the men and women 
that I have talked to that have returned home.
    Mr. Cooper. Thank you.
    Chairman Akaka  [presiding]. Senator Cornyn?

                STATEMENT OF HON. JOHN CORNYN, 
                    U.S. SENATOR FROM TEXAS

    Senator Cornyn. Thank you, Mr. Chairman, and thanks to each 
of our witnesses for what you do each and every day to serve 
our Nation and our men and women in uniform. We have a lot of 
work to do, I agree with Senator McCaskill.
    I have just some specific questions. First, I have a 
question about life insurance and I have a question about how 
spouses of our wounded warriors are dealt with, and then one 
final question, Secretary Cooper, about the number of 
disability claims that an individual claims adjuster, or 
whatever the title is, handles each year.
    But first of all, I, too, have been visiting with some of 
the families and the wounded warriors. They bring up specific 
concerns they have. One is a woman who is married to a soldier 
who was burned rather extensively and is still being evaluated. 
They have five children. She was essentially ordered to come to 
Brook Army Medical Center to attend to her husband's care, and 
she, of course, wanted to come anyway. She didn't need to be 
ordered. But the practical impact of that was that she had to 
quit her job. And while the wounded warrior receives their 
income, that may mean, and in this case for a family with five 
children, that the family is living on much diminished income.
    I, frankly, don't know exactly what to do about that, but I 
wondered whether Secretary England or Secretary Chu, you might 
be the appropriate people to speak to that. Is there any 
assistance under current authorization that we could provide to 
the spouses or family members who essentially give up their 
jobs to come care for these wounded warriors?
    Dr. Chu. We do provide, under current law, assistance with 
travel. We pay for the travel, basically, if they wish to come, 
and it should be ``wish.'' I am a little startled by the report 
that they were ordered to do this and that certainly bears 
looking into.
    Senator Cornyn. I think that was one particular woman's 
interpretation, but the fact is, she wanted to be there----
    Dr. Chu. It still bears looking into----
    Senator Cornyn. She wanted to be there.
    Dr. Chu. So we pay for, under the statute you have enacted, 
we pay for transportation for multiple trips to the bedside. We 
pay for per diem for a period of time to cover your expenses. 
But it does not go to salary replacement under the current 
statutes.
    Mr. Cooper. May I--I don't usually like to interrupt and 
answer questions if I don't have to, but let me mention that a 
primary program that was set up 2 years ago is something called 
Traumatic SGLI. Traumatic SGLI was set up specifically to cover 
this type of problem, and it is given out predicated on what 
the disease or disability is, as determined by OSD.
    Senator Cornyn. Is that what Senator Clinton was referring 
to----
    Mr. Cooper. Yes, it is, and I do not know----
    Senator Cornyn [continuing].--and some problems with the 
claims there?
    Mr. Cooper. She said there was a problem, but the fact is--
--
    Senator Cornyn. What is the purpose of that program?
    Mr. Cooper [comtinuing].--that the decision is made by OSD 
that, yes, this person is eligible for that insurance and that 
then comes to us because we are the ones that take care of the 
insurance itself. Within 4 days, we will release a check, and 
it is in $25,000 increments up to a maximum $100,000, 
predicated upon the disability. But it was set up very 
specifically to help people who had to give up jobs and bring 
their family and live in someplace distant from their home.
    Senator Cornyn. Well, thank you for that clarification. 
Quickly, since my time is running out, one other feature that 
one of these spouses of the wounded warriors mentioned to me is 
that some of them, of course, suffer very disabling injuries, 
and that is what we are talking about, how to deal with those, 
but she was very concerned that the life insurance which they 
could afford at one point, once they are separated from the 
service, becomes unaffordable because many of these individuals 
have shortened life spans and are virtually either uninsurable 
or insurable at only a tremendous cost which is difficult for 
them to afford, so they let it go and they lose that financial 
security that might otherwise provide them some protection.
    Is there any provision under the current law made for 
either pre-paying or providing some additional premium benefit 
to assist these families? I don't know who the appropriate 
person to ask, but Secretary Cooper?
    Mr. Cooper. I think it is me again.
    Senator Cornyn. Thank you.
    Mr. Cooper. The SGLI does remain in effect for a brief time 
after the person leaves the service. However, we have other 
insurance policies that provide coverage for disabled veterans 
and the premiums are lower than what they would be 
commercially. So there are insurance programs and I would 
certainly be willing to have our people get together with your 
staff and talk about that very specific issue because we have a 
very strong insurance program within VA for this type of thing.
    Senator Cornyn. I would like that. My time has expired. Let 
me ask just one clarification. Secretary Cooper, did you say 
that your claims adjustors at the VA handle 109 disability 
claims per year each? Did I hear that correctly?
    Mr. Cooper. You heard correctly. When we take all the 
people in our compensation and pension program and divide them 
into the number of disability rating claims, it comes out to 
something like that. However, we have people that are doing 
many other types of claims, as well as public contact and 
outreach activities. Those people who are actually doing 
ratings are required to do 3.5 ratings a day. So those actually 
doing ratings on a day-to-day basis, of course, are doing many 
more. We also have others that are out at hospitals to help us 
ensure that we are working together with the veterans out 
there. So we have people placed to help us do the job better in 
treating the veterans.
    Senator Cornyn. Thank you very much. Thank you, Mr. 
Chairman.
    Chairman Akaka. Thank you.
    Senator Isakson?

               STATEMENT OF HON. JOHNNY ISAKSON, 
                   U.S. SENATOR FROM GEORGIA

    Senator Isakson. Thank you very much, Mr. Chairman, and I 
apologize to the panel and to you for being late, but this was 
one of those mornings. I am delighted that all of you could be 
here and I really have two questions and I will be brief, but I 
think I see General Schoomaker in the room and I want to take a 
moment here. I know there have been lots of questions about the 
Seamless Transition from DOD to VA. In our great State of 
Georgia, at the Eisenhower Medical Center in Augusta, Georgia, 
the General has single-handedly influenced a terrific 
transition from DOD to Veterans Health. It is a great success 
story. The volume of people now being processed there from 
Walter Reed and others has skyrocketed. I don't have my notes 
from a previous hearing, but it has gone up tremendously. I 
want to acknowledge General Schoomaker and how much I 
appreciate, the State of Georgia appreciates, and Augusta 
appreciates your demonstrating a ``can-do'' attitude and a 
``can-do'' seamless system for our veterans. So that is not a 
question, that is just a comment that I commend to everyone.
    Secondly, Secretary England--and this is a question and not 
a comment--this is DD Form 2900. This is the form that I 
understand is filled out as a serviceman is exiting the service 
to determine whether there is traumatic brain injury or Post 
Traumatic Stress Disorder. There is a nurse practitioner 
interview, but I am wondering if this form and what it asks, if 
you believe it, is adequate to make that determination or if 
there is a different way in which we should do it or more 
information that we should ask for.
    Mr. England. Senator, I believe that there is a lot we 
still need to know about TBI and so while there are evident 
cases and we have facilities and all to deal with that, I mean, 
part of our concern is that delayed TBI, I mean, people that 
actually have TBI and we do not recognize that early, so we are 
putting in programs and VA actually evaluates people now later 
on to determine, you know, do they have any TBI symptoms.
    So I think based on the knowledge we have today, this is an 
issue that we need to look at periodically. So whatever it is 
that we do immediately, there needs to be follow-up to that and 
I would say that that is the most important part of this thing, 
is to have a follow-up so that if we have evidence of this 
later on in life, that we can still help people deal with it.
    Senator Isakson. OK, and again, I am dealing with 
information and things I have been told, not things I know, so 
I want to qualify this statement by that. But having exited the 
service at one time, I know how quick an exit I wanted to make 
and filling out forms, I could do quite quickly. There have 
been some conversations about maybe there is a motivation to 
get the forms in, to get the work done, and then later those 
problems come up. So it seems to me like it would be very 
important to ensure there were follow-up mechanisms for that 
evaluation to take place.
    Mr. England. Can I have Dr. Chu address this a little more 
in detail?
    Dr. Chu. We completely agree with the issue of the 
serviceman eager to get home may wish to limit his or her 
involvement. That is the reason we have initiated a similar 
follow-up for everyone--active, Guard, and Reserve--3 to 6 
months after they have come back, and we are revising these 
questions specifically to deal better with Traumatic Brain 
Injury symptoms.
    Senator Isakson. My last statement is a comment that I 
thought I would share with all of you. We have all been working 
hard to see to it that the care our veterans get both while 
they are active DOD, under DOD, and when they leave the 
military is the best we can make it and VA has gotten 
tremendous accolades, last year in particular by being declared 
the gold standard, I think, in terms of an organization for 
health care.
    I wanted to share with you that I go out to Walter Reed any 
time there is a Georgia soldier there that I can visit with, 
and I happened to be going out ahead of a scheduled appointment 
the Monday after the Building 18 incident hit the media, and I 
went on out for two reasons. One was to see the soldier that 
was back from Iraq, and the other was to see Building 18. And 
while the Building 18 situation was somewhat disappointing, the 
soldier that I met with had been at Walter Reed for 10 days and 
I did what I always do. I asked for his mother and father's 
name and phone number and I told him I would call them and give 
them my cell phone number so if there were something he needed, 
instead of them having to come back on the spur of the moment, 
maybe my office could assist him.
    So I called his father and left a message and that night--
my time is expired but I am going to finish this statement, if 
the Chairman doesn't mind----
    Chairman Levin [presiding]. Keep going. Keep going.
    Senator Isakson. That night, his father called me back and 
thanked me for it and then he said, you know, I have been 
reading all this stuff about the questions, he said, but I was 
with my son for nine of the last 10 days and I have never seen 
someone receive better care.
    So you hear all the bad things, but that is not coming from 
me, that is coming from a constituent of a young man who had a 
very traumatic and severe arm injury. So as we work to improve 
the things we need to improve and make sure every case is a 
positive case, we can't forget the countless thousands of very 
positive things that are happening day in and day out in health 
care for our men and women in the military.
    And with that said, distinguished Senator from Michigan, I 
was handed a note to say we ought to go in recess, but you 
outrank me, so I am going to yield back to you and you do 
whatever we need to do.
    Chairman Levin. Fine. Thank you. We are going to go to a 
second round briefly and hope that some of the other Senators 
who were here, who didn't have a chance to ask questions and 
then had to go and vote, might come back in the next few 
minutes. We know, Secretary England, you need to leave at 
12:30, we understand.
    Mr. England. I was actually hoping to leave at 12 o'clock, 
Senator Levin----
    Chairman Levin. No, that is fine.
    Mr. England. Secretary Gates is----
    Chairman Levin. We understand. We will try to accommodate 
you. I misspoke. They did tell me it was noon and I misspoke.
    Mr. England. Thank you.
    Chairman Levin. Anyway, Senator Isakson, if you have 
additional questions, feel free to ask them. If not, I will ask 
questions.
    Senator Isakson. Go right ahead, Mr. Chairman.
    Chairman Levin. Thank you. The Army Inspector General 
report found that the VA schedule for rating disabilities does 
not accurately reflect medical conditions and ratings in 
today's environment. That schedule was developed when the 
American economy was more industrial-based. It is now more of 
an information age where employability does not rely as much on 
physical factors, although that has been changing over time, 
obviously.
    To a greater extent in an industrial economy, losing a hand 
or a foot might render somebody unemployable, at least for some 
positions, while in the information economy--and it is not all 
just black and white but I think you understand what I am 
driving at--to a greater degree in an information economy, an 
amputee's professional life would not be affected by the loss 
of an arm or leg, for instance. On the other hand, in an 
information economy, PTSD or TBI might render someone more 
unemployable or less employable who is otherwise healthy by 
measures of the greater industrial economy.
    I am just wondering whether or not there is any truth for 
that and whether or not this VA schedule for rating 
disabilities adequately reflects any changes in medical 
technology as well as changing economic realities. So Secretary 
Cooper, let me call on you for that.
    Mr. Cooper. We have attempted to look at the various 
ratings through the years and make some minor changes, but it 
is all predicated, of course, on Title 38 which was essentially 
put together, I think, back in 1944. This is one of the primary 
reasons I believe that Congress set up General Scott's 
Commission to look at the entire ratings schedule, as well as 
the application of it. So I would like to defer to General 
Scott.
    Chairman Levin. All right. I know you have to leave, 
Secretary England, and I will call on General Scott in a 
moment, but since you have to leave, let me address a question 
to you, and I don't know if it has already been answered, just 
say so and I will look up your answer.
    There was a GAO report in March of 2006 which criticized 
the Department and the services for failing to systematically 
determine the consistency of disability decisionmaking. The 
Department has issued timeliness goals for processing 
disability cases, but there is no collection of information to 
determine compliance. Finally, the consistency and the 
timeliness of decisions depend in part on the training that 
disability staff receive. However, the GAO found that the DOD 
is not exercising oversight over training for staff in the 
disability system. Are you familiar with that GAO report?
    Mr. England. No, sir, I am not. Dr. Chu, could you----
    Chairman Levin. I will tell you what, Doctor, because I see 
we have got a number of Senators here and I want to call on at 
least a couple of them, if I could, before Secretary England 
leaves, and I want to yield at this point my time to, if you 
are ready, Senator Murray.
    Mr. England. We will get back with you on that question, 
Senator.
    Chairman Levin. I am going to yield my time here. I know 
Senator Murray has been so deeply involved in these matters and 
has made such a huge commitment to reform in this area and to 
making changes which will help veterans that I want to yield my 
time now to Senator Murray so that she can ask you questions, 
if that is her intent, before you leave in a few minutes. 
Senator Murray?

                STATEMENT OF HON. PATTY MURRAY, 
                  U.S. SENATOR FROM WASHINGTON

    Senator Murray. Mr. Chairman, thank you very much. I am 
delighted to be able to get back. There are a number of 
hearings going on, but I think this is probably one of the most 
important hearings that we are having in the Senate in quite 
some time because bringing all of you together to have a chance 
to see how we can solve this crisis that is facing so many of 
our young men and women who fought so hard for us. I was here 
for all of your testimony before, and General Scott, I know you 
are retired, you mentioned that, but I certainly was impressed 
with the recommendations that you brought to us and I hope, Mr. 
Chairman, we can incorporate some of those in whatever we need 
to do legislatively to help us move to a system that is 
seamless, that we don't lose so many of our men and women in.
    I have been out talking to them, like many of us have here, 
and the frustration is so high among those people who just feel 
like the system is against them. They fought the war and now 
they are fighting their own system here to try and get what 
they have earned rightfully. So I really appreciate all of your 
testimony and all the Committee Members to take the time to 
really look at how we can get a seamless transition, and I 
appreciate it very much, Mr. Chairman.
    I do have a couple of questions, and I am sorry I wasn't 
here for a number that were asked, but I am extremely concerned 
about the low number of permanent disability retirements. Back 
in 2001, we had 642 people with permanent disability. That has 
dropped all the way down to 209 in 2005 and it just doesn't 
make sense to me, looking at the statistics we have. We know 
that in Vietnam, the wound-to-kill ratio was 3:1. It is now 
16:1, so we know we have a high number of men and women who are 
coming home injured.
    Secretary Cooper, I wanted to ask you, there is a lot of 
concern out in the community that DOD is deliberately 
underestimating servicemen's disabilities to either lowball the 
cost of it or to not have it become apparent. Can you address 
that concern for us, perhaps tell us why there is such a low 
number of disability numbers and what we need to do to assure 
people, or what you can do to assure people, or what we are 
going to do in the future to make sure these people get the 
correct disability rating?
    Mr. Cooper. Could I please divert that question to Deputy 
Secretary England, because it is a DOD question and I would 
just as soon he answer it.
    Senator Murray. OK.
    Mr. Cooper. He is here just for a few more moments.
    Senator Murray. I will let him do that.
    Mr. England. I didn't leave in time.
    [Laughter.]
    Mr. England. No, Senator, I am not familiar with the 
statistics. Obviously, you are right. There are more wounded 
now than we had before on a ratio basis. I am not sure why 
those numbers are lower.
    I do want to comment, however. There is absolutely no 
incentive in this Department to save money on the backs of 
disabled people, people who have served our country. I mean, 
the people who do this are professional people. I think in 
aggregate, they absolutely have no idea how much money we 
spend, et cetera, so I think----
    Senator Murray. Well, you should know that of those 
soldiers that I have talked to, many of them feel that they are 
being deliberately lowballed when it comes to their disability 
rating in order to save money.
    Mr. England. Well, let me assure you that is not the 
reason. I mean, I commented to Senator Specter, I would step 
back, because again, sometimes at my level you get inputs and 
it is different than what you perceive, but I can tell you, at 
my level, I mean, we fund what we need to fund in all of our 
medical and all of our disability, and if people are running 
short on cash we just reprogram and make that money available 
to them.
    I believe people operate professionally within the 
guidelines they have in terms of making these determinations. 
We will step back and make sure that is absolutely the case. 
But I have no evidence that that has ever occurred, but I will 
step back and take a look at it. I mean, if that is a concern 
of the people, then we will step back and look at that again.
    Senator Murray. Well, I think all of us aggressively moving 
with a number of the things you have talked about to make sure 
that they have proper counseling, to make sure that they are 
supported, that their injuries are sufficiently diagnosed, will 
help that in the long run. But I am especially concerned about 
those members of the military who have been discharged, who 
have that unseen wound of the war, Traumatic Brain Injury or 
post-traumatic stress syndrome, who were rated incorrectly 
because, for whatever reason, lack of knowledge. How are we 
going to go back and capture those people and make sure that 
they are rated accurately?
    Mr. England. I share that concern. That is a discussion I 
have had, particularly TBI because it shows up later. We do 
have to have a way to deal with that. I know VA commented today 
that they actually assess people on an ongoing basis. Valid 
issue, valid concern. We need to make sure we address it right 
and we will work with VA. We are putting programs in place, but 
I share your concern because this is not something that shows 
up necessarily right away, and in fact, we are not even sure 
when it will show up----
    Senator Murray. No, and there aren't ten questions you can 
ask because everybody is impacted differently. I was at the 
Polytrauma Center in Seattle last week and they said that 
sometimes a soldier won't even remember he was in the vicinity 
of an explosion as the result of that explosion. So I am 
hearing you all that you are moving forward to try and address 
those issues so we don't lose those people, but I do want to 
make sure that those people who have already been discharged 
and are now finding that they have TBI, that they aren't lost. 
So I would like to hear back from you as to your recommendation 
on that.
    Mr. Chairman, I just want to point out one other quick 
issue and that is the whole issue of how our soldiers are 
rated. There was an article in the Takoma News Tribune about 
Fort Lewis in my home State last week that reported that 
allegations were being made that there was a Wal-Mart greeter 
test for an injured soldier. Basically, if they could respond 
and smile, then they were going to be OK. That was a very 
serious concern. I will get that article to you, but I wanted 
to make sure that you were investigating those allegations 
about what was happening there and could get a response back to 
us to make sure that we were not seeing that----
    Mr. England. No, I appreciate the input. We will--I 
appreciate knowing, hearing that, and we will get back with 
you, Senator. That is the first I have heard about that.
    Senator Murray. I have had soldiers say to me, I got the 
Wal-Mart greeter test so I got sent back to Iraq, even though 
they were suffering from post-traumatic stress syndrome and 
TBI, which to me is a real disservice both to the men and women 
who are there in Iraq and need to be able to count on the 
soldiers in their unit, but also to that soldier himself.
    Thank you, Mr. Chairman.
    Chairman Levin. Thank you, Senator Murray, and thank you 
for your leadership in this area.
    Senator Martinez?

                STATEMENT OF HON. MEL MARTINEZ, 
                   U.S. SENATOR FROM FLORIDA

    Senator Martinez. Mr. Chairman, thank you very much.
    I want to thank all the gentlemen here this morning for 
their testimony and dealing with these very, very important 
issues.
    I thought I would also add, Secretary England, my word on 
the announcement yesterday, and I would say that from my 
perspective and the people that I have talked to, I think the 
predictability in their lives of knowing, for families knowing 
when Daddy is coming home or when Mom is going to be back or 
how long they are going to be home is terribly important. And 
understanding the stresses that the Global War on Terror is 
placing on our military, particularly on the Army, I think that 
it is a good policy. While it would be best if we had a larger 
Army, one that I would support and one that I think we need to 
address as we look to the future, I think it is important for 
now, as we are going through these stressful times, that we 
give the families the predictability that Secretary Gates gave 
them yesterday. So I thank him for that.
    One issue that has appeared obvious to me as I have delved 
into this and, like others, visited with our wounded warriors 
is the adversarial nature of the way a disability rating and 
system all seems to go. I spent most of my professional life 
representing injured people before insurance companies and it 
doesn't seem to me that the attitude of an insurance adjustor 
ought to be the attitude with which the people that work for 
you, whether in the VA or in DOD, treat our wounded warriors. I 
think there needs to be a very different system and a much more 
benign system, particularly when we are dealing with combat-
related injuries, not just working at a base and filling up a 
truck and getting a back injury. I think these are very 
different kinds of injuries.
    One of the things that has been pointed out to me by one of 
our Floridians who has been injured is the issue of diagnostic 
codes for the Traumatic Brain Injury issue. It seems like the 
International Classification of Diseases does not have a 
specific classification or coding for DOD-wide on TBI patients 
and it would seem to me that that would be a good idea. Can 
you, Dr. Cross, or any one of you, address that specific issue?
    Dr. Cross. Senator, that is correct. When we assess the 
numbers of TBI, we look at a number of related ICD-9 codes. For 
doing statistical purposes, we look at perhaps a half-dozen of 
them or so that seem to be most related, for instance, post-
concussive syndrome. So we think that as medical science 
develops in this area, this is, in fact, an unmet need that we 
need to look at nationwide, a better way to identify this 
syndrome.
    Senator Martinez. If we did and had a code that was 
specific for the syndrome, then we would also be able to track 
people wherever they might be in the system and at whatever 
point in treatment they might be, correct?
    Dr. Cross. It would assist in that.
    Senator Martinez. Where are we on that? Are we going to be 
able to----
    Dr. Cross. What we are doing right now, of course, is that 
we are tracking and we are case managing and screening and the 
screening is a really important part. The mild to moderate 
cases, the ones that are not so easy to recognize when they 
first show up, the ones that I am concerned that we may miss, 
we are training our folks, developed the screening test, put it 
in place as part of our electronic health record so that when 
that OIF and OEF veteran shows up, we will put him through that 
preliminary test, and then if that triggers any concern at all, 
then at least the secondary screening and further assessment 
and treatment.
    Senator Martinez. But then the coding with a certain 
diagnosis would also be a part of it?
    Dr. Cross. Yes, sir. Then the diagnosis goes into our 
electronic health record.
    Mr. Cooper. Senator, may I also add----
    Senator Martinez. Yes, please.
    Mr. Cooper [continuing].--that under the ratings system 
that we have in VA, we do have three separate ratings for 
different kinds of brain injury, TBI being one of them. So, in 
tracking those people and their disability ratings, we do see 
that.
    Senator Martinez. Another issue that I have also seen in 
visiting the Polytrauma Center in Tampa is the issue of, you 
know, they are getting patients, but it seems to me in talking 
to the patients and them that it would have been better for the 
patient had they been moved to a facility like this much sooner 
rather than been at Walter Reed, say, for months on end. It 
would seem to me that the care would have been more precise and 
their rehabilitation would have been speedier had they been at 
one of your very excellent veterans' Polytrauma Centers than at 
Walter Reed or Bethesda, perhaps. Can you comment on that, sir?
    Dr. Cross. Senator, each case is unique and I want to point 
out something, that we work closely with our DOD associates on 
a daily basis at Walter Reed, at Bethesda, Brook Army Medical 
Center, and other locations. Our doctors are on the phone, our 
doctors are on e-mail, our doctors consulting back and forth. 
In fact, I wanted to point out from Tampa, we have a video 
teleconference back to Walter Reed and Bethesda where the staff 
at our Polytrauma Center talk to the staff at the Walter Reed 
treatment facilities. This is the kind of communication that 
helps us assess and make a unique assessment on each 
individual.
    Senator Martinez. The issue of the life insurance, again, 
has been brought to my attention, and I wonder if it is true 
that wounded soldiers suffering from loss of cognitive function 
from a TBI cannot be compensated for that loss absent an 
inability to perform an activity of daily living. In other 
words, if they have no ADL dysfunction as such, that they may 
then not be able to qualify for what may, in fact, be a 
lifetime injury.
    Mr. Cooper. You are correct. There are specific components 
in the law that are considered. An ADL is the one that covers a 
lot of things that are not otherwise covered specifically. So 
as the process works, someone helps the individual apply for 
TSGLI. DOD decides whether that individual is eligible, and 
then it comes to VA to distribute the money.
    Senator Martinez. But it seems to me that a Traumatic Brain 
Injury patient who may be able to perform all the activities of 
daily living, it is just that his cognitive capacity is 
diminished, but sometimes this is fairly discrete. It is not an 
obvious diminution. So they are, therefore, disabled, and 
perhaps permanently disabled. Is it fair that they would not be 
able to then be compensated?
    Dr. Chu. I think, Senator, you raised an excellent issue. 
It goes back to the statutory design of the traumatic injury 
insurance, which was modeled on standard commercial insurance 
products, and I think this issue should be looked at as part of 
this whole review.
    Chairman Levin. We will, Senator, take a look at that. As a 
matter of fact, it is very important that you raised that 
issue, and if you could give us data on that, and with your 
leadership, Senator Martinez, on that issue, because we are 
going to be marking up bills and we would include that.
    Senator Martinez. All right. Thank you, sir.
    Chairman Levin. Thank you so much. Senator Bayh?
    Mr. England. Mr. Chairman----
    Chairman Levin. I know you have to leave----
    Mr. England. Does Senator Bayh have a quick question, 
Senator?

                 STATEMENT OF HON. EVAN BAYH, 
                   U.S. SENATOR FROM INDIANA

    Senator Bayh. I have just one quick question for you, 
Secretary, if you can hang on for 30 seconds. My understanding 
is that--and I hope this is in your bailiwick, if not, you can 
feel free to delegate it to the appropriate panelist--active 
duty personnel, as I understand it, who suffer from a Traumatic 
Brain Injury have access to private facilities, caregivers that 
contain some of the latest cognitive therapies. Why has the DOD 
decided to do that?
    Mr. England. I believe they have the right to TRICARE. I 
mean, that is part of what they have. They have TRICARE and 
they have VA, so they can select. I mean, that is just part of 
the package of benefits----
    Senator Bayh. Well, the reason is the VA does not grant 
access to that kind of care. I am wondering why active duty 
soldiers do.
    Dr. Chu. Because, sir, it is part of the TRICARE package. 
We don't want people to feel they are constrained in their 
choices and that is why we built that kind of network.
    Senator Bayh. Well, implicit in that must be some sort of a 
determination that it is beneficial treatment.
    Dr. Chu. Sir, we are not trying to----
    Mr. England. Pardon me. Sometimes, it is just closer to 
where they live, so it just may be physically convenient. There 
are four Traumatic Brain Centers, for example, VA has, but 
there are people who may not be close to those, but there may 
be a private center that is also very, very well known, so they 
may elect through TRICARE to go to that center.
    Senator Bayh. And why is that care not available to the 
retirees in the VA system?
    Dr. Chu. If you are retired, you also get TRICARE, so it is 
available to retirees.
    Senator Bayh. What I have been told is that they have 
access to some private providers in other areas, but not for 
TBI services.
    Dr. Chu. We will have to look at that.
    Senator Bayh. Because I think the VA has considered this 
kind of cognitive therapy to be unproven.
    Mr. England. It has come to my attention--we have had some 
of these discussions, and so I can talk broadly. We have had a 
couple of specific cases where I know have come to my office 
where we worked with VA and they have gone to private TRICARE 
type of care, so I don't know about this broadly, Senator, but 
my understanding is that is available. Now, of course, there 
are four expert VA centers, and, of course, people tend to want 
to go to those centers because they are expert, but there are 
also very excellent private care centers and people have 
expressed a desire to go there. So the cases I am familiar 
with, they did end up at a TRICARE facility.
    Senator Bayh. I am told that is a result of appealing the 
initial determination that they could not receive that kind of 
care.
    Mr. England. I don't know exactly what led to it, but my 
understanding is that is an option that they do have.
    Senator Bayh. So what you are telling me is there's no 
disconnect between active and retired status, that they have 
access to the same kind of private care, the same kind of 
cognitive therapy----
    Dr. Chu. Yes, Senator----
    Senator Bayh [continuing].--whether they are active or 
retired?
    Dr. Chu. The network is the same whether you are active or 
retired. It is the TRICARE network. If the private facility is 
part of the network, then, yes, sir, it is available to 
everybody who has TRICARE.
    Senator Bayh. I don't know whether, Secretary Geren, this 
is appropriate for you or Secretary Cooper----
    Chairman Levin. Senator Bayh, could we release Secretary 
England?
    Senator Bayh. Oh, absolutely. Thank you. You have been very 
patient.
    Mr. England. Thank you very much. Mr. Chairman, let me just 
say, I sincerely appreciate it. This has been very thoughtful, 
it has been very helpful, and extraordinarily beneficial. So I 
do thank you. This has been an excellent discussion this 
morning. I personally have gotten a lot of input that will be 
very helpful as we go forward. I expect that my colleagues here 
have also. And we do look forward to working with you in this 
area. I mean, we will work collaboratively to end up with the 
very best process we can as we go forward and I do thank you.
    Chairman Levin. We thank you and you are excused. We know 
you have got to fill the shoes of Secretary Gates today.
    Senator Bayh, let me get back to you.
    Senator Bayh. Thank you. I just have a couple more 
questions. Secretary Chu, let me get back to this. There seems 
to be some disconnect here. A couple of the groups that I have 
been in touch with, the Reserve Officers Association and the 
Wounded Warriors Association, are under a different impression 
about whether they are granted regular access to private 
cognitive care when they move from active to retired status. 
This has been a problem, at least from their perspective, for 
some time now, and what I understood you to say is that it 
shouldn't be a problem.
    Dr. Chu. It shouldn't, but if your office will forward us 
the specifics, we will be glad to look into these cases and 
understand where the confusion might arise.
    Senator Bayh. OK, because there have been a number of 
instances and they are clearly under the impression that many 
of these individuals who have their status changed, not in all 
cases, but for TBI the kind of therapy that they have access to 
is not as generous. They are clearly under that impression.
    Dr. Chu. If you give us the details, we will be glad to 
look into it.
    Senator Bayh. OK. I would very much appreciate following 
up, because I would like to correct any deficiencies that exist 
and I know you feel the same way.
    My final question, Mr. Chairman, would be to either 
Secretary Cooper, you or Secretary Geren, and I will leave it 
up to you gentlemen to decide who is appropriate. By the way, I 
appreciate all of your testimony. Secretary Geren, I was 
particularly impressed by your recitation of all the different 
things you are doing to try and get on top of some of the 
issues that need to be addressed. Maybe this is best left in 
your bailiwick, or Secretary Cooper. I will start with you.
    What is the VA doing so that 2 or 3 years from now, this 
whole TBI situation do we have the kind of system in place that 
ensures that they get the state-of-the-art care that we would 
like to see these individuals have?
    Mr. Cooper. I would like to ask Dr. Cross of VHA to please 
address that.
    Dr. Cross. Senator, this is an absolutely critical concern 
of ours, as well, so we share your concern. What we have done 
is this. I want to just give you a very brief answer but 
outline, and we can go into more detail with your staff at any 
time that you like. We created the TBI centers about 15 years 
ago and we now added to those by making them multi or 
Polytrauma Centers addressing a wide range of concerns, even 
blindness. But we have added onto that because we thought that 
was not enough and we want to get people closer and closer back 
to home and be able to follow them long-term----
    Senator Bayh. Can I interrupt you for just one second, Dr. 
Cross? To get back to my previous questioning, is it your 
understanding that individuals, in addition to the VA centers 
that you have described, have access to private providers in 
addition to that, or----
    Dr. Cross. I can't answer for TRICARE directly, but my 
understanding is that if you are TRICARE-eligible, you would be 
eligible for civilian care.
    Senator Bayh. Well, there is clearly a difference of 
opinion out there, but please continue.
    Dr. Cross. Level two, we wanted to get centers that were 
closer to home because we know the individual patient is not 
going to stay at those four centers. We created 21 of them, and 
building the expertise at those sites closer to home. But then 
we thought, still not enough, so we created our Polytrauma 
Support Clinic Teams even at smaller facilities, and we have 76 
of those as of this morning. And then at every facility, every 
medical center, a polytrauma point of contact.
    So what we are doing is building for the long-term, 
Senator. We want to make sure that we have robust capability, 
geographically dispersed wherever the veteran needs it.
    Senator Bayh. Good. Well, I appreciate that. This is, 
unfortunately, the signature injury of these conflicts and we 
are just beginning to understand how best to treat it, but 
clearly we have an obligation to these men and women for the 
long haul, so I am grateful for your efforts in that regard.
    Secretary Chu, we will follow up with you and your office 
to try and----
    Dr. Chu. We would be delighted, sir.
    Senator Bayh [continuing].--reconcile these two different 
impressions that exist. Thank you very much.
    Mr. Geren. Senator, if I could say something on the blast 
injuries, on Traumatic Brain Injury, I would like to just add 
one thing that has not been discussed today. In your 
authorization bill last year, you all created a program for 
blast effect research for brain injuries, for PTSD, for loss of 
limb, loss of eyesight, every aspect of it, and the Army is 
executive agent for that program. It is up at Fort Dietrich and 
we are building a system that is going to--it is a joint 
program, looks across all the services, and try to marshal all 
the resources and coordinate them so we do our best research 
and best application of that research we possibly can.
    It was an initiative that came out of the Congress a year 
ago and it is one where we have made great progress and I 
invite you and other Members of the Committee to go up to Fort 
Dietrich. General Schoomaker was there before he came down to 
Walter Reed, was in charge of that program and can speak with 
great detail to it. But it is a program that has made some 
great strides. There is much to learn, as has been reiterated 
today often. But the program up there is making considerable 
progress and it is one of the areas where the Congress and the 
Department have worked together to move ahead, so I want to 
thank you all for that.
    Senator Bayh. Thank you for that information and for your 
efforts. Mr. Chairman, thank you.
    Chairman Levin. Thank you, Senator Bayh.
    Senator Sessions?

               STATEMENT OF HON. JEFF SESSIONS, 
                   U.S. SENATOR FROM ALABAMA

    Senator Sessions. Thank you, Mr. Chairman.
    I guess I would agree with the vast majority of our 
Committee that people are working very hard. We have got some 
great capabilities in VA and in Walter Reed. I have been out 
there recently, and I don't think we have a lot of criticisms 
of it, the actual hospital and care, although I am sure there 
are things that could be done to improve. But fundamentally, 
there is too much bureaucracy, there are too many problems with 
paperwork, there are too many things not getting done on time, 
and I believe with some money and some determination, we can 
obliterate some of those walls and silos that are blocking easy 
communication and we can make life a lot less stressful for 
people who have suffered injury in the service to their 
country.
    Secretary Geren, I am not sure I understood what you said 
earlier, but did you indicate that the 15-month policy would 
not alter the National Guard policy on deployment?
    Mr. Geren. Yes, sir, it would not. Now, there is a National 
Guard unit that is in theater that has already been extended to 
16 months and that 16 months will stand. But the 15 month is 
for active duty.
    Senator Sessions. From reading the paper, I thought 
different, and that is the first I have heard that. I am glad 
to hear that because our Guard people are under a different 
relationship with the military and the Department of Defense. 
They are part-time soldiers and it is even more difficult for 
them to be called up very rapidly because they have jobs, and 
when they come back, they have to go back to those jobs. Our 
contemplation for their deployment is different, although I 
certainly agree with the others that we have this fabulous all-
volunteer active duty Army that can be overworked, also. So I 
am concerned about that and I am glad that you clarified this 
National Guard policy.
    I visited Walter Reed and Bethesda a few weeks ago, 2 or 3 
weeks ago, and General Schoomaker gave me a tour of the 
hospital and he had just--I am not sure he had even come on, 
maybe that day or the day before the hospital had fallen under 
his supervision. I noticed as he went about, he asked all the 
soldiers that we met with questions related to Traumatic Brain 
Injury. He asked them whether they were having trouble 
sleeping. He asked them several questions that would indicate 
whether or not they may have had a brain injury and he made it 
clear to me that he considered that a very important thing, 
that we were learning more about the problems of Traumatic 
Brain Injury, it was critical that we diagnose it early and 
that we help soldiers who are having difficulties, some of 
which are physical difficulties as a result of brain injury 
rather than post-traumatic stress syndrome-type situations. I 
did feel somewhat--I felt good about that because it is a real 
important part of what we are doing today.
    The current backlog on VA claims has grown. We got those 
numbers down, I guess, Secretary Cooper, the numbers were going 
down several years ago. Now, they are back to about 600,000, 
with 800,000 applications arriving or something. What is the 
status now, and isn't the number of backlogged, unanswered 
claims higher than it was several years ago, a couple of years 
ago?
    Mr. Cooper. The answer is, yes, they are higher. The number 
that we count is actually 400,000 disability claims. In 2003, 
we took it down to 253,000 and then a judge made a decision 
that made us stop dead in the water for about 4 months. His 
decision was that we could make no negative decisions for 1 
year. That immediately shot us up to about 320,000. Since then, 
we have done a lot of outreach. We have done a lot of things 
telling people to come in and the numbers have increased.
    Senator Sessions. How can a judge do that? The Department 
of Justice, somebody should be working to relieve orders that 
cause that much disturbance in your process, I would think.
    My time has expired, so I would just point this out. If you 
need additional people to meet this challenge, I think you 
should ask for it. I also think that perhaps you could use 
retirees, people part-time. People who have had experience in 
this could help you deal with this crunch if they were paid 
adequately. I just would support the concept that we can't have 
these numbers going up. They need to be going back down, and I 
was hoping that we would be below 200,000 instead of being back 
up to 400,000.
    Mr. Cooper. May I just tell you that in the last 5 months 
we have brought aboard 54 retired annuitants to help us do some 
of this work. Now, they are not direct employees, so there are 
certain things that they cannot do, but we bring them back----
    Senator Sessions. Could we change the law that would help 
us a little bit on that?
    Mr. Cooper. You might be able to. What we are using them 
for right now are the oldest claims because we can allow them 
to do that. They are also helping in training. They are helping 
in mentoring.
    Chairman Levin. Thank you, Senator Sessions.
    Senator Rockefeller?

           STATEMENT OF HON. JOHN D. ROCKEFELLER IV, 
                U.S. SENATOR FROM WEST VIRGINIA

    Senator Rockefeller. Thank you, Mr. Chairman. I apologize 
for being late but we are trying to make a little progress on 
the intelligence authorization, not much, just a little.
    A couple of things. I know that Senator Warner and Senator 
Webb described this earlier, but I was listening to NPR this 
morning and they were reporting, therefore it was their report, 
not the actual words, the military was saying that this stretch 
to 15 months was to give predictability and stability to the 
family. I just had a very bad reaction to that simply because 
we all know that DOD is trying desperately to recruit and you 
are having a very hard time and you are offering all kinds of 
things. If that is the case, there is nothing wrong with saying 
that. The American people are prepared to hear that. But if you 
say, we are trying to increase the predictability for families 
so they can plan better for a whole year home, it struck me as 
difficult. I am not asking for a response.
    I don't know how much mental health has been discussed 
here, and I am at a disadvantage that way, but you do have an 
executive council with VA and DOD and it is a mental health 
working group and it is focusing on the increasing 
collaboration between VA and DOD, which I am always, always 
for, on mental health illnesses to both VA and DOD 
beneficiaries.
    Now, as I understand it, the assessment of opportunities 
for greater collaboration, which is a logical first step before 
you do something, on mental health issues were in education and 
administration and in transition of care. What I would like to 
get is an update, number one, what has been done with respect 
to these recommendations? Secondly, is there a time line as to 
when you wish to see them in effect?
    Dr. Chu. Let me address that and invite my VA colleagues to 
join me. First, the intent is to pool our efforts so we can 
serve our populations better. We recognize some of these issues 
are issues that continue long after military service and that 
is the thrust, the theme of these initiatives.
    In terms of completion----
    Senator Rockefeller. No, I didn't mean completion in terms 
of PTSD, because it can last a lifetime and usually does. I am 
asking when they will be in place so you can proceed--VA and 
DOD can proceed.
    Dr. Chu. We have already put in place important elements of 
what we aim to achieve in this regard and that starts with, as 
has been discussed earlier this morning, or was discussed this 
morning, the ability of servicemembers who believe they have a 
disability that would be positive rated by DOD-VA to begin the 
benefits delivery process before they leave military service. 
So now, under the process we have put in place, you can start 
applying while you are on active duty to begin dealing with 
this rather than dealing with it after----
    Senator Rockefeller. I have got to understand better. What 
can the VA or the DOD military personnel look forward to at 
this point? What can they say, this is in place, this----
    Dr. Chu. If they believe they have a disability that will 
be positively rated, they can begin applying to the VA for VA-
based benefits while they are still on active duty starting 6 
months before their discharge, so that the old system where you 
had to wait until you were discharged in order to apply, which, 
of course, immediately creates a gap, is----
    Senator Rockefeller. Understood. When you say they believe 
they need the help----
    Dr. Chu [continuing].--we attempt to close by saying you 
can start----
    Senator Rockefeller. It is an American characteristic to 
deny mental illness. We are getting over it, but I would 
imagine that there are a lot of people denying it--you 
understand my question.
    Dr. Chu. I understand, and on that--so in terms of 
availability, we are trying to move it up to start while you 
are active duty.
    Second, in terms of trigger, in terms of clinical review, 
an important tool, as you know, is our assessment of your 
status before you depart, our reassessment when you return, and 
then our post-deployment reassessment 3 to 6 months after you 
have returned, whether you are still in the military or not. 
Now, those assessments are used to trigger referrals. We are in 
the process of sending those records also to VA so they can use 
the basis for their care effort. Both enterprises have sought 
to increase staffing levels to deal with PTSD and similar 
mental health problems as part of the overall demarche.
    Senator Rockefeller. I wish we could explore this a lot 
further, but my time has expired.
    Chairman Levin. Thank you, Senator Rockefeller.
    Senator Akaka?
    Chairman Akaka. Thank you very much, Mr. Chairman. I want 
to first ask unanimous consent, Mr. Chairman, that two items be 
made a part of the record of today's hearing, a statement from 
the Disabled American Veterans regarding their research into 
the disparities of disability ratings among the military 
services, and the recent U.S. News and World Report article 
entitled, ``Cheating Our Vets: How the Pentagon Is 
Shortchanging Wounded Soldiers.''
    Chairman Levin. That will be made part of the record, and 
any other statements of other organizations representing 
veterans, I know that both you and I would welcome them for our 
record, as well.
    Chairman Akaka. Thank you. Mr. Cooper, what prevents VA 
from awarding disability benefits for seriously wounded and 
injured servicemembers in the month following their separation 
from active duty?
    Mr. Cooper. We attempt to decide the claim immediately. But 
the way the law is set up, and I think General Scott addresses 
it quite well in his report, is that if the judgment is made at 
a given point, the veteran cannot get paid during that month. 
If the veteran files within a year of discharge, we go back to 
the date of discharge. If he is discharged sometime during the 
month, we can't pay for that first month and he does not start 
accruing the pay until the beginning of the following month. So 
there is up to a 40- or 45-day gap--am I not right, General 
Scott?
    General Scott. Yes, that is my understanding.
    Mr. Cooper. So it is strictly a decision that has come 
about as a consequence of the omnibus bill of several years 
ago.
    Chairman Akaka. So what you are saying is that because of 
the law----
    Mr. Cooper. Yes, sir.
    Chairman Akaka [continuing].--VA is not able to award 
disability benefits?
    Mr. Cooper. Yes, and General Scott recommended that 
something be done about that.
    Chairman Akaka. Thank you for that.
    Secretary Geren, I understand that many members of the 
National Guard who are seeking VA disability ratings may have 
to wait an additional 2 to 3 months for their claim to be 
processed pending authorization for their National Guard unit 
to release their records. I would ask you to please look into 
this and report back on what can be done to resolve this 
problem, or if you have any comments at this time on that.
    Mr. Geren. I am not familiar with that specific problem, 
but we certainly will look into it.
    Chairman Akaka. Thank you. General Scott, I know that you 
cannot speak for the Commission, but in your personal view, 
based on your work as the Commission Chairman, do you have any 
thoughts on what is needed to improve the cooperation and 
coordination between DOD and VA?
    General Scott. Thank you for the question, Mr. Chairman. I 
would like to start out by saying that nothing I have said 
should be construed to imply that VA and DOD aren't doing their 
jobs well. What I have attempted to portray is the difficulty 
at the transition for a soldier, wounded or otherwise, but we 
are mostly focused on the wounded and injured right now, from 
active military service into the VA system.
    I do have some specific recommendations on that. There are 
a number of them in my written statement and I mentioned them 
in the oral statement, as well. I really believe that beyond 
what I have already said, I don't have anything really to add 
to that. If you would like to follow up with a little more 
specific question, I will try to answer it, sir.
    Chairman Akaka. I don't at this time have any specific 
question except to rely on your experience and background and 
your knowledge of the problems we are talking about. As we work 
together here, we are trying to look for solutions to these 
problems and you have been very, very helpful today in your 
comments. We look forward to continuing to work with you on 
that.
    Thank you, Mr. Chairman.
    Chairman Levin. Thank you, Chairman Akaka.
    Senator Rockefeller?
    Senator Rockefeller. Thank you, Mr. Chairman. I will just 
ask this final one.
    The hearings on disability benefits vary enormously amongst 
the services and it sort of takes me back to Gulf War I when 
the services couldn't communicate with each other because they 
all had different--well, this is a very different kind of a 
difference, but it is also a very painful one and a very costly 
one. Each one has separate Physical Evaluation Board systems, 
each service. In the Air Force, 27 percent of disabled airmen 
receive a disabilities rating of 30 percent or higher, whereas 
in the Army only 4 percent of disabled soldier receive the 30 
percent rating. In the Marine Corps, it is 3 percent, and that 
means that the ground troops who are collectively taking the 
brunt of all of this and getting the grievous injuries are the 
ones who are being rewarded with disproportionately less 
generous disability benefits. I am not trying to make a 
statement about the rules here, but I would be curious as to 
any comments that you had on that.
    Mr. Geren . Let me just speak to the statistics that you 
have cited. It was reported widely in the press, and I believe 
to the Congress, that the Army disability retirement number was 
4 percent, and it gave the Air Force a number in the 20's and 
the Navy in the 30's, I believe, 34 percent. For some reason, 
that report failed to include temporary and permanent 
retirement for the Army. The Army number is actually around 20 
percent, 19.5. This coming year, or the last year, it is in the 
low 20's. But there is a difference between the services. I am 
not suggesting there is not.
    Our evaluation board looks at fitness for service. Every 
service sees its mission differently. I can't tell you today 
without having looked at all the different services if that 
explains the disparity. It is something that we have to look 
at. But the disability system for each service is based on 
fitness for service in that service, so there is some 
variation. But whether or not that explains that wide 
difference, I can't tell you today, but that is one of the 
issues we will certainly look at.
    Senator Rockefeller. What is the engine that drives the 
pursuit toward getting that question answered, why the 
differences? I mean, in other words, you are all tasked with 
it. Everybody has their own approach to it. But there has to be 
some kind of an engine or an incentive or something which 
drives you, and I presume that is what the Board was set up 
for.
    Mr. Geren. I am not sure I understand which board you are 
referring to.
    Senator Rockefeller. Well, the Physical Evaluation Board 
systems.
    Mr. Geren. The Physical Evaluation Board system is a Title 
10 product and each service uses it to determine whether or not 
a servicemember, in our case a soldier, is fit for duty, can 
remain on active duty, and we have different missions and 
different criteria for making that determination. So from the 
service perspective, that is really the reason for that board--
--
    Senator Rockefeller. So is it your point of view, in other 
words, the system is working exactly as it ought to be working?
    Mr. Geren. No, sir, I wouldn't draw that conclusion at this 
point. I am explaining the purpose behind the system. Now, as 
we look at this system, I believe that what we have seen and 
what we have learned over the last several months and what we 
have learned, frankly, over the last several years is this 
system does not work well. It is cumbersome, it is 
bureaucratic, in some cases it is adversarial when it should 
not be. I think at the end of the day, the recommendations that 
are going to come from the services and from these various 
commissions is that we come up with a new system.
    What we have tried to do, working within the system, until 
we have that long-term fix, is make the system work better for 
the soldiers and we have done that by providing stronger 
advocacy for each of the soldiers working through the system, 
improving the quality of the liaison officers that work with 
them, improving the quality of the nurse case managers that 
work with them, giving them advocates to help them make the 
system--giving them an 800 number that they can call if the 
system fails.
    But what I can't speak to today is a full explanation for 
the difference between our results, the Navy's results, the Air 
Force's results, but that is an area that we will look into.
    Senator Rockefeller. I thank you and I thank the Chairman.
    Chairman Levin. Thank you, Senator Rockefeller.
    There has been a lot of discussion today about having a 
single physical exam and who should do it and whether or not we 
ought to have a function that is given to the military as to 
whether you are fit for further duty, and then perhaps the VA 
to have the physical exam so we have one physical exam. Another 
approach or perhaps an interim approach to that would be for 
the Services to have a mandatory physical examination as a 
prerequisite for completing the separation process. This was a 
recommendation of the Presidential Task Force back in 2003.
    So, Secretary Chu, what about it? What do you think about 
having a single mandatory physical examination before you are 
separated out?
    Dr. Chu. I think the conclusion of the medical community is 
that that is probably more than you want and would threaten the 
excellence of the rest that you do, which ought to be focused 
on those who have an issue that comes forward. Now, in the 
military service, I think it is an issue of timing. In the 
military service, you are required to have a physical 
examination at fixed periods, and so we do have a baseline of 
data as to your situation to use for the future.
    Chairman Levin. How often is this examination given?
    Dr. Chu. Our preference would be to focus on those who have 
a difficulty that means that there is going to be a claim. That 
is why we have put so much energy into the Benefits Delivery 
Discharge program, to address those cases with a single 
physical, really a single physical process would be a more 
accurate description, between VA and DOD at that point, make 
sure we do all the tests once. That means all the tests get 
done, but also we don't do them twice when they are 
overlapping, et cetera.
    Chairman Levin. We have legislation that would accomplish 
that.
    Dr. Chu. Sir?
    Chairman Levin. One of the things that we are going to be 
asking you all for is comments on the pending legislation and 
the bills that have been introduced in the Senate, plus the 
bill that passed the House, some of which address this multiple 
physical examination issue. And we are going to need your 
comments within 14 days because we are going to have a markup.
    We are going to obviously work closely with the Veterans' 
Affairs Committee, but the legislation has been assigned to the 
Armed Services Committee. I don't know if there is a sequential 
referral or not, but in any event, one way or another, the 
Veterans' Affairs Committee and any other committee that has 
jurisdiction over some of those issues will be not only welcome 
to be involved, but necessarily needs to be involved, so we 
will work closely with Senator Akaka and his Committee on that.
    But from your perspective, we are going to need your 
comments on the House bill and on the Senate pending 
legislation, the bills that have been introduced on not just 
that issue, but on all the other matters which are included in 
those bills.
    You said, Secretary Chu, that there is a routine physical 
examination so you have a baseline in the military. How often 
is that physical examination given?
    Dr. Chu. It varies, but I believe it is typically several 
years as the minimum period of time.
    Chairman Levin. Between exams?
    Dr. Chu. Between exams, right.
    Chairman Levin. So that is not----
    Dr. Chu. For a young, healthy population, I think most 
people would say that is appropriate.
    Chairman Levin. Well, it is not a great baseline, though, 
particularly when you are in active duty.
    Dr. Chu. Well, I think this is the beauty of our electronic 
records system which we have moved to, as well, and that is 
that you can accumulate data on the patient, so the fact that 
you don't have a complete physical doesn't mean you don't 
have--let me put it positively. When you see the patient and do 
various tests, those are all accumulated in the record.
    Chairman Levin. There are a number of questions which we 
have asked today which we will be needing replies from both of 
your agencies and it would be, I think, a very appropriate 
response to this joint hearing of two Committees if we actually 
could get joint replies from our military and from the VA on 
issues such as the electronic records system. When is that 
going to be ready? What is your time line? That is a question 
we asked earlier, also the single physical exam and a number of 
other issues.
    I would urge you to do that. We can't require you to do 
that, but we are trying to have a seamless approach here 
between these two Committees and that is what today's hearing 
really represents. It would be very, very valuable to us if 
your agencies would also make that same effort. I don't know if 
you need to print up new stationery, but somehow or other, get 
us letters and responses which reflect the common view.
    Dr. Chu. We are committed to that, sir. In fact, perhaps if 
I might give you some evidence, I will send you our annual 
report from our joint executive council which has been in place 
for several years now.
    Chairman Levin. I am not talking about a joint annual 
report. I am talking about specific answers to the specific 
questions which we have asked as to whether or not we can have 
a common position on a number of the key issues which have 
worked through this hearing. So we would just welcome that, and 
to the extent that you are able to do that, that would be a 
significant plus for us.
    Chairman Akaka, I think we will leave it to you, if you 
would, to wind up your thoughts. Excuse me, Senator Thune, you 
quietly entered here. I apologize. Senator Thune?

                 STATEMENT OF HON. JOHN THUNE, 
                 U.S. SENATOR FROM SOUTH DAKOTA

    Senator Thune. Thank you, Mr. Chairman, and I will be 
brief. I know you are interested in wrapping up and I 
appreciate you and Senator Akaka and your Ranking Members, 
Senator McCain and Senator Craig, for holding this hearing. I 
think this is very important that we get both the VA and the 
Department of Defense here together. These are issues that we 
all care deeply about. There is nothing more important than 
taking care of our military men and women.
    I guess I just have a couple of quick questions maybe to 
wrap things up here, and I would like to direct this to General 
Scott. The preliminary results provided to assess the level of 
consistency between disability ratings assigned by the DOD and 
VA, in that preliminary study, the study breaks out the 
disability ratings by service, and I guess my question is, has 
any analysis been done to look at how disability ratings for 
members of the National Guard and Reserve compare to the VA and 
to the active duty services?
    General Scott. Sir, that has not been part of the 
Commission's study.
    Senator Thune. Is there any thought about doing that, just 
to----
    Dr. Chu. If I may, Senator, the GAO report from March of 
2006 did actually address that question, did some fairly 
sophisticated statistical review of the records. It concluded, 
interestingly, that in terms of the percentage for rated 
disabilities, that if you have disability X, you did get more 
or less the same rating, no difference between active and Guard 
or Reserve. It did note there appeared to be some difference in 
terms of the disposition of the case in the sense of did you 
get severance, did you get temporary disability, did you get a 
permanent disability rating, although it acknowledged it did 
not have enough data with which to understand why those 
differences might exist.
    Mr. Cooper. I would say also that, in looking at some of 
our figures, when someone files a claim, we don't look to see 
if they are Reserve, National Guard, or regular. We get a 
claim. We then send them for a medical diagnosis and then we 
rate the claim with the information we have. So we attempt not 
to even think about that.
    One of the things I have noted is that, across the board, 
not for individual disabilities but for Reserve versus active 
service, you will find the active duty has a higher percentage 
of compensation. However, many of the active duty members are 
retiring following a long military career, and so we find that 
their ratings are a good bit higher than those of the 
reservists.
    The second thing is that the longer you are on active duty, 
the longer you are exposed to whatever problems you may have or 
you may get during that time. So it looks like there is a 
disparity if you compare the average Reserve and the average 
active duty servicemembers. But there are explanations for it.
    The third thing, if a person is a Reservist and retired on 
disability, that person is identified as active duty retired. 
So the person that is greatly disabled who is in the Reserves 
and being separated is recorded in the active duty column. 
There is nothing I can do about that yet, but that is the way 
the data is now reported.
    But I can guarantee you that when a person comes in, it is 
a person who comes in with a given disability and to the best 
of our ability we will do it exactly the same.
    Mr. Geren. Let me mention one thing additionally, just a 
safeguard in the system. If a member of the Reserve component, 
the Guard or Reserve appears before the Physical Evaluation 
Board, one of the Board members is always from the Reserve 
component just to make sure that that perspective is 
represented in the consideration. It is not saying it is fail-
safe and it is something that we have looked into, but that is 
one of the safeguards that is built into the system.
    Senator Thune. I appreciate all of your answers to that 
because I think it is obviously an issue that I never heard 
discussed or talked about until--and getting some of that 
testimony to that effect is very helpful.
    Mr. Geren. Let me add something else, if I may. The Togo 
West-John Marsh Commission as well as many of us who have met 
with soldiers at Walter Reed and elsewhere, we have heard some 
expressions of concern. They feel that the Reserve component, 
the Guard and Reserve is treated differently. Those are 
concerns we take very seriously. It should not happen, but 
there are perceptions in some quarters that there are 
differences in treatment and we are working very hard to 
address those concerns. I know General Schoomaker has worked at 
Walter Reed to address that. I have heard him speak to his 
staff out there on that point.
    We are one force today. As has been remarked earlier to 
Senator McCaskill, we are calling on the Guard and Reserve to 
be part of the operating force, no longer a strategic reserve. 
We are asking a great deal of them and their families. We are 
one force. We fight as one. We train as one. And to the extent 
there are any vestiges in the system that cause the Reserve 
component to be treated less well, we are doing everything we 
can to wipe them out. It is not to say there aren't some 
vestiges of that different status, but I can assure you it is a 
concern of your Army leadership, DOD leadership. We are one 
force and we are trying to make our systems reflect that.
    Senator Thune. I appreciate it. Thank you for that 
expression of your commitment, and I would say that we need 
to--we can ill afford to have that kind of a distinction based 
on what we are asking the Guard and Reserve to do these days. 
So to the degree that there are any discrepancies that exist 
residual from the old days, I hope that you will continue, and 
if we can be helpful in that regard in any way, please let us 
know how we can do that, as well. Thank you. I appreciate that.
    Thank you, Mr. Chairman.
    Chairman Levin. Thank you, Senator Thune.
    Senator Akaka?
    Chairman Akaka. Thank you very much, Mr. Chairman.
    For me, in closing, I note that I found this hearing to be 
quite helpful in the ongoing effort to promote greater 
coordination and cooperation between the Departments of Defense 
and Veterans Affairs.
    It is apparent to me, however, that our two Committees need 
to continue to coordinate our efforts if there is to be lasting 
and long-term improvement on how the two departments work 
together. I want to reiterate the message that the Chairman 
delivered here about wanting to have joint responses also to 
our specific issues and questions that we may have. This is 
particularly true on those specific areas where there appear to 
be gaps in the coverage provided to servicemembers and 
veterans. I am not sure we need to have regular joint hearings 
on that, although keeping that possibility in reserve may do 
wonders for focusing the attention of the leadership of the two 
departments. But I do believe we need to seek innovative ways 
to meld our oversight and legislative 
activities.
    As Chairman of the Veterans' Affairs Committee and as one 
of four Members who sit on both Committees, I pledge my effort 
to improve our joint activity, Mr. Chairman. As I said earlier, 
although there are two departments, both deal with the same 
individuals and we must ensure that servicemembers and veterans 
get the benefits and services they need and deserve, the 
benefits and services they have earned by their service.
    This, I feel, has been a great hearing and I want to thank 
Chairman Levin for his efforts and thank all of you for your 
responses and your helpfulness to what we are trying to do 
here. Thank you very much, Mr. Chairman.
    Chairman Levin. Thank you, Chairman Akaka. I think your 
statement speaks for all of us.
    I thank our witnesses. We look forward to your answers. It 
has been a very, very helpful hearing in many ways, not just in 
terms of the substance, the material that we have been able to 
obtain and understand, but also just the fact that these two 
Committees have met together in this way hopefully will compel 
some very close working together of the agencies that need to 
work together if we are going to eliminate the gaps that exist 
and the holes that we need to fill.
    So again, with thanks to all of our witnesses, we will 
stand adjourned.
    [Whereupon, at 12:58 p.m., the Committees were adjourned.]

                            A P P E N D I X

                              ----------                              

        Prepared Statement of Brian Lawrence, Assistant National 
            Legislative Director, Disabled American Veterans
    Chairmen and Members of the Committees:

    On behalf of the 1.3 million members of the Disabled American 
Veterans (DAV), thank you for the opportunity to bring greater 
awareness to a longstanding problem in the military disability 
evaluation system. In recent weeks, much attention has been drawn to 
substandard housing conditions found at Walter Reed Army Medical 
Center. While outrage over such inexcusable conditions was proper, a 
more serious issue than mold and mildew in dormitory rooms appears to 
have escaped initial public scrutiny. This problem, the serious 
underrating of disabilities that render servicemembers unfit for 
further service, adversely affects military personnel for years, 
perhaps the remainder of their lives.
    Injured servicemembers, are routinely denied benefits to which they 
are entitled. This occurs for a variety of reasons. Primary among them 
is that some military services consistently underrate the severity of 
those disabling conditions found to render the servicemember unfit for 
further service. One veteran was recently discharged while undergoing 
treatment for leukemia. Although treatment for leukemia entitled the 
veteran to military disability retirement, a 100 percent rating, and 
medical care for her children, among other benefits, the Army Physical 
Evaluation Board (PEB) and Physical Disability Agency (PDA) awarded her 
a 10 percent rating and severance pay. This soldier lost lifetime 
commissary and exchange privileges, military health care, and all other 
benefits associated with military retirement. Other examples include 
the PDA finding that mental disorders first diagnosed in service, as 
determined by military doctors, pre-existed service. The PEB and PDA 
have found pre-existence based on such evidence as the soldier having 
sought guidance counseling while in high school. There are other 
examples of abuses in the Department of Defense (DOD) administration of 
its disability evaluation system.
    Abuses such as these give the appearance that the DOD is seeking to 
avoid granting retirement benefits at the expense of war-time disabled 
veterans. While such an assertion may at first seem bold, one can 
derive few other conclusions in light of the numerous cases where 
nearly simultaneous disability ratings adjudicated by VA have been 
substantially higher than those assigned by the PEB and PDA. Over the 
past few months, since the DAV has once again begun efforts to urge the 
DOD to address this serious issue, we have collected more than fifty 
examples of cases where the disparity between PEB and VA ratings make 
it evident that a systemic problem exists. More examples arrive every 
week.
    As a military retiree, one of the most important benefits earned is 
comprehensive health care coverage. TRICARE is the DOD health and 
dental care program for retirees and members of the uniformed services, 
their families, and survivors. While veterans with VA service-connected 
disabilities are entitled to VA health care, their family members and 
survivors are not. Therefore, when a servicemember with a family is 
denied retirement benefits, the loss of those benefits can create 
significant financial difficulties. Imagine how such financial burdens 
can add to the hardships a servicemember and his or her family must 
endure during an already tumultuous period. In addition to facing 
serious and sometimes catastrophic health concerns along with a major 
career change, the servicemember must incur significantly increased 
expenses to provide for his or her family.
    There is no justification for the PEB and the PDA consistently 
underrating cases. PEB's do not adhere to the VA Schedule for Rating 
Disabilities (VASRD) as required by chapter 61 of title 10 United 
States Code because some in DOD assert that the law is ambiguous. The 
DAV asserts that this statute and the ruling by the U.S. Court of 
Claims in John F. Hordechuck vs. The United States (U.S. Ct. Cl. 492, 
1959) make it clear that DOD must use the VASRD as its standard for 
rating disabilities. Our opinion conflicts with that of the DOD General 
Counsel, which seems to hold that the law permits DOD to modify the 
VASRD for DOD purposes. While the DAV has serious reservations that 
such modifications are in accordance with the law, the purpose of this 
statement is not to debate our differences with DOD; rather, we seek 
legislative action to eliminate any ambiguity on this issue. Such 
legislation should make unmistakably clear that there is only one 
rating schedule, the one adopted by the Department of Veterans Affair, 
that the DOD does not have the authority to modify that schedule, and 
that decisions of the Court of Appeals for Veterans Claims interpreting 
the rating schedule must be followed by the DOD.
    We hope that the Committees will recognize the injustices that have 
been imposed by the PEB and PDA on members of the Armed Forces who 
became ill or were injured in the line of duty. We ask that the 
Committees will report a bill that resolves these serious problems.
                                 ______
                                 
    [S. 1065 introduced by Senators Clinton and Collins, and S. 1113 
introduced by Senators Bayh and Clinton follow:]

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 [From the U.S. and World News Report, posted online on April 8, 2007]

Insult to Injury New Data Reveal an Alarming Trend: Vets' Disabilities 
                          Are Being Downgraded

                          (By Linda Robinson)

    In the middle of a battle in Fallujah in April 2004, an M80 grenade 
landed a foot away from Fred Ball. The blast threw the 26-year-old 
Marine sergeant 10 feet into the air and sent a piece of hot shrapnel 
into his right temple. Once his wound was patched up, Ball insisted on 
rejoining his men. For the next three months, he continued to go on 
raids, then returned to Camp Pendleton, Calif.
    But Ball was not all right. Military doctors concluded that Ball 
was suffering from a Traumatic Brain Injury, Post Traumatic Stress 
Disorder (PTSD), chronic headaches, and balance problems. Ball, who had 
a 3.5 grade-point average in high school, was found to have a sixth-
grade-level learning capability. In January of last year, the Marine 
Corps found him unfit for duty but not disabled enough to receive full 
permanent disability retirement benefits and discharged him.
    Ball's situation has taken a dire turn for the worse. The tremors 
that he experienced after the blast are back, he can hardly walk, and 
he has trouble using a pencil or a fork. Ball's case is being handled 
by the Department of Veterans Affairs--he receives $337 a month--but 
while his case is under appeal, he receives no medical care. He works 
16-hour shifts at a packing-crate plant near his home in East 
Wenatchee, Wash., but he has gone into debt to cover his $1,600 monthly 
mortgage and support his wife and 2-month-old son. ``Life is coming 
down around me,'' Ball says. Trained to be strong and self-sufficient, 
Ball now speaks in tones of audible pain.
    Fred Ball's story is just one of a shocking number of cases where 
the U.S. military appears to have dispensed low disability ratings to 
wounded service members with serious injuries and thus avoided paying 
them full military disabled retirement benefits. While most recent 
attention has been paid to substandard conditions and outpatient care 
at Walter Reed Army Medical Center, the first stop for many wounded 
soldiers stateside, veterans' advocates say that a more grievous 
problem is an arbitrary and dysfunctional disability ratings process 
that is short-changing the nation's newest crop of veterans. The 
trouble has existed for years, but now that the country is at war, tens 
of thousands of Americans are being caught up in it.
    Now an extensive investigation by U.S. News and a new Army 
inspector general's report reveal that the system is beset by ambiguity 
and riddled with discrepancies. Indeed, Department of Defense data 
examined by U.S. News and military experts show that the vast 
majority--nearly 93 percent--of disabled troops are receiving low 
ratings, and more have been graded similarly in recent years. What's 
more, ground troops, who suffer the most combat injuries from the 
ubiquitous roadside bombs, have received the lowest ratings.
    One counselor who has helped wounded soldiers navigate the process 
for over a decade believes that as many as half of them may have 
received ratings that are too low. Ron Smith, deputy general counsel 
for the Disabled American Veterans, says: ``If it is even 10 percent, 
it is unconscionable.'' The DAV is chartered by Congress to represent 
service members as they go through the evaluation process. Its national 
service officers are based at each rating location, and there is a 
countrywide network of counselors. Smith says he recently asked the 
staff to cull those cases that appeared to have been incorrectly rated. 
Within 6 hours, he says, they had forwarded him 30 cases. ``So far,'' 
Smith says, ``the review supports the conclusion that a significant 
number of soldiers are being fairly dramatically underrated by the U.S. 
Army.''
    Magic number. In an effort to learn how extensive the problem is, 
U.S. News spent 6 weeks talking to wounded service members, their 
counselors, and veterans advocacy groups and reviewing Pentagon data. 
At first glance, the disability ratings process seems straightforward. 
Each branch of service has its own Physical Evaluation Boards, which 
can comprise military officers, medical professionals, and civilians. 
The PEBs determine whether the wounded or ill service members are fit 
for duty. If they are, it's back to work. Those found unfit are 
assigned a disability rating for the condition that makes them unable 
to do their military job. The actual rating is key, and here's why: 
Service members who have served less than 20 years--the great majority 
of wounded soldiers--who receive a rating under 30 percent are sent 
home with a severance check. Those who receive a rating of 30 percent 
or higher qualify for a host of lifelong, enviable benefits from the 
DOD, which include full military retirement pay (based on rank and 
tenure), life insurance, health insurance, and access to military 
commissaries.
    But the system is hideously complicated in practice. The military 
doctors who prepare the case for the PEBs pick only one condition for 
the service member's rating, even though many of the current injuries 
are much more complex. The PEBs use the Department of Veterans Affairs 
ratings scale, which grades disabilities in increments of 10 a leg 
amputation, for example, puts a soldier at between 40 and 60 percent 
disabled. The PEBs claim they have the leeway to rate a soldier 20 
percent disabled for pain, say, rather than 30 percent disabled for a 
back injury. If rated at 20 percent or below and discharged, the 
soldier enters the VA system as a retiree where he is evaluated again 
to establish his healthcare benefits. Ball, for example, was found by 
the VA to be 50 percent disabled for PTSD.
    Since 2000, 92.7 percent of the disability ratings handed out by 
PEBs have been 20 percent or lower, according to Pentagon data analyzed 
by the Veterans' Disability Benefits Commission, which Congress formed 
in 2004 to look into veterans' complaints. Moreover, fewer veterans 
have received ratings of 30 percent or more since America went to war 
in Afghanistan and Iraq, according to the Pentagon's annual actuarial 
reports. As of 2006, for example, 87,000 disabled retirees were on the 
list of those exceeding the 30 percent threshold; in 2000, there were 
102,000 recipients. Last year, only 1,077 of 19,902 service members 
made it over the 30 percent threshold.
    The total amount paid out for these benefit awards has remained 
roughly constant in wartime and peacetime, leading disabled veterans 
like retired Lt. Col. Mike Parker, who has become an unofficial 
spokesperson on this issue, to allege that a budgetary ceiling has been 
imposed to contain war costs. A DOD spokesperson, Maj. Stewart Upton, 
said that the Pentagon ``is committed to improving the Disability 
Evaluation System across the board and to  .  .  .  a full and fair due 
process with regard to disability evaluation and compensation.''
    Other data reveal glaring discrepancies among the military 
services. Even though most of those wounded in Iraq and Afghanistan 
have been ground troops, the Army and Marine Corps have granted far 
fewer members full disabled benefits than the Air Force. The Pentagon 
records show that 26.7 percent of disabled airmen have been rated 30 
percent or more disabled, while only 4.3 percent of soldiers and 2.7 
percent of marines made the grade. Services engaged in close combat, 
experts say, could be expected to find more members unfit for duty and 
meriting full retirement benefits. Instead, the Air Force decided that 
2,497 airmen fall into that category while the much larger Army, with 
its higher tally of wounded, has accorded those benefits to only 1,763 
soldiers since 2000.
    How many of these veterans' cases have been decided incorrectly? 
Nobody knows. These statistics show trends that are clearly at odds 
with what logic would dictate, but there has been no effort to discover 
how many of those low ratings were inaccurately conferred or to 
ascertain why the number receiving full benefits has declined during 
wartime or why there is such a discrepancy between the Air Force and 
the other services. But there is abundant anecdotal evidence of a 
process cloaked in obscurity and riddled with anomalies, and of ratings 
that are inconsistent and often arbitrarily applied.
    DAV lawyer Smith, for example, took on the case of a soldier whose 
radial nerve of his dominant hand had been destroyed, the same 
affliction former Sen. Bob Dole has. Like Dole, the soldier was unable 
to write with a pen or to button his shirt. ``There is one and only one 
rating for that condition, which is 70 percent disability,'' says 
Smith. The PEB gave the soldier 30 percent, the lawyer said, ``which I 
found to be fairly outrageous.'' Upon appeal to the Army Physical 
Disability Agency, the entity that oversees that service's disability 
evaluation process, the rating was raised to 60 percent. Smith recently 
took on another case, that of Sgt. Michael Pinero, a soldier who 
developed a degenerative eye condition called keratoconus that required 
him to wear contact lenses. Army regulations prohibit wearing contacts 
in combat, which should have made him ineligible for deployment and 
therefore unfit to perform his specific military duties. But the PEB 
ignored the eye condition, which Smith believes merited a 30 percent 
rating or more, and rated Pinero 10 percent disabled for shin splints. 
Smith has asked the Army to clarify whether it considers the regulation 
on contact lenses binding or, as one board member alleged, merely a 
guideline. Disputes over such distinctions are common in the Alice in 
Wonderland world of disability ratings.
    Controversy frequently surrounds decisions on which conditions make 
a soldier unfit for duty. Smith took issue with a recent statement made 
by the Army Physical Disability Agency's legal adviser, quoted in Army 
Times newspaper. The official said that short-term memory loss would 
not necessarily render soldiers unfit for duty since they could 
compensate by carrying a notepad. ``Memory loss is a common sign of 
TBI,'' Smith said, using the abbreviation for Traumatic Brain Injury, 
which has afflicted many soldiers hit by the roadside bombs commonly 
used in Iraq. ``The rules of engagement are a seven-step process  .  .  
.  If a suicide bomber is coming at you, you cannot stop and consult 
your notepad,'' he added. ``I find this demonstrative of the attitude 
that pervades the Physical Disability Agency,'' which is in charge of 
reviewing evaluations for accuracy and consistency.
    Trying to overturn a low rating can be a full-time job and an 
exasperating one. Take Staff Sgt. Chris Bain, who lost the use of his 
arms but not his sense of humor. ``They call me T-Rex because I have a 
big mouth and two hands and I can't do nothing with them,'' he jokes. 
He left the Army in February, but he still has plenty of fight in him. 
During an ambush in Taji, Iraq, in 2004, a mortar round exploded 2 feet 
away from him, ripping through his left arm and hand. A sniper's bullet 
passed through his right elbow. His buddies saved his life, throwing 
Bain on the hood of a humvee and rushing him to a combat hospital. Once 
transferred to Walter Reed, Bain refused to have his arm amputated and 
underwent eight surgeries to save it. That choice cost him. While an 
amputation would have automatically put him over the 30 percent 
threshold, the injury to his left arm was rated at 20 percent even 
though he cannot use the limb.
    Bain was angry. A noncommissioned officer who had planned on 20 or 
30 years in the Army, he knew his career was over, but he wasn't going 
to go quietly. ``I wanted to be an example to all soldiers,'' he said. 
``My job was to take care of troops.'' He went to find Danny Soto, the 
DAV representative at Walter Reed he'd heard so much about. ``Danny is 
just an awesome guy. He took great care of me, but he should not have 
had to,'' Bain says. Soto is a patron saint to many soldiers at Walter 
Reed. He walks the halls, finding the newly injured and urging them to 
collect documents for their journey through the tortuous--and, to many, 
capricious--system. Many soldiers are young, and after they have spent 
months or years recuperating, they just want to get home and are 
unwilling to argue for the rating they deserve. Even though he missed 
his wife and three children, Bain decided: ``I've already been here 2 
years, another one ain't going to hurt me. Too many people are getting 
lowballed.''
    With Soto's help, Bain gathered detailed medical evidence of his 
injuries and went to face the board. They gave him a 70 percent rating 
for injuries related to the blast except for his hearing loss, which 
was not considered unfitting since he had a hearing aid. Oddly enough, 
however, the board put him on the temporary disabled retirement list 
instead of the permanent list. ``What do they think, that after 3 
years, my arm is going to come back to life?''
    A lifetime of adjusting lies ahead for Bain. ``I can't tie my 
shoes, open bottles of water, or cut my own food,'' he says. ``I have 
to ask for help.'' The 35-year-old veteran has found a new sense of 
purpose. He's decided to run for Congress in 2008, and fixing the 
veterans' system is his top priority. ``I do not want this s - - - - to 
happen again to anyone. No one can communicate with each other. The 
paper trail doesn't catch up.'' It's a tall order, but the soldier says 
that he has ``100,000 fights'' left in him.
    A systemic fix doesn't appear to be anywhere in sight. A March 2006 
report by the Government Accountability Office found that Pentagon 
officials were not even trying to get a handle on the problem. ``While 
DOD has issued policies and guidance to promote consistent and timely 
disability decisions,'' the report concluded, ``[it] is not monitoring 
compliance.'' But the GAO report did spur Army Secretary Francis 
Harvey, who was forced to resign last month in the wake of the Walter 
Reed scandal, to order the Army's inspector general to conduct an 
investigation of the disability evaluation system. After almost a year 
of work, the inspector general's office last month issued a 311-page 
report that begins to pierce the confusion and opacity surrounding the 
process. While it does not determine how many erroneous ratings were 
accorded to the nearly 40,000 soldiers rated 20 percent disabled or 
less since 2000, it does make three critical points: (1) the ambiguity 
in applying the ratings schedule should end; (2) wide variance in 
ratings is indisputable, even among the three Army boards, and (3) the 
Army's oversight body is not doing its job.
    Way overdue. Army officials met with U.S. News to discuss the 
inspector general's report. ``This is something that has been near and 
dear to our hearts for a long time, and it's probably way overdue as 
far as having someone go and take a look at it,'' says a senior Army 
official. The inspector general's team found that Army policy was not 
consistent with the policies of either the Pentagon or the Department 
of Veterans Affairs. It recommended that the Army ``align [its] 
adjudication of disability ratings to more closely reflect those used 
by the Department of Veterans Affairs.'' For years, the Army has 
asserted that it has the right to depart from VA standards on grounds 
that it is assessing fitness for duty and compensating for loss of 
military career, not decreased civilian employability.
    Veterans' advocates argue that Federal law requires the military to 
use the Veterans Affairs Schedule for Rating Disabilities as the 
standard for assigning the ratings. But over the years, Pentagon 
directives on applying the schedule have opened up a whole new gray 
area by saying the schedule is to be used only as a guide. And the 
services have interpreted them in different ways, engendering further 
discrepancies. Soto, the DAV national service officer at Walter Reed, 
says that inconsistencies are especially prevalent in complex cases of 
Traumatic Brain Injury and Post Traumatic Stress Disorder. ``There is a 
saying going around the compound here,'' Soto says, ``that if you are 
not an amputee, you are going to have to fight for your rating.''
    The inspector general's report calls for ending the ambiguities. 
``What we're saying is it shouldn't be left to interpretation; it 
should be clearly defined,'' says one Army official. ``If there were a 
way to cut down on that ambiguity, I think that variance would 
decrease.''
    Finally, the report bluntly concludes that the system's internal 
oversight mechanism is not functioning. ``The Army Physical Disability 
Agency's quality assurance program does not conform to DOD and Army 
policy,'' it says the same conclusion the GAO came to a year ago. The 
inspector general's report adds evidence of just how little the 
watchdog is doing to ensure that cases are correctly decided. The 
agency is supposed to send cases to either of two review boards when 
soldiers rebut their rating evaluations, but from 2002 through 2005, 
the agency sent only 45 out of 51,000 cases to one of the boards. The 
other review board has not been used at all.
    The inspector general's team made 41 recommendations in all, 
finding among other things that the Army lacks a formal course for 
training the liaison officers who are supposed to guide soldiers 
through the PEB process, that the disposition of cases lags badly, that 
the computerized information systems are antiquated, and that the two 
key medical and personnel data bases are not integrated and cannot 
communicate with each other. The report has been forwarded to the 
action team that Army Vice Chief of Staff Richard Cody convened--one of 
many official groups formed since the revelations of substandard 
conditions and bureaucratic delays at Walter Reed.
    Veterans' advocates are skeptical that the administration or the 
military bureaucracy will make major changes anytime soon. In testimony 
to Congress last month, Veterans for America director of veterans' 
affairs Steve Robinson recommended taking the entire ratings process 
away from the Pentagon and giving it to the Department of Veterans 
Affairs. ``It's hard to ignore the fact that in time of war they are 
giving out less disability,'' he says. ``Is it policy? I don't know. 
But it is a fact.''
    Congress has not responded to this problem. Says Rep. Vic Snyder, 
the Arkansas Democrat who chairs the House Armed Services subcommittee 
on military personnel: ``This whole issue of disability ratings is very 
complex. It is not well understood by many people, including many in 
Congress. That is why we set up the [Veterans' Disability Benefits] 
Commission in 2004. We are hoping it will help us sort this out.''
    A lot is riding on the commission. Its chairman is Lt. Gen. Terry 
Scott, who retired in 1997 and ran Harvard's Kennedy School of 
Government's National Security Program until 2001. After the Pentagon 
data on the disability process were presented to the commission last 
week, Scott said ``we still don't understand the whys and wherefores'' 
of the skewed ratings. The core problem, he believes, is that ``the 
military was not designed to look after severely wounded people for a 
long time.'' The commission has not yet decided what changes it will 
recommend, but he said there is a general sense that ``one physical 
exam at the end of service should be enough for both agencies, DOD and 
VA.''
    Cash and staff. Any solutions that call for transferring more 
responsibility to the Department of Veterans Affairs will have to be 
matched by enormous infusions of cash and staff. Already, the VA is 
reeling under a backlog of over 600,000 claims from retired veterans, 
which the agency predicts will grow by an additional 1.6 million in the 
next 2 years. Harvard Prof. Linda Bilmes, an economist who has 
published two studies on the costs of the Iraq war and the associated 
veterans' costs, projects that as much as $150 billion more will be 
required to deal with the wounded returning from Iraq and Afghanistan.
    Meanwhile, people like Danny Soto want to know who is going to stop 
the military boards from giving out ratings like the 10 percent given 
to one soldier for a skull fracture and Traumatic Brain Injury, when 
the VA later assigned a 100 percent rating. Soto is also frustrated by 
a recent case in which a soldier whose legs had been severely injured 
in a blast in Iraq was given only a 20 percent disability rating for 
pain and by the treatment of a man who has a bullet hole through his 
eye and suffers from seizures. As Soto sat with that soldier in front 
of the board, he asked why he had been placed on the temporary list. 
``At what point do you think he is going to fall below 30 percent?''
    Soto is unsparing in his criticism of the bureaucracy. ``This 
system,'' he says, ``is so broke.'' Old soldiers say the root of the 
problem is an Army culture that preaches a ``suck it up'' attitude. 
``If you ask for what you are due, you are perceived to be whining or 
trying to pad your pocket,'' says a retired command sergeant major. 
``If you're not bleeding, you're not hurt. That's what we were 
taught.''

  

                                  
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