[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
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[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.''