[Senate Hearing 110-638]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 110-638
 
 REVIEW OF VETERANS' DISABILITY COMPENSATION: EXPERT WORK ON PTSD AND 
                              OTHER ISSUES

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

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                       ONE HUNDRED TENTH CONGRESS

                             SECOND SESSION

                               __________

                           FEBRUARY 27, 2008

                               __________

       Printed for the use of the Committee on Veterans' Affairs



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



                   U.S. GOVERNMENT PRINTING OFFICE
41-916 PDF                  WASHINGTON : 2008
----------------------------------------------------------------------
For sale by the Superintendent of Documents, U.S. Government Printing 
Office Internet: bookstore.gpo.gov Phone: toll free(866) 512-1800; DC 
area (202) 512-1800 Fax: (202) 512-2104  Mail: Stop IDCC, 
Washington, DC 20402-0001


                     COMMITTEE ON VETERANS' AFFAIRS

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


                            C O N T E N T S

                              ----------                              

                           February 27, 2008
                                SENATORS

                                                                   Page
Akaka, Hon. Daniel K., Chairman, U.S. Senator from Hawaii........     1
Murray, Hon. Patty, U.S. Senator from Washington.................     2
Burr, Hon. Richard, Ranking Member, U.S. Senator from North 
  Carolina.......................................................     3

                               WITNESSES

McMahon, Joyce, Ph.D., Managing Director, Center for Health 
  Research and Policy, CNA Corporation; accompanied by Eric 
  Christensen, Ph.D., Senior Project Director, Center for Health 
  Research and Policy, CNA Corporation...........................     5
    Prepared statement...........................................     7
    Response to written questions submitted by Hon. Daniel K. 
      Akaka......................................................    13
Bristow, Lonnie R., M.D., MACP, Former President, American 
  Medical Association; accompanied by Michael Mcgeary, Senior 
  Program Officer, Division of Health Sciences Policy, Institute 
  of Medicine, National Academies................................    16
    Prepared statement...........................................    18
Kilpatrick, Dean G., Ph.D., Professor and Director, National 
  Crime Victims Research and Treatment Center, Medical University 
  of South Carolina..............................................    21
    Prepared statement...........................................    22
    Response to written questions submitted by Hon. Daniel K. 
      Akaka......................................................    25
Zeger, Scott L., Ph.D., Member, Committee on Evaluation of the 
  Presumptive Disability Decision-Making Process for Veterans, 
  Board on Military and Veterans Affairs, Institute of Medicine, 
  The National Academies and Professor, Johns Hopkins Bloomberg 
  School of Public Health; accompanied By Rick Erdtmann, M.D., 
  Mph, Director, Medical Follow-Up Agency, Institute of Medicine, 
  National Academies.............................................    26
    Prepared statement...........................................    28
        Enclosure: Improving the Presumptive Disability Decision-
          Making Process for Veterans............................    32
    Response to written questions submitted by Hon. Daniel K. 
      Akaka......................................................    48


 REVIEW OF VETERANS' DISABILITY COMPENSATION: EXPERT WORK ON PTSD AND 
                              OTHER ISSUES

                              ----------                              


                      WEDNESDAY, FEBRUARY 27, 2008

                                       U.S. Senate,
                            Committee on Veterans' Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 9:33 a.m., in 
room 562, Dirksen Senate Office Building, Hon. Daniel K. Akaka, 
Chairman of the Committee, presiding.
    Present: Senators Akaka, Murray, and Burr.

     OPENING STATEMENT OF HON. DANIEL K. AKAKA, CHAIRMAN, 
                    U.S. SENATOR FROM HAWAII

    Chairman Akaka. The hearing will be in order. Aloha and 
welcome to all of you to today's hearing.
    Disability compensation is at the heart of what our 
government offers to wounded warriors, yet many veterans and 
others believe that VA's compensation system is fundamentally 
broken. To understand what significant changes, if any, are 
needed, the committee will devote significant time and energy 
to disability compensation. No one on this committee undertakes 
this endeavor lightly.
    As I said at an earlier hearing on compensation, the 
Veterans' Disability Benefits Commission report is part of the 
road map that we are following to improve the system. Today is 
the third hearing in a series. The first hearing focused on the 
overall findings and recommendations in the Commission's 
report. That report relied heavily on the expert work performed 
by the witnesses before us today.
    There were two organizations that provided the bulk of the 
research used by the Commission, the CNA Corporation and the 
Institute of Medicine. IOM did a series of studies, including a 
hard look at VA's system for evaluating military service and 
PTSD. The recommendations in these studies have tremendous 
ramifications for servicemembers who are right now in harm's 
way. IOM also looked at the way VA makes decisions about 
presumptive disabilities and how disabilities are medically 
evaluated and rated. IOM's work has broad implications for VA's 
disability compensation system.
    The Veterans' Disability Benefits Commission asked the CNA 
Corporation for help on one essential question, whether the 
benefits provided to veterans and their survivors for 
disability and deaths are appropriate. The recommendations made 
by IOM and CNA Corporation could potentially impact millions of 
veterans and their survivors.
    I am pleased that we have representatives of both groups 
here today to help us better understand those findings.
    In particular, there are some who question whether 
disability compensation serves as a disincentive for wellness. 
Given IOM's recent report in this area, I would like to know 
whether this view is supported by the literature IOM reviewed.
    In the interest of time, I will stop here and ask the 
committee members for their statement. Senator Murray?

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

    Senator Murray. Thank you very much, Chairman Akaka, for 
holding today's hearing to review the findings of the Veterans' 
Disability Benefits Commission. This hearing is a very good 
opportunity for all of our committee members to better 
understand the expert work that was done for the Commission by 
the Institute of Medicine and the CNA Corporation. I want to 
thank all of today's witnesses who provided the Commission with 
their medical expertise and their professional analysis. Their 
collective analysis was critical to the VDBC's final 
recommendations, recommendations that were evidence-based and 
data driven.
    As most everyone here knows, the VDBC made 113 suggestions 
designed to bring the VA's disability compensation program into 
the 21st century. They cover a wide range of issues to ensure 
that our veterans' benefits compensate all service-disabled 
veterans and their families fairly and consistently. The men 
and women who served our country deserve a VA disability 
benefits system that is worthy of their sacrifice. As a 
country, we owe it to them to make sure that we do everything 
to make their transition to civilian life as smooth as 
possible, and that we compensate them for the physical and 
mental wounds they incurred as a result of their service.
    Unfortunately, that is not happening. The current system is 
outdated, and it is burdensome. It fails to successfully 
address the wide range of disabilities that impact the lives of 
veterans of all ages and rank. It is excessively complex and it 
all too often is just too slow.
    The Veterans' Disability Benefits Commission has made a 
number of worthy suggestions to address those shortfalls and 
bring the disability benefits system into the 21st century. 
Among the most significant recommendations made by the 
Commission is to update the current ratings schedule and to 
revise the purpose of the current system, from a model that now 
only compensates for work disability, to a model that, instead, 
compensates for three consequences of service-connected 
injuries and diseases: work disability, loss of ability to 
engage in usual life activities other than work, and loss in 
quality-of-life.
    It is clear that a lot of work went into producing the 
document that is now before us. After two and one-half years, 
the VDBC produced a 500-plus-page report with 113 
recommendations. This is the most expansive analysis of 
veterans' disability benefits in more than 50 years. The work 
done by the IOM and the CNA were key factors in the 
Commission's decision to make their recommendations. I thank 
all of you for being here today and look forward to hearing 
your discussion about how you came to those conclusions. Thank 
you very much for your work.
    Chairman Akaka. Thank you very much, Senator Murray.
    Now we will hear from our Ranking Member, Senator Burr.

        STATEMENT OF HON. RICHARD BURR, RANKING MEMBER, 
                U.S. SENATOR FROM NORTH CAROLINA

    Senator Burr. Mr. Chairman, thank you. More importantly, 
thank you to our witnesses for their willingness to be here to 
discuss the work you performed for the Veterans' Disability 
Benefits Commission.
    It is clear that you spent countless hours studying the 
benefits and services provided to our Nation's veterans and 
thinking of ways to improve them, and for that, I truly want to 
say thank you on behalf of this entire committee. Your efforts 
helped the Disability Commission form its recommendations and 
they will also help guide this committee's efforts to improve 
the lives of our Nation's veterans.
    Before we hear your presentation, I would like to comment 
on a couple of broad themes that are raised in your report.
    First, your report highlights the lack of coordination 
among the many benefits and services that VA provides to 
injured veterans. As we all know, VA has a world class health 
care system, a comprehensive vocational rehabilitation and 
employment program, and a disability compensation program, 
among many other benefits. But as the Institute of Medicine 
found, while VA has the services needed to maximize the 
potential of veterans with disabilities under one roof, they 
are not actively coordinated and thus are not as effective as 
they could be.
    As part of a more integrated approach, the Institute of 
Medicine suggested that we move away from the current process 
that requires many veterans with Post Traumatic Stress Disorder 
to obtain a disability rating from VA before they get priority 
access to VA's mental health services. The Institute of 
Medicine expressed the belief that, and I quote, ``if it were 
possible to provide a path to treatment that did not involve 
seeking a disability rating, it would enhance opportunities for 
recovery and for wellness,'' unquote. That is what it is all 
about. I couldn't agree more.
    That is why I introduced the Veterans Mental Health 
Treatment First Act last month. That bill would help veterans 
suffering from PTSD get treatment before they go through any of 
the disability rating process. Under my bill, VA would provide 
veterans with a wellness stipend to help them financially as 
they seek and complete their treatment program. What a novel 
approach. All veterans would have to do is agree to comply with 
the treatment program and hold off on filing disability claims 
for a short period, hopefully the completion of their 
rehabilitation period. My goal is to try to change the existing 
mind set from one that emphasizes disability status to one that 
emphasizes wellness and restoration. I look forward to hearing 
from our witnesses today about how we might be able to 
accomplish that specific goal.
    The second important theme that these reports highlighted 
is the need to update VA's disability compensation system. As 
the Institute of Medicine found, the current system has not 
kept pace with society in understanding disabilities. As we 
will hear today, the studies point out that some parts of VA's 
disability rating schedule have not been properly updated for 
more than six decades. And even the parts that have been 
updated are not adequate for assessing disabilities like PTSD 
and Traumatic Brain Injury--conditions that are affecting so 
many veterans of the War on Terror.
    One report also found that the rating schedule does not 
adequately compensate veterans who become seriously disabled at 
a young age and have most of their working lives ahead of them. 
This deficiency is being felt by many young veterans of the War 
on Terror, like Ted Wade, a veteran from my home State of North 
Carolina who suffered a devastating injury at the age of 25 
while serving in Iraq. As his wife Sarah put it, ``due to his 
injuries, Ted will never again get a pay raise.''
    In short, the findings in these reports make it very clear 
that there is an urgent need to update and modernize this 
system. To do that, the report recommended a wide range of 
improvements, such as compensating veterans for loss of 
quality-of-life, completely updating VA's rating schedule, and 
developing incentives that will promote vocational 
rehabilitation and help our heroes return to work, which is, I 
think, our charge.
    With these reports and others showing us the serious 
deficiencies of the current system, we simply cannot ignore the 
need for modernization. We have young men and women returning 
home from war with devastating injuries and they need to come 
back to a system that cuts the red tape and quickly provides 
them the benefits and, more importantly, the services they need 
to return to a full and productive life.
    To start us on that path, I have been working on a bill 
that would incorporate many of the recommendations of these 
reports. In part, my bill would require the entire rating 
schedule to be replaced with an updated schedule. It would 
require VA to compensate veterans for any loss of quality-of-
life caused by service-related disabilities. It would also 
require VA to conduct a study on the factors that may prevent 
injured veterans from achieving their career goals and what 
steps could be taken to help them overcome those obstacles. 
Also, this bill would create a new transition payment for 
injured veterans who were found unfit for duty. These payments 
would help cover family living expenses so an injured veteran 
would be better able to focus on rehabilitation, training, and, 
more importantly, returning to the workforce.
    As the Institute of Medicine pointed out, this type of 
modernization of the disability system will not be easy and may 
require a large up-front cost. In my view, it is the right 
thing to do, and I believe we shouldn't stop this process from 
moving forward.
    Mr. Chairman, before I turn back over the mike to you, I 
want to mention an interesting quote that the Institute of 
Medicine included in the beginning of its report, and I quote, 
``Knowing is not enough. We must apply. Willing is not enough. 
We must do.'' Unquote. I think it is a great reminder to all of 
us that we need to do more than just read the reports. We need 
to take action to fix the problems that have been identified by 
you and so many others.
    Mr. Chairman, I hope we will work together to do just that, 
so that our wounded warriors will have a modern, fair, and, 
more importantly, a coordinated system to help them return to 
full and productive lives. I thank the Chair and I yield the 
floor.
    Chairman Akaka. Thank you very much, Senator Burr, for your 
statement.
    I want to welcome our panel here and first welcome Dr. 
Joyce McMahon, Managing Director of the Center for Health 
Research and Policy with CNA Corporation. She is accompanied by 
Dr. Eric Christensen.
    Representing IOM is Dr. Lonnie Bristow, the Chair of the 
Committee on Medical Evaluation of Veterans for Disability 
Compensation. He is also a former President of the American 
Medical Association. He is accompanied by Michael McGeary.
    Also representing IOM is Dr. Dean Kilpatrick, a member of 
the Committee on Veterans' Compensation and PTSD. He is also 
the Director of the National Crime Victims Research and 
Treatment Center at the Medical University of South Carolina. 
He is accompanied by Dr. David Butler.
    Finally, we have Dr. Scott Zeger, who is a member of IOM's 
Committee on Evaluation of the Presumptive Disability Decision 
Making Process for Veterans. He is also a professor at Johns 
Hopkins Bloomberg School of Public Health. He is accompanied by 
Dr. Rick Erdtmann.
    Dr. McMahon, will you please begin with your statement?

 STATEMENT OF JOYCE McMAHON, PH.D., MANAGING DIRECTOR, CENTER 
FOR HEALTH RESEARCH AND POLICY, CNA CORPORATION; ACCOMPANIED BY 
 ERIC CHRISTENSEN, PH.D., SENIOR PROJECT DIRECTOR, CENTER FOR 
          HEALTH RESEARCH AND POLICY, CNA CORPORATION

    Ms. McMahon. Thank you. Chairman Akaka, Senator Burr, 
distinguished members, I appreciate the opportunity to testify 
before the Senate Committee on Veterans Affairs today on the 
subject of the findings and recommendations of the Veterans' 
Disability Benefits Commission. This testimony is based on the 
findings reported in CNA's final report for the Veterans' 
Disability Benefits Commission.
    Our overall focus was to provide analysis regarding the 
appropriateness of the current benefits program for 
compensating for loss of average earnings and degradation of 
quality-of-life resulting from service-connected disabilities 
for veterans. In addition, the Commission asked us to address 
additional topics, including disincentives for disabled 
veterans to work or receive recommended treatment; surveys of 
raters and veterans' service officers with regard to how they 
perceive the processes of rating claims and assisting 
applicants; the economic well-being and quality-of-life of 
survivors; comparing the VA disability compensation program to 
other Federal disability programs; evaluating offering a lump-
sum option to some service-disabled veterans; individual 
unemployability, mortality, and Social Security Disability 
income; and finally, comparing DOD disability determinations to 
those conducted by the VA.
    I am going to briefly summarize our major findings. The 
other details are in the written testimony.
    With regard to earnings comparisons for service-disabled 
veterans, our primary task was to address how well VA 
compensation serves to replace the average loss in earnings 
capacity for service-disabled veterans, in other words, to 
bring them to parity. We looked at this overall as well as by 
subgroups based on the body system of the primary disability 
and on the total combined disability rating, from 10 percent to 
100 percent.
    We found that for male service-disabled veterans, they are 
about at parity overall with respect to lost earnings capacity 
balanced by VA compensation at the average age of entry, which 
is approximately age 55. However, there are some important 
differences by subgroup. In general, those with a primary 
mental disability have lower earnings ratios than those with a 
primary physical disability, and many of the rating subgroups 
for those with a primary mental disability had earnings rates 
below parity. In addition, entry at a young age is associated 
with below-parity earnings ratios, especially for those who are 
in the severely disabled subgroups.
    The second major tasking from the Commission was to assess 
veterans' quality-of-life degradation resulting from service-
connected disability. Addressing this issue requires surveying 
service-disabled veterans to estimate their average quality-of-
life. We used health-related questions that were taken from a 
standardized bank of questions that are widely used to examine 
health status in the overall population. This allowed us to 
compare the results for the service-disabled veterans to widely 
published population norms.
    We found that as the degree of disability increased, in 
general, overall health declined. There were differences 
between those with physical and mental primary disabilities in 
terms of physical and mental health. For those who had a 
primary physical disability, there was a marked diminishing in 
the amount of the physical health scores that they received, 
but in general that did not lead to lowered mental health 
except for those who were the most severely disabled. On the 
other hand, having a primary mental disability led not only to 
lowered mental health scores, but was also associated with 
lower physical health, as well. For those with a primary mental 
disability, physical scores were well below the population 
norms for all rating groups, and those with PTSD had the lowest 
physical health scores of all.
    In essence, the earnings parity measure that I spoke of 
allows an estimate of whether the VA compensation benefits 
provide an implicit quality-of-life payment. There is no 
explicit quality-of-life payment, of course. If an earnings 
ratio is above parity, the veteran would be receiving an 
implicit positive quality-of-life payment. Those with a ratio 
less than parity effectively receive a negative quality-of-life 
payment.
    Going back to our earnings ratios, we found on average that 
VA compensation does not provide a positive quality-of-life 
payment overall, but there are implicit negative quality-of-
life payments for severely disabled veterans who enter the 
system at a young age, and more generally for those with a 
mental primary disability. This goes along with the context 
that the loss of quality-of-life appears to be greatest for 
those with a mental primary disability.
    I have other findings, but I am about out of time; so I 
think I will close at this point. Thank you.
    [The prepared statement of Ms. McMahon follows:]
 Prepared Statement of Joyce McMahon, Ph.D., Managing Director, Center 
            for Health Research and Policy, CNA Corporation
    Chairman Akaka, Senator Burr, distinguished members; I appreciate 
the opportunity to testify before the Senate Committee on Veterans' 
Affairs today on the subject of the findings and recommendations of the 
Veterans' Disability Benefits Commission (VDBC). This testimony is 
based on the findings reported in Final Report for the Veterans' 
Disability Benefits Commission: Compensation, Survey Results, and 
Selected Topics, by Eric Christensen, Joyce McMahon, Elizabeth 
Schaefer, Ted Jaditz, and Dan Harris, of the CNA Corporation (CNA). 
Details on the specific findings discussed here can be found in the 
report, which is available at http://www.cna.org/domestic/health care/.
    The Commission asked CNA to help assess the appropriateness of the 
benefits that the Department of Veterans Affairs (VA) provides to 
veterans and their survivors for disabilities and deaths attributable 
to military service. Our overall focus was to provide analyses 
regarding the appropriateness of the current benefits program for 
compensating for loss of average earnings and degradation of quality-
of-life resulting from service-connected disabilities for veterans. We 
also evaluated the impact of VA compensation for the economic well-
being of survivors and assessed their quality-of-life.
    In addition, the Commission asked us to address additional topics, 
including:

     Disincentives for disabled veterans to work or to receive 
recommended treatment.
     Surveys of raters and Veterans Service Officers with 
regard to how they perceive the processes of rating claims and 
assisting applicants.
     Comparing the VA disability compensation program to other 
disability programs
     Evaluating offering a lump sum option to some service-
disabled veterans.
     Individual unemployability (IU), mortality, and Social 
Security Disability Income
     Comparing DOD disability determinations to those conducted 
by the VA.
           earnings comparisons for service-disabled veterans
    Our primary task was to answer the question of how well the VA 
compensation benefits serve to replace the average loss in earnings 
capacity for service-disabled veterans. Our approach identified target 
populations of service-disabled veterans and peer or comparison groups 
(non-service-disabled veterans) and obtained data to measure earned 
income for each group. We also investigated how various factors such as 
disability rating, type of disability, and age impact earned income. 
Finally, we compared lifetime earned income losses for service-disabled 
veterans to their lifetime VA compensation, adjusting for expected 
mortality and discounting to present value terms, to see how well VA 
compensation replaces lost earning capacity.
    Congressional language indicates that the intent of VA compensation 
is to provide a replacement for the average impairment in earning 
capacity. VA compensation is not an individual means-tested program, 
although there are minor exceptions to this. Therefore, we focused on 
average losses for all service-disabled veterans and for subgroups. We 
defined the subgroups of disabled veterans, through consultation with 
the Commission, on the body system of the primary disability (16 in 
all) and on the total combined disability rating (10 percent, 20-40 
percent, 50-90 percent, and 100 percent disabled). In addition, we 
further split the 50-90 percent disabled group into those with and 
without individual unemployability status (IU). After meeting certain 
disability criteria as well as providing evidence that they are unable 
to engage in substantial gainful employment, IU disabled veterans 
receive compensation at the 100 percent disabled level.
    To make earnings comparisons over a lifetime, it is necessary to 
have a starting point. In other words, a young service-disabled veteran 
will have a long period of lost earnings capacity during prime wage-
earning years, while a veteran who enters into the VA disability 
compensation system at an older age will face reduced earnings capacity 
for a smaller number of years. If a veteran first becomes eligible for 
VA compensation at age 65 or older, the average expectation of lost 
earnings is very low, because a large share of individuals are retired 
or planning to retire soon by this age. The data show that the average 
age of entry into the VA compensation system is about 55 years, 
although many enter at a younger or older age. Also, the average age of 
entry varies somewhat across the body systems of the primary disability 
and combined degree of disability.
    We looked at average VA compensation for all male service-disabled 
veterans, and found that they are about at parity with respect to lost 
earnings capacity at the average age of entry (55). We compared the 
discounted present value of their lifetime expected earnings to the 
earnings of their peer group (i.e., veterans who were not service-
disabled). To calculate expected earnings parity, we took the ratio of 
service-disabled earned income plus VA compensation divided by the 
present value of total expected earnings for the peer group. This 
figure is 0.97, which is near parity. A ratio of exactly 1 would be 
perfect parity, indicating that the earnings of disabled veterans, plus 
their VA compensation, give them the same lifetime earnings as their 
peers. A ratio of less than one would mean that the service-disabled 
veterans receive less than their peers on average, while a ratio of 
greater than one would mean that they receive more than their peers.
    We also evaluated the parity of earned income and VA compensation 
for service-disabled veterans compared to the peer group by disability 
rating group and age at first entry into the VA compensation system. 
Our findings indicate that it is important to distinguish whether the 
primary disability is a physical or a mental condition. We found that 
there is not much difference in the results among physical body systems 
(e.g., musculoskeletal, cardiovascular), and for mental disabilities, 
it does not matter much whether the disability is for PTSD or some 
other mental disability.
    Examining veterans with a physical primary disability, our findings 
indicate that service-disabled veterans are generally at parity at the 
average age of first entry into VA compensation system (50 to 55 years 
of age). However, we observed earnings ratios substantially below 
parity for service-disabled veterans who were IU, and slightly below 
parity for those who were 100 percent disabled, who entered at a young 
age. Those who first entered at age 65 or older were generally above 
parity.
    For veterans with a mental primary disability, we found that their 
earnings ratios were generally below parity at the average age of 
entry, except for the severely disabled (IU and 100 percent disabled). 
We found that the severely disabled who enter at a young age are 
substantially below parity. Those who entered at age 65 or older 
generally were above parity, except for the 10 percent disabled group, 
which was still slightly below parity.
    To summarize the earnings ratio findings for male veterans, there 
is general parity overall. However, when we explored various subgroups, 
we found that some were above parity, while others were below parity. 
The most important distinguishing characteristic is whether the primary 
disability is physical or mental. In general, those with a primary 
mental disability have lower earnings ratios than those with a primary 
physical disability, and many of the rating subgroups for those with a 
primary mental disability had earnings rates below parity. In addition, 
entry at a young age is associated with below parity earnings ratios, 
especially for severely disabled subgroups.
                veterans' quality-of-life survey results
    The second principal tasking from the Commission was to assess 
whether the current benefits program compensates not just for loss of 
average earnings, but also for veterans' quality-of-life degradation 
resulting from service-connected disability. Addressing this issue 
required collecting data from a representative sample of service-
disabled veterans, which would allow us to estimate their average 
quality-of-life. To do this, we constructed, in consultation with the 
Commission, a survey to evaluate the self-reported physical and mental 
health of veterans and other related issues. CNAC's subcontractor, ORC 
Macro, conducted the survey and collected the data. As with the earned 
income analysis, we designed the survey to collect data by the major 
subgroup. We defined subgroups by the body system of the primary 
disability and combined disability rating, and three SMC categories. We 
were also able to characterize the survey results by IU status within 
the 50-90 percent disabled subgroup.
    The survey utilized 20 health-related questions taken from a 
standardized bank of questions that are widely used to examine heath 
status in the overall population. These questions allowed us to 
calculate a physical health summary score (physical component summary, 
or PCS) and a mental health summary score (mental component summary, or 
MCS). This approach is widely used to measure health status in a 
variety of national surveys, and it allowed us to compare the results 
for the service-disabled veterans to widely published population norms. 
We also calculated five additional health subscales that also have 
widely published population norms.
    For evaluating the survey, we analyzed the results by subgroup 
similar to the strategy we used for comparing earnings ratios. We 
looked at those with a primary physical disability and those with a 
primary mental disability separately. We also examined the PCS and MCS 
scores for additional subgroups within those categories. For the 
population norms, the PCS average is set at 50 points, and the norms 
decrease slightly with age. For the MSC scores, the population norm is 
quite flat at an average of 50, and decreases only for the oldest age 
categories.
    For service-disabled veterans with a primary physical disability, 
we found that their PCS measures were below population norms for all 
disability levels, and that the scores were in general lower as the 
disability level increased. In addition, having a primary physical 
disability was not generally associated with reduced mental health as 
measured by MCS. Mental health scores for those with a primary physical 
disability were close to population norms, although those who were 
severely disabled had slightly lower mental scores.
    For service-disabled veterans with a primary mental disability, we 
found that both the physical and mental component summary scores were 
well below population norms. This was true for each of the rating 
groups. This was a distinction from those with a primary physical 
condition, who (except for the severely disabled) did not have MCS 
scores below population norms.
    To summarize our overall findings, as the degree of disability 
increased, generally overall health declined. There were differences 
between those with physical and mental primary disabilities in terms of 
physical and mental health. Physical disability did not lead to lowered 
mental health in general. However, mental disability did appear to lead 
to lowered physical health in general. For those with a primary mental 
disability, physical scores were well below the population norms for 
all rating groups, and those with PTSD had the lowest PCS values.
    We also used the Veterans Survey to investigate other issues that 
the Commission raised. First, we investigated whether service-disabled 
veterans tended to not follow recommended medical treatments because 
they felt it might impact their disability benefits. We used a series 
of indirect questions to ascertain this information. We found that this 
does not appear to be an issue.
    In addition, the Commission asked us to investigate whether VA 
benefits created a disincentive to work for service-disabled veterans. 
Again, we used a series of indirect questions to ascertain this 
information. For example, a disincentive to work might be seen through 
working part-time instead of full-time, or retiring early. We did not 
find this to be a major issue, as only 12 percent of the service-
disabled veterans indicated that they might work, or work more, if it 
were not for their VA benefits. However, it could be that these 
individuals felt that they would have no choice but to work more, if 
they had no VA benefits, and that it might be quite difficult for them 
to actually work more.
          combining earnings and quality-of-life findings for 
                       service-disabled veterans
    The quality-of-life measures allow us to examine earnings ratio 
parity measures in the context of quality-of-life issues. In essence, 
the earnings parity measures allow an estimate of whether the VA 
compensation benefits provide an implicit quality-of-life payment. If a 
subgroup of service-disabled veterans has an earnings ratio above 
parity, they are receiving an implicit quality-of-life payment. At 
parity, there is no quality-of-life payment, and those with a ratio 
less than parity are effectively receiving a negative quality-of-life 
payment. We turned next to considering the implicit quality-of-life 
payment in the context of the veterans' self-reported health status.
    With regard to self-reported quality-of-life, we had multiple 
measures to consider, such as the PCS and MCS measures, and a survey 
question on overall life satisfaction. In addition, there is no 
intrinsic valuation of a PCS score of 42 compared to a score of 45. We 
know that a score of 45 reflects a higher degree of health than a score 
of 42 does, but we have no precise way to categorize the magnitude of 
the difference. To simplify the analysis, we combined the information 
from the PCS and MCS into an overall health score, with a population 
norm of 100 points (each scale had a norm of 50 points separately). 
Then we calculated the population percentile that would be attributed 
to the combined score. For example, for a score of 77 points, we know 
that 94 percent of individuals in the age range 45 to 54 would score 
above 77. This gave us a way to calibrate our results, in terms of how 
the overall physical and mental health of the service-disabled veterans 
compares to population norms. By construction, the 50th percentile is 
the population norm of this measure.
    The results of this analysis confirmed our earlier finding that 
there are more significant health deficits for those with a primary 
mental disability than a primary physical disability. We found that 
overall health for those with a mental primary disability is generally 
below the 5th percentile in the typical working years for those who are 
20 percent or more disabled (this would represent a combined score of 
77). Even for the 10 percent group, the overall health score is 
generally below the 20th percentile (a combined score of 83).
    This approach allows us to consider the implicit quality-of-life 
payment, based on the parity of the earnings ratio, compared to the 
overall health percentile and the overall life satisfaction measure 
(the percentage of respondents who say that they are generally 
satisfied with their overall life). We investigated this by rating 
groups and average age at first entry, separately for those with a 
physical primary disability compared to a mental primary disability. We 
discuss our findings separately for those with a physical primary 
disability and for those with a mental primary disability, considering 
the implicit quality-of-life payment, the overall health percentile and 
the overall life satisfaction.
    For those with a physical primary disability, the average age at 
first entry varied from 45 to 55, rising with the combined degree of 
disability. For 10 percent and 20-40 percent disability, there was a 
negative quality-of-life payment, although their overall health 
percentile ranged from 28 to 15 percent. For these groups, the overall 
life satisfaction ranged from 78 to 73 percent. For higher level of 
disability groups, there was a modest positive quality-of-life payment, 
ranging as high as $2,921 annually for the 100 percent disabled group. 
For the 100 percent disabled group, the overall health percentile was 
4, meaning that 96 percent of the population would have a higher health 
score than the average score for this subgroup, and the overall life 
satisfaction was only 60 percent.
    For service-disabled veterans with a mental primary disability, we 
found that there was an implicit negative quality-of-life payment for 
veterans of all disability levels except for those designated as IU. 
Also, for these subgroups, the overall health percentile was at the 
13th percentile for 10 percent disabled and at the 6th percentile for 
20-40 percent disabled. In fact, for the higher disability groups, the 
overall health score was at or below 1 percent, meaning that 99 percent 
of the population would have a higher overall health score. Overall 
life satisfaction, even for the 10 percent disability level, was only 
61 percent. For disability levels 50-90 percent, IU, and 100 percent 
disabled, the overall life satisfaction measure hovered around 30 
percent.
    With regard to implicit quality-of-life payments, we found positive 
quality-of-life payments for those with a physical primary disability 
at a combined rating of 50 to 90 percent or higher (except for IU). For 
those with a mental primary disability, we found a positive quality-of-
life payment only for the IU subgroup. In comparing overall health 
percentiles and life satisfaction, however, we found that for all 
rating groups, those with a mental primary disability had lower overall 
health percentiles, and substantially lower overall life satisfaction, 
than those with a physical primary disability. Those with a mental 
primary disability had lower health and life satisfaction compared to 
those with a physical primary disability, but received less in implicit 
quality-of-life payments.
    To summarize, we found that VA compensation is about right overall 
relative to earnings losses based on comparison groups for those at the 
average age at first entry. But the earnings ratios are below parity 
for severely disabled veterans who enter the system at a young age and 
more generally below parity among subgroups for those with a mental 
primary disability. Earnings ratios tend to be above parity for those 
who enter the VA system at age 65 or older. On average, VA compensation 
does not provide a positive implicit quality-of-life payment. Finally, 
the loss of quality-of-life appears to be greatest for those with a 
mental primary disability.
          earnings and quality-of-life findings for survivors
    We computed earnings profiles for survivors using a methodology 
analogous to that used for service-disabled veterans. We calculated 
earnings income by age group and compared these earnings levels to the 
earnings of surviving spouses in the general population. Segmenting by 
age group is critical as 69 percent of survivors are 65 or more years 
old.
    We also constructed and conducted a survey for survivors to assess 
how their self-reported health compared to population norms. We focused 
our comparisons on female survivors and their peers from the Current 
Population Survey (CPS). We were asked to explore how well Dependency 
and Indemnity Compensation (DIC) provided a partial replacement for 
lost earnings attributed to the loss of a servicemember or veteran.
    The earnings comparisons show that on average survivors generally 
have lower earnings than their civilian peer groups, but that the 
combination of earned income plus VA compensation is as high as, or 
higher than, the average earned income of their peer groups at every 
age. In addition, based on our survey results, 90 percent of the 
respondents said that they were satisfied with DIC. We concluded that 
DIC appears to provide an adequate replacement for lost earnings for 
survivors.
    The health differences among survivors and their peers are not as 
dramatic as the health differences were for service-disabled veterans 
and their peers, but there are some departures from population norms. 
The PCS for survivors is below population norms for age 55 and over, 
and the MCS is below population norms for ages 35 to 64. Those 
survivors who provided substantive care to a disabled veteran (4 or 
more hours per day, 5 days a week, for 2 or more years) appeared to 
suffer some negative effects on physical health and participation in 
social activities.
                     raters and vsos survey results
    The Commission asked us to survey VBA rating officials and 
accredited veterans service officers (VSOs) of National Veterans 
Service Organizations (NVSOs) to gather insights from those who work 
most closely with the benefits determination and claims rating process. 
Through consultation with the Commission, we constructed separate (but 
largely parallel) surveys for raters and VSOs. The surveys focused on 
the challenges in implementing the benefits determination and claims 
rating process and perspectives on how the process works. Training, 
proficiency on the job, and resource availability and usage were among 
the issues examined.
    The overall assessment indicated that the benefits determination 
process is viewed as difficult to use. Many VSOs find it difficult to 
assist in the benefits determination process. In addition, VSOs report 
that most veterans and survivors find it difficult to understand the 
determination process and difficult to navigate through the required 
steps and provide the required evidence. Most raters and VSOs agreed 
that veterans have unrealistic expectations of the claims process and 
benefits.
    Raters and VSOs noted that additional clinical input would be 
useful, especially from physicians and mental health professionals. 
Raters felt that the complexity of claims was rising over time, and 
that additional resources and time to process claims would help. Some 
raters felt that they were not adequately trained or that they lacked 
enough experience. They viewed mental claims, especially PTSD, as 
requiring more judgment and subjectivity and as being more difficult 
and time-consuming compared to physical claims. Many raters indicated 
that the criteria for IU are too broad and that more specific decision 
criteria or evidence would help in deciding IU claims.
    va disability compensation program compared to other disability 
                                programs
    The Commission was interested in operational aspects of the 
veterans' disability compensation program and asked us to compare VA's 
program with other Federal disability compensation programs to 
determine whether there are any useful practices that VA could adopt to 
improve its own operations. Our first task was to identify the major 
criticisms of operations in the VA disability program. We reviewed a 
variety of sources that discussed problems with VA performance, 
including reports from the Government Accountability Office (GAO), 
reports from the VA Office of the Inspector General (OIG), 
congressional testimony, and the results of the Commission's site 
visits.
    After identifying the major criticisms of VA, we spoke with the 
relevant VA staff to get additional information on the areas being 
criticized. We interviewed individuals who worked in VBA's Compensation 
and Pension Service, VBA's Office of Employee Development and Training, 
the Board of Veterans' Appeals, and the Office of the General Counsel. 
We discussed specific aspects of VA operations that were identified as 
problematic and the approaches that the other disability programs take 
in those areas.
    Except for the very important issue of timeliness, VA does not 
appear to be under-performing in comparison with other disability 
programs. Recent training improvements seem promising for improving VA 
timeliness in the long term, but effects will not be seen for a while. 
Some of VA's problems with timeliness could be the result of a complex 
program design, with multiple disabilities per claim, the need to 
determine service connection (sometimes many years after separation), 
and the need to assign a disability rating to each disability.
                   option for a lump sum alternative
    The Commission asked us to explore options for replacing the 
current annuity benefits stream for some service-disabled veterans with 
a lump sum alternative. We looked at this from the perspective of the 
potential benefits and costs both to the VA and to service-disabled 
veterans, and with respect to potential implementation barriers. We 
also investigated how other countries use a lump sum alternative for 
their service-disabled veterans. We focused on exploring possible 
options for those at the lowest disability levels (10 to 20 percent). 
In addition, we determined that this would be most feasible for body 
systems where rating changes were infrequent, as re-rating might 
generate the need to recalculate lump sum payments or provide an 
annuity.
    For the VA, the anticipated benefits of a lump sum derive primarily 
from the potential for reduced administrative interactions (which might 
lead to speedier claims processing) and savings in compensation and 
administrative costs. If the lump sum were optional, this would 
increase the choices open to service-disabled veterans. Finally, there 
are a number of concerns about how the lump sum amounts would be 
determined, what would happen if a veteran's condition worsened after 
he/she had taken a lump sum, and whether veterans would use a lump sum 
``wisely'' or not.
    We looked at Australia's, Canada's, and the United Kingdom's 
disability compensation systems for their service-disabled veterans, 
all of which utilize some version of a lump sum alternative. These 
countries generally use an annuity system to compensate for 
``economic'' losses, and reserve the lump sum for compensating for 
``non-economic'' or quality-of-life losses. Canada and the UK use lump 
sums to compensate for lost quality-of-life, while Australia offers the 
veteran a choice between an annuity and a lump sum.
    We made a number of simplifying assumptions and selected a small 
number of examples to simulate how a lump sum program might be 
implemented. We found that the VA could obtain net savings, but a lump 
sum option would be costly up front, taking between 17 and 25 years for 
the VA to achieve net savings. In addition, we identified a number of 
institutional issues that would pose execution challenges.
                            iu and mortality
    The Commission asked us to conduct an analysis of those receiving 
the individually unemployable (IU) designation. This designation is for 
those who do not have a 100 percent combined rating but whom VA 
determines to be unemployable. The designation enables them to receive 
disability compensation at the 100 percent level.
    Overall 8 percent of those receiving VA disability compensation 
have IU, but 31 percent of those with PTSD as their primary diagnosis 
have IU status. Ideally, if the rating schedule works well, the need 
for IU will be minimal because those who need 100 percent disability 
compensation will get it from the ratings schedule. The fact that 31 
percent of those with PTSD as their primary condition have IU may be an 
indication that the ratings schedule does not work well for PTSD.
    Another concern is the rapid growth in the number of veterans 
designated as IU--from 117,000 in 2000 to 223,000 in 2005. This 
represents a 90 percent increase, an increase that occurred while the 
number of disabled veterans increased 15 percent and the total number 
of veterans declined by 8 percent. The issue is whether disabled 
veterans were taking advantage of the system, using IU status to 
increase their disability compensation. The data suggest that this was 
not the case. While there has been some increase in the prevalence of 
getting IU status for certain rating-and-age combinations, the vast 
majority of the increase in the IU population is explained by 
demographic changes (specifically the aging of the Vietnam cohort) in 
the veteran population.
    We also used mortality rates to determine whether IU recipients 
were taking advantage of the system. If those with IU had higher 
mortality rates than those without IU, it would appear to identify 
clinical differences between those with and without IU. Our findings 
confirm that those with IU status have higher mortality rates than 
those rated 50-90 percent without IU, although IU mortality rates are 
less than for the 100 percent disabled.
                comparison of dod/va disability ratings
    Due to concern with consistency of DOD and VA disability ratings, 
the Commission asked CNAC to study the issue. We first looked to see 
how much overlap there was between the two systems. We found that 
roughly four-fifths of those who receive a DOD disability rating end up 
in the VA compensation system in less than 2 years.
    Next we explored whether DOD and VA gave approximately the same 
combined disability rating. On average, we found that service-disabled 
veterans received substantially higher ratings from VA than from DOD. 
The question is why? First, VA rates more conditions than DOD does: on 
average VA rates about three more conditions per person than DOD does. 
Second, we found that even at the individual diagnosis level, VA gives 
higher ratings than DOD does on average. For some codes, the average 
rating from DOD is slightly higher than from VA. But for others, such 
as mental diagnostic codes, the average rating from VA is substantially 
higher than the rating from DOD.
    Note that while we found differences in combined and individual 
ratings given by DOD and VA, we make no judgment as to the correctness 
of the ratings in either system. We have neither the data nor the 
clinical expertise to make such judgments. What we have done is point 
out aspects of the VA and DOD disability systems that differ.
                  overall options and recommendations
    One issue that emerges from the data concerns service-disabled 
veterans with a mental primary disability. Their overall health 
percentiles and overall life satisfaction percentiles are far below 
those with physical primary disabilities at the same rating level. 
Their earnings in general are well below those with physical primary 
disabilities. The data clearly indicate that their life experience is 
less satisfying than that of their counterparts. It is important to 
consider how veterans' programs could be made more effective at 
benefiting this group of veterans. However, there is no current metric 
to translate the quality-of-life losses documented in the Veterans 
Survey into dollars.
    There are several options for addressing the lack of earnings 
parity where it exists and for compensation for lost quality-of-life. 
Earnings parity of those with mental conditions could be improved 
through higher ratings for mental conditions or special monthly 
compensation similar to that currently paid for other conditions. 
However, using higher ratings would require re-rating all of those with 
a mental disability. Earnings parity for the severely disabled who 
enter the system at ``young'' ages could be improved by making 
disability compensation levels a function of age at first entry into 
the disability system or through a special monthly compensation.
    Another issue is the IU designation that many veterans receive 
because they are unemployable. If the purpose of this designation truly 
relates to employment, there could be a maximum eligibility age 
reflecting typical retirement patterns. If the purpose is to correct 
for rating schedule deficiencies, an option is to correct the ratings 
schedule so that fewer need to be artificially rated 100 percent 
through IU.
                                 ______
                                 
  Response to Written Questions Submitted by Hon. Daniel K. Akaka to 
                          The CNA Corporation
    Question 1. Please elaborate on the assertion that VA does not 
appear to be underperforming in comparison with other disability 
programs.
    Response. The Commission was interested in operational aspects of 
the veterans' disability compensation program and asked us to compare 
VA's program with other Federal disability compensation programs. Our 
focus was limited to comparisons with Federal programs paying monetary 
benefits to disabled individuals, including Social Security Disability 
Insurance (SSDI) and Supplemental Security Income (SSI) under the 
Social Security Administration (SSA), Workers' Compensation under the 
Federal Employees' Compensation Act (FECA), disability retirement for 
Federal employees under the Federal Employee Retirement System (FERS) 
and the Civil Service Retirement System (CSRS), and DOD's Disability 
Evaluation System (DES).
    Unfortunately, we found that there were no formal evaluations of 
the effectiveness of specific practices in the other programs we 
examined, in the areas identified as problematic for VA. This limited 
our ability to do meaningful comparisons across the programs.
    We also found that there are many differences across the various 
disability programs in terms of purpose, administrative processes, 
eligibility, benefits, and size. These differences may also limit the 
potential applicability for VA of lessons from the other programs. For 
example, each disability program has different administrative processes 
for filing claims and making appeals. The various disability 
compensation programs also have different criteria for determining 
eligibility and benefit levels, and different purposes of the monetary 
compensation, varying from partial or full replacement of earnings to 
an income supplement, or even to compensation for a shortened career. 
The amount and type of information needed for each program are 
important determinants of how difficult and time-consuming it is to 
process and resolve a claim.
    For any disability compensation program, three important measures 
of performance in claims processing are timeliness, accuracy, and 
consistency. In addition, we considered issues involving training, 
productivity standards, and staff turnover.
Timeliness
    Beginning with timeliness, we noted that the time required to 
decide and resolve a claim depends on how complex the design of the 
program is. For example, although the VA program does not need to know 
a claimant's earnings history, it does need to determine service 
connection and severity for each disability, and each claim can have 
multiple disabilities.
    Compared to the other disability programs, VA performance in terms 
of timeliness was poor. The average time for VA to complete a claim 
(without appeals) in FY2006 was 177 days. In comparison, the average 
for SSDI was 88 days in FY2006, and OPM staff reported that the FERS/
CSRS average is currently 38 days. In general, the FECA and DES 
programs also reported shorter times to adjudication than the VA 
average. But because of the differences across programs in the work 
required to process a claim, it is difficult to say whether VA's 
timeliness problems are due to the complex nature of its disability 
decisions, or to other factors. VA should evaluate what stages of their 
claims process are contributing most to the total processing time.
    With respect to specific strategies to improve timeliness, VA makes 
use of ``Tiger Teams'' to deal with cases that are designated as high 
priority, such as very long-standing cases or cases where the veteran 
is very old or terminally ill. But because the success of those teams 
comes from the fact that they are made up of the most experienced 
staff, unfortunately the Tiger Team approach is not something that VA 
can replicate on a larger scale (i.e., there are not enough experienced 
employees to staff a large number of Tiger Teams). VA might also 
consider SSA's new Quick Disability Determination (QDD) process, which 
uses a predictive model to identify cases with a high probability of 
being granted benefits and then trying to act on those cases within 20 
days.
Accuracy
    Accuracy is another major dimension of the quality of claims 
processing. VA's accuracy rate in 2006 was 88 percent. Accuracy is 
based on whether all issues in the claim were addressed, whether the 
claim was developed in compliance with the Veterans Claims Assistance 
Act, and whether the rating decision, effective date, and payment date 
were correct. VA's accuracy was slightly below the overall accuracy 
rate for SSDI, which was 96 percent. However, the programs have 
different claims processing requirements. VA has to rate the severity 
of a disability, creating more potential for error than the yes-or-no 
disability decision that is required for SSDI.
    We were unable to obtain overall accuracy rates for the other 
programs. However, in comparing other programs' practices with VA's, 
the only practice that is substantively different from VA's is SSA's 
practice of focusing on reviewing the most error-prone type of cases.
Consistency
    Measuring consistency is difficult, and none of the programs 
currently has a measure of consistency of the level that GAO recommends 
(examining disability decisions with multivariate analysis, controlling 
for multiple factors, and in-depth independent review of statistically 
selected case files). It is currently impossible to compare consistency 
across programs.
    Possible ways to improve consistency might include standardizing 
training for raters, improving standardization of medical examinations, 
and consolidating the rating process into fewer locations. VA 
disability compensation claims are currently processed in 57 Regional 
Offices (ROs), and GAO has recommended that VA consolidate some of its 
disability compensation operations as one way to improve claim 
processing quality and reduce variation across regional offices. VA 
reports that it does in fact have plans to consolidate some of its 
disability claims processing in the future. However, this might create 
less in-person access for some veterans.
    SSA has a similar regional variation to that observed for the VA. 
The other programs face fewer consolidation issues or concerns, because 
they are much smaller programs and have fewer offices and locations for 
processing claims.
Training issues
    VA has also been criticized regarding staff training. However, 
examination of the other disability programs shows that VA is not 
lagging behind in its training efforts. None of the other programs 
seems to have any formal evaluation of their training. VBA has recently 
focused on increasing the standardization of training. No other 
disability program has VA's level of standardization.
Staff turnover
    For the VA program, high staff turnover is viewed as creating a 
problem for the quality of claims processing. But it is not clear that 
the 1-year attrition rate for VA disability examiners differs from the 
rate for all new Federal employees. However, minimizing turnover is 
especially important for VA because of the lengthy training time 
required for claims processing. GAO has recommended that it might be 
useful for the VA to take steps to quantify the reasons that raters 
resign. In any event, VA is not the only disability program facing the 
problem of high staff turnover, which has been identified as a 
particularly difficult issue for SSA. The other disability compensation 
programs reported similar staff turnover concerns.
Summary of comparisons across programs
    Except for timeliness, we found no evidence that VA was under-
performing in comparison with other disability programs. Some of VA's 
problems with timeliness could be the result of a complex program 
design, with multiple disabilities per claim, the need to determine 
service connection (sometimes many years after separation), and the 
need to assign a disability rating to each disability. For VA to 
improve timeliness, it first needs to evaluate the stages of the claims 
process that are contributing most to the total elapsed time required 
to complete a claim.

    Question 2. IOM made a distinction between overall quality-of-life, 
and physical limitations that impair a veteran beyond the workplace. 
Did CNA make a similar distinction in its survey? In other words, did 
CNA consider overall physical limitations and quality-of-life as 
independent concepts?
    Response. CNA evaluated two scales to describe quality-of-life 
outcomes for disabled veterans. These scales were the same scales that 
have been used in a wide variety of research across the years, which 
enabled us to compare results for disabled veterans to widely-
established population norms. First, we calculated a physical health 
score based on answers to a subset of the questions. We also calculated 
a mental health score based on answers to a different subset of the 
questions. Our ``overall'' quality-of-life assessment was based on 
adding together these two scores, and weighting them equally--in other 
words, we counted the physical assessment and the mental assessment as 
equally important. So to specifically answer the question, the overall 
quality-of-life measure we calculated was composed of two separate 
subcomponents--one based on physical limitations, and one based on 
mental limitations.
    We also asked other questions on the survey, such as questions 
about the respondents' overall satisfaction with life. We did not fold 
these questions into a quality-of-life measure, because there were no 
equivalent population norms that the respondents' answers could be 
compared to.

    Question 3. Can you please describe what additional resources 
raters felt would be helpful as they adjudicated claims for 
compensation?
    Response. The survey findings identified several issues related to 
the benefits determination process.

     Both raters and VSOs identified additional clinical input 
on rating teams as potentially useful, especially from physicians of 
appropriate specialties and from mental health professionals. VSOs 
identified rehabilitation specialists and medical records specialists 
as other potentially useful sources of input.
     There is a relatively wide range of perceived training 
adequacy, perceived proficiency in knowledge, skills and abilities 
(KSAs), KSAs relevant to the performance of the rater's role, and years 
of rating experience among rating officials that appears to be related 
to raters' abilities to implement the process and their ease at rating 
and deciding claims. Raters who feel less well-trained or less 
proficient and those who have fewer years of rating experience 
generally find the process more problematic.
     Raters' perceptions regarding their training adequacy and 
their KSA proficiency are both somewhat related to their perceptions of 
the availability of the resources they need to decide a claim such as 
computer system support, information and evidence, time, and 
administrative/managerial and clerical support. As perceived training 
adequacy and KSA proficiency increase, so does perceived resource 
availability.
     In many respects, rating or deciding mental disorder 
claims is more problematic than rating or deciding physical condition 
claims. Raters and VSOs see claims with mental disorder issues, 
especially PTSD, as requiring more judgment and subjectivity than 
claims with physical condition issues. Raters and VSOs indicated that 
it is less likely that mental disorder issue claims rated by different 
raters at the same VA Regional Office would receive similar ratings, 
and that deciding the various criteria of a claim is more problematic 
for mental disorder than for physical condition claims.
     Rating physical conditions in several body systems or 
subsystems also appears problematic. Raters identified neurological and 
convulsive disorders, musculoskeletal disorders (especially involving 
muscles), and disorders of special sense organs (especially eyes), as 
the most difficult and time consuming physical conditions to rate.
     A significant majority of raters indicate that more 
specific decision criteria or more specific evidence regarding 
individual unemployability (IU) would be helpful and that the criteria 
for IU are too broad.
     Time to rate or decide a disability claim is a scarce 
resource and a major challenge for raters. Time appears to be most 
challenging when raters are deciding complex claims, and raters report 
that claims getting more complex over time.
     A large majority of raters reported that they had 
insufficient time to rate or otherwise decide a claim, and both raters 
and VSOs reported that there was too much emphasis on speed relative to 
accuracy.
     Obtaining needed evidence, especially given the challenge 
and scarcity of time and the insufficiency of many medical examinations 
(in particular from private examiners, according to raters) is a 
challenge in its own right.
     Raters reported that the use of standardized assessment 
tools and more specific criteria for rating and deciding mental health 
issues--especially PTSD--would be useful.
     The process is difficult for most veterans and survivors 
to understand and navigate. Assisting clients to understand the process 
and the evidence needed for it is a major challenge for VSOs. A 
majority of VSOs further report that they disagree that the process is 
satisfactory to most of their clients. Most raters and VSOs believe 
veterans have unrealistic expectations of the claims process and the 
benefits they should receive.
     Overall, most raters and VSOs report that they believe 
that the claims rating process generally arrives at a fair and right 
decision for veterans. Further, in general, raters and VSOs assessed 
the performance of their VSOs (and each other) as good; however, most 
raters reported that they believe VSOs inappropriately coach their 
clients.

    Question 4. The Veterans' Disability Benefits Commission 
recommended that VA explore developing a tool to assess quality-of-life 
due to disability. This quality-of-life scale could either be 
incorporated into the current rating criteria or assessed 
independently. Which do you believe is preferable? Are there precedents 
from other disability compensation systems that might be instructive?
    Response. We do not aware of precedents to guide this decision. In 
our opinion, it would be more appropriate to keep the quality-of-life 
scale as a separate element. If the quality-of-life were to be 
incorporated into the current rating criteria, this would add another 
complexity to the rating system of compensation that is already quite 
difficult for veterans to understand. The current system of 
compensation is to make up for lost earnings capacity. It would be best 
not to layer another different purpose on top of that until we 
understand more about which categories of disabled veterans will be 
entitled to a quality-of-life adjustment, and how that adjustment will 
be determined (e.g., based on average quality-of-life, based on 
combined disability rating, based on combined disability rating and 
primary type of disability, etc.).

    Chairman Akaka. Thank you. Thank you very much, Dr. 
McMahon.
    Now we will hear from Dr. Bristow.

 STATEMENT OF LONNIE R. BRISTOW, M.D., MACP, FORMER PRESIDENT, 
 AMERICAN MEDICAL ASSOCIATION; ACCOMPANIED BY MICHAEL McGEARY, 
  SENIOR PROGRAM OFFICER, DIVISION OF HEALTH SCIENCES POLICY, 
           INSTITUTE OF MEDICINE, NATIONAL ACADEMIES

    Dr. Bristow. Thank you, Mr. Chairman. Chairman Akaka, 
Ranking Member Burr, and other Members of the Committee, my 
name is Lonnie Bristow. As you have heard, I am a physician and 
I have served as the President of the American Medical 
Association. I am joined on this panel today by Drs. Dean 
Kilpatrick and Scott Zeger, who will introduce themselves 
shortly. But on their behalf, let me thank you for the 
opportunity to testify about the work that our three Institute 
of Medicine, or IOM, committees have been engaged in.
    My task today is to present the recommendations of the IOM 
committee that I chaired, which was asked to evaluate the VA's 
schedule for rating disabilities and related matters. Dr. 
Kilpatrick will follow me to speak about his committee's work, 
which focused on Post Traumatic Stress Disorder, which is a 
particular challenge for the VA to evaluate. And Dr. Zeger will 
conclude our panel's presentation by briefing you on the 
findings of his committee, which was asked to offer its 
perspective on the scientific considerations that must underlie 
the question of whether a health outcome should be presumed to 
be connected to military service.
    We each have submitted our written testimony for the 
record, which we will summarize in our presentations here. 
Afterwards, of course, we will be happy to answer the 
Committee's questions.
    In my time remaining, I will quickly list our key findings 
and recommendations concerning the VA rating schedule and be 
glad to go into more detail about any of them during the 
question period.
    Our committee found that the statutory purpose of 
disability compensation, which is to compensate for the average 
loss of earning capacity, is an unduly restrictive rationale 
for the program and it is inconsistent with the current or 
modern concept of disability. The committee recommends that the 
VA compensate for three consequences of service-connected 
injuries and diseases: First, for work disability, which is 
currently does; second, the loss of ability to engage in usual 
life activities other than work, what disability experts today 
call functional limitations; and third, for the loss in 
quality-of-life.
    Concerning the ratings schedule, the committee found that 
the schedule is not as current medically as it could and should 
be. It found that the actual relationship of the rating levels 
to the average loss of earning capacity was not known at the 
time of our assessment. Also, the schedule does not evaluate 
impact on the veteran's ability to function in everyday life 
and the schedule does not evaluate the loss in quality-of-life.
    Our committee, therefore, recommends that VA immediately 
update the current ratings schedule medically, beginning with 
those body systems that have gone the longest without a 
comprehensive update, and adopt a system for keeping that 
schedule up to date medically.
    Second, VA should establish an external Disability Advisory 
Committee to provide advice during the updating process.
    And third, as part of updating the schedule, it should move 
to the ICD and DSM diagnostic classification systems.
    Fourth, it should investigate the relationship between the 
ratings and actual earnings to see the extent to which the 
ratings schedule is compensating for loss of earnings on 
average and adjust that rating criteria to reduce any 
disparities that are found.
    Fifth, it should compensate for functional limitations on 
usual life activities to the extent that the rating schedule 
does not.
    And sixth, it should develop a method of measuring the loss 
of quality-of-life, and where that schedule does not adequately 
compensate for it, VA should adopt a method for doing so. 
[Lights went off.]
    The committee also reviewed individual unemployability, or 
IU, and our main finding concerning IU is that it is not 
something that can be determined on medical grounds alone. 
Therefore, our committee recommends that VA conduct vocational 
assessments as well as medical evaluations in determining 
eligibility for IU.
    This concludes my remarks and I want to thank you again for 
the opportunity to testify and for testing my vision. 
[Laughter.]
    I would be happy to address any questions you might have 
about our report subsequently.
    [The prepared statement of Dr. Bristow follows:]
Prepared Statement of Lonnie Bristow, M.D., Chair, Committee on Medical 
 Evaluation of Veterans for Disability Benefits, Board on Military and 
     Veterans Health, Institute of Medicine, The National Academies
    Good morning, Chairman Akaka, Ranking Member Burr, and Members of 
the Committee. My name is Lonnie Bristow. I am a physician and a Navy 
veteran, and I have served as the president of the American Medical 
Association. I'm joined on this panel by Drs. Dean Kilpatrick and Scott 
Zeger, who will introduce themselves shortly. On their behalf, thank 
you for the opportunity to testify about the work of our Institute of 
Medicine (IOM) committees. Established in 1970 under the charter of the 
National Academy of Sciences, the IOM provides independent, objective 
advice to the Nation on improving health.
    My task today is to present to you the recommendations of the IOM 
committee I chaired, which was asked to evaluate the VA Schedule for 
Rating Disabilities and related matters. Dr. Kilpatrick will follow me 
to speak about his committee's work, which focused on Post Traumatic 
Stress Disorder, which is a particular challenge for the VA top 
evaluate. Dr. Zeger will conclude our panel's presentation by briefing 
you on the findings of his committee, which was asked to offer its 
perspective on the scientific considerations underlying the question of 
whether a health outcome should be presumed to be connected to military 
service.
    I had the great pleasure and honor of chairing the IOM Committee on 
Medical Evaluation of Veterans for Disability Compensation, which was 
established at the request of the Veterans' Disability Benefits 
Commission and funded by the Department of Veterans Affairs (VA).
             updating the basis for disability compensation
    Our report, A 21st Century System for Evaluating Veterans for 
Disability Benefits, which was issued last July, makes a number of 
important recommendations regarding the VA Rating Schedule and related 
matters. Our first recommendation is to broaden the purpose of the VA 
disability compensation program, which currently is to compensate for 
average loss of earning capacity, or work disability. We recommend that 
VA also compensate for loss of ability to engage in the usual 
activities of everyday life other than work and, if possible, for 
diminished quality-of-life. We recognize that legislative action will 
be required to change the statutory purpose of the disability 
compensation program, but doing so would bring the compensation program 
in line with our current understanding that disability has broad 
effects (see attached figure 4-1 from the report).
                     assessing the rating schedule
    When the Committee reviewed the Rating Schedule, we found that:

     Although it is called the Schedule for Rating 
Disabilities, it currently evaluates degree of impairment (i.e., loss 
of a body part or function) rather than degree of disability (i.e., 
limits on a person's ability to function at work or in life).
     Even in rating degree of impairment, the Schedule is not 
as current medically as it could and should be.
     The relationship of the rating levels to average loss of 
earning capacity is not known.
     The Schedule does not evaluate impact on a veteran's 
ability to function in everyday life.
     The Schedule does not evaluate loss of quality-of-life.

    Accordingly, we made a series of recommendations to update and 
revise the Rating Schedule.
                      updating the rating schedule
    First, the committee recommends that VA should immediately update 
the current Rating Schedule, beginning with those body systems that 
have gone the longest without a comprehensive update (i.e., the 
orthopedic part of the musculoskeletal system, the neurological system, 
and the digestive system). Revisions of the remaining systems could be 
done on a rolling basis--several a year--after which, VA should adopt a 
system for keeping the Schedule up to date medically. Also, VA should 
establish an external disability advisory committee to provide advice 
during the updating process.
    As part of updating the Rating Schedule, VA should move to the 
International Classification of Diseases (ICD) and Diagnostic and 
Statistical Manual of Mental Disorders (DSM) diagnostic classification 
systems that are used in today's health care systems, including VA's.
                   evaluating traumatic brain injury
    We were asked by your staff about improving the criteria for 
Traumatic Brain Injury, or TBI. TBI is an excellent example of where 
the rating criteria in the Schedule need to be updated in accord with 
current medical knowledge and practice.
    TBI is rated under diagnostic code 8045, ``Brain disease due to 
trauma,'' which was last updated substantively in 1961. Today, we 
understand much better how concussions from blast injuries can affect 
cognition even though there is no evident physical injury. In Iraq, 
many servicemembers have been subjected to multiple improvised 
explosive device blasts. The current criteria emphasize physical 
manifestations, such as paralysis and seizures. The Rating Schedule 
recognizes that symptoms such as headache, dizziness, and insomnia are 
common in brain trauma but limits them to a 10 percent rating. It is 
time to review how to properly evaluate and rate TBI in light of 
current medical knowledge, along with the rest of the neurological 
conditions, most of which have not been revised since 1945.
        relating the rating schedule to average loss of earnings
    In addition to updating the Schedule medically, VA should 
investigate the relationship between the ratings and actual earnings to 
see the extent to which the Rating Schedule as revised is compensating 
for loss of earnings on average. This would build on the analyses done 
by the CNA Corporation at the body system level but use samples large 
enough to study the most prevalent conditions being rated. Just 38 
conditions account for two-thirds of the compensation rating decisions. 
If VA finds disparities in average earnings, for example, that veterans 
with a mental disorder rated 70 percent earn substantially less on 
average than veterans rated 70 percent for other kinds of disabilities, 
it could adjust the rating criteria to narrow the gap.
        compensating for non-work-related functional limitations
    The Committee recommends that VA compensate for non-work 
disability, defined as functional limitations on usual life activities, 
to the extent that the Rating Schedule does not. To do this, VA should 
develop a set of functional measures--e.g., ADLs (activities of daily 
living), IADLs (instrumental activities of daily living)--and specific 
performance measures, such as time to ambulate a certain distance, or 
ability to do specific work-related tasks in both physical domains 
(e.g., climbing stairs or gripping) and cognitive domains (e.g., 
communicating or coordinating with other people). After the measures 
are validated in the disability compensation population, VA should 
conduct a study of functional capacity among applicants to see how well 
the revised Rating Schedule compensates for loss of functional 
capacity. There may be a close correlation between the rating levels 
based on impairment and degree of functional limitations (i.e., the 
higher the rating, the more functional capacity is limited), in which 
case the Rating Schedule compensates for both impairment and functional 
loss. But if the correlation is not high or does not exist, VA should 
develop a mechanism to compensate for loss of function that exceeds 
degree of impairment. This could be done by including functional 
criteria in the Rating Schedule or by rating function separately, with 
compensation based on the higher of the two ratings.
                compensating for loss of quality of life
    The Committee also recommends that VA compensate for loss of 
quality-of-life. We realize that quality-of-life assessment is 
relatively new and still at a formative stage, which makes this 
recommendation conditional on further research and development. VA 
should develop a tool for measuring quality-of-life validly and 
reliably in the veteran population, and then VA should conduct research 
to determine the extent to which the Rating Schedule might already 
account for loss in quality-of-life. We might find that veterans with 
the lowest quality-of-life already have the highest percentage ratings, 
but if not, VA should develop a procedure for evaluating and rating 
loss of quality-of-life of veterans with disabilities where it exceeds 
the degree of disability based on impairment and functional limitations 
determined according to the Rating Schedule.
                 evaluating individual unemployability
    The Committee also reviewed individual unemployability, or IU, 
which has been a fast-growing part of the compensation program. Our 
main finding concerning IU is that it is not something that can be 
determined on medical grounds alone. IU is based on an evaluation of 
the individual veteran's capacity to engage in a substantially gainful 
occupation, rather than on the Rating Schedule, which is based on the 
average impairment of earnings concept. Thus the determination of IU 
must consider occupational as well as medical factors. To analyze IU 
claims, raters have medical evaluations from medical professionals and 
other medical records but usually they do not have comparable 
functional capacity or vocational evaluations from vocational experts. 
Therefore, the Committee recommends that, in addition to medical 
evaluations by medical professionals, VA require vocational assessment 
in the determination of eligibility for individual unemployability 
benefits. Raters should receive training on how to interpret findings 
from vocational assessments for the evaluation of individual 
unemployability claims.
                         other recommendations
    The Committee made additional recommendations on issues other than 
the VA Schedule for Rating Disabilities, which I am not reviewing 
today. They can be found in our report and our recommendations for 
improving the medical examination and rating processes were presented 
to you by our staff director, Michael McGeary, on February 14 (for 
example, mandating the use of the on-line medical examination templates 
and having medical consultants to advise the raters on medical 
evidence).
    This concludes my remarks. Thank you for the opportunity to 
testify. I would be happy to address any questions the Subcommittee 
might have.

FIGURE 4-1 The consequences of an injury or disease.


From: A 21st Century System for Evaluating Veterans for Disability 
Benefits. National Academies Press, 2007.

    Chairman Akaka. Thank you. Thank you very much, Dr. 
Bristow. I would tell you that your vision is 20/20. 
[Laughter.]
    Let me say that all of your full statements will be 
included in the record.
    Now we will hear from Dr. Kilpatrick.

STATEMENT OF DEAN G. KILPATRICK, PH.D., PROFESSOR AND DIRECTOR, 
 NATIONAL CRIME VICTIMS RESEARCH AND TREATMENT CENTER, MEDICAL 
                  UNIVERSITY OF SOUTH CAROLINA

    Mr. Kilpatrick. Thank you, Mr. Chairman and Members of the 
Committee, for the opportunity to testify on behalf of the 
Committee on Veterans Compensation for Post Traumatic Stress 
Disorder. Last June, we completed this report, ``PTSD 
Compensation in Military Service,'' and I understand that this 
is available to you. We had several conclusions that I would 
like to summarize.
    First, we had testimony that was presented to committee 
indicating that clinicians often feel pressured to severely 
constrain the time they devote to doing the compensation and 
pension examination that is used and is really the basis for 
making the disability determinations. These exams may last as 
little as 20 minutes, even though the protocol suggested in a 
best practice manual developed by the National Center for PTSD 
in the VA can take 3 hours or more to complete. The committee 
believed that the key to proper administration of the VA's PTSD 
compensation program is a thorough C&P examination conducted by 
an experienced and well-trained mental health professional. 
Many of the problems and issues with the current process can be 
addressed by consistently allocating and applying the time and 
resources needed for a thorough examination.
    The VA, for a second point, establishes a rating for the 
level of disability associated with service-connected disorders 
through a review that uses the information gathered in the C&P 
examinations and criteria set forth in the schedule for rating 
disabilities. Currently, the same set of criteria are used for 
rating all mental disabilities. They focus on symptoms from 
schizophrenia, mood, and anxiety disorders.
    Our committee found that these criteria are at best a crude 
and overly general instrument for the assessment of PTSD 
disability. We recommended that new criteria be developed and 
applied that specifically address PTSD symptoms and associated 
disability problems that are firmly grounded in the standards 
set out in the DSM used by mental health professionals. The 
committee also recommended that PTSD-specific training for both 
clinicians and raters be done in order to promote more 
accurate, consistent, and uniform disability ratings.
    The VA asked the committee to address whether it would be 
advisable to establish a set schedule for reexamining veterans 
who receive compensation for PTSD. We concluded that it is not 
appropriate to require across-the-board periodic reexaminations 
and recommended that reexamination be done only on a case-by-
case basis when there are sound reasons to expect that major 
changes in disability status might occur.
    We based this conclusion on two reasons. First, there are 
finite resources, both personnel and money, to conduct PTSD 
exams; and we believe these should be focused on the 
performance of uniformly high-quality and timely initial exams. 
Second, across-the-board periodic reexaminations are not 
required for other mental disorders or mental conditions. We 
felt there was no scientific justification for singling out 
PTSD disability for special action and we thought that doing so 
might stigmatize those veterans by implying that their 
condition requires extra scrutiny.
    The Veterans' Disability Benefits Commission subsequently 
recommended that the VA should conduct PTSD reevaluations every 
two to 3 years. This, I think, is an honest disagreement from 
two committees that were looking at the same thing. There are 
advantages and disadvantages to both of these approaches that 
our two groups put forward, but the important thing is for the 
VA to give these both careful consideration when they formulate 
their policy. I believe that if periodic PTSD reexaminations 
are implemented, this should not be done until there are 
sufficient resources to ensure that every veteran gets a first-
rate C&P exam done by a well-trained mental health professional 
conducted in a timely fashion.
    With respect to the issue that has been raised about 
whether compensation for PTSD is a disincentive for veterans 
receiving or benefiting from treatment or therapy, our 
committee concluded that there is little direct evidence that 
receiving compensation or seeking it has negative effects on 
treatment outcome. This is reviewed substantially in our 
report.
    We also received testimony in the committee which indicated 
that compensation seeking, or people who were service-connected 
for PTSD, was shown to be unrelated to clinical outcome or 
treatment response in a number of randomized clinical trials 
that had been done to treat PTSD that had been conducted by the 
VA.
    Our committee also reached a whole series of other 
recommendations regarding the conduct of VA's compensation and 
pension system for PTSD that are outlined in the body of our 
report and I appreciate your attention and would be happy to 
answer questions at the appropriate time.
    [The prepared statement of Mr. Kilpatrick follows:]
    Prepared Statement of Dean G. Kilpatrick, Ph.D., Distinguished 
  University Professor, Director, National Crime Victims Research and 
  Treatment Center, Medical University of South Carolina and Member, 
Committee on Veterans' Compensation for Post Traumatic Stress Disorder, 
   Institute of Medicine and National Research Council, The National 
                               Academies
    Good morning, Mr. Chairman and Members of the Committee. My name is 
Dean Kilpatrick and I am Distinguished University Professor in the 
Department of Psychiatry and Behavioral Sciences and Director of the 
National Crime Victims Research and Treatment Center at the Medical 
University of South Carolina. Thank you for the opportunity to testify 
on behalf of the members of the Committee on Veterans' Compensation for 
Post Traumatic Stress Disorder. This committee was convened under the 
auspices of the National Research Council and the Institute of 
Medicine. Our committee's work was requested by the Department of 
Veterans Affairs, which provided funding for the effort. Its work was 
also presented to and used by the congressionally-constituted Veterans 
Disability Benefits Commission.
    Last June, our committee completed its report--entitled PTSD 
Compensation and Military Service--which addresses potential revisions 
to the Schedule for Rating Disabilities in the context of a larger 
review of how VA administers its PTSD compensation program. I am 
pleased to be here today to share with you the content of that report, 
the knowledge I've gained as a clinical psychologist and researcher on 
traumatic stress, and my experience as someone who previously served as 
a clinician at the VA.
    I will begin with some background information on Post Traumatic 
Stress Disorder. Briefly described, PTSD is a psychiatric disorder that 
can develop in a person after a traumatic experience. Someone is 
diagnosed with PTSD if, in response to that traumatic experience, he or 
she develops a cluster of symptoms that include:

     reexperiencing the traumatic event as reflected by 
distressing recollections, memories, nightmares, or flashbacks;
     avoidance of anything that reminds them of the traumatic 
event;
     emotional numbing or feeling detached from other people;
     hyperarousal as reflected by trouble sleeping, trouble 
concentrating, outbursts of anger, and having to always be vigilant for 
potential threats in the environment; and
     impairment in social or occupational functioning, or 
clinically significant distress.

    PTSD is one of an interrelated and overlapping set of possible 
mental health responses to combat exposures and other traumas 
encountered in military service. It has been described as one of the 
signature wounds of the most recent Iraq conflicts. Although PTSD has 
only been an official diagnosis since the 1980's, the symptoms 
associated with it have been reported for centuries. In the U.S., 
expressions including shell shock, combat fatigue, and gross stress 
reaction have been used to label what is now called PTSD.
    Our committee's review of the scientific literature regarding PTSD 
led it to draw some conclusions that are relevant to this hearing. It 
found abundant evidence indicating that PTSD can develop at any time 
after exposure to a traumatic stressor, including cases where there is 
a long time interval between the stressor and the recognition of 
symptoms. Some of these cases may involve the initial onset of symptoms 
after many years of symptom-free life, while others may involve the 
manifestation of explicit symptoms in persons with previously 
undiagnosed PTSD. The determinants of delayed-onset PTSD are not well 
understood. The scientific literature does not identify any differences 
material to the consideration of compensation between these delayed-
onset or delayed-identification cases and those chronic PTSD cases 
where there is a shorter time interval between the stressor and the 
recognition of symptoms.
    Our review also identified several areas where changes to VA's 
current practices might result in more consistent and accurate ratings 
for disability associated with PTSD.
    There are two primary steps in the disability compensation process 
for veterans. The first of these is a compensation and pension, or C&P, 
examination. These examinations are conducted by VA mental health 
professionals or outside professionals who meet certain education and 
licensing requirements. Testimony presented to our committee indicated 
that clinicians often feel pressured to severely constrain the time 
that they devote to conducting a PTSD C&P examination--sometimes to as 
little as 20 minutes--even though the protocol suggested in a best 
practice manual developed by the VA National Center for PTSD can take 3 
hours or more to properly complete. The committee believes that the key 
to proper administration of VA's PTSD compensation program is a 
thorough C&P clinical examination conducted by an experienced mental 
health professional. Many of the problems and issues with the current 
process can be addressed by consistently allocating and applying the 
time and resources needed for a thorough examination. The committee 
also recommended that a system-wide training program be implemented for 
the clinicians who conduct these exams in order to promote uniform and 
consistent evaluations.
    The second primary step in the compensation process for veterans is 
a rating of the level of disability associated with service-connected 
disorders identified in the clinical examination. This rating is 
performed by a VA employee using the information gathered in the C&P 
exam and criteria set forward in the Schedule for Rating Disabilities. 
Currently, the same set of criteria is used for rating all mental 
disorders. They focus on symptoms from schizophrenia, mood, and anxiety 
disorders. The committee found that the criteria are at best a crude 
and overly general instrument for the assessment of PTSD disability. We 
recommended that new criteria be developed and applied that 
specifically address PTSD symptoms and that are firmly grounded in the 
standards set out in the Diagnostic and Statistical Manual of Mental 
Disorders used by mental health professionals.
    Our committee also suggested that VA take a broader and more 
comprehensive view of what constitutes PTSD disability. In the current 
scheme, occupational impairment drives the determination of the rating 
level. Under the committee's recommended framework, the psychosocial 
and occupational aspects of functional impairment would be separately 
evaluated, and the claimant would be rated on the dimension on which he 
or she is more affected. We believe that the special emphasis on 
occupational impairment in the current criteria unduly penalizes 
veterans who may be capable of working, but significantly symptomatic 
or impaired in other dimensions, and thus it may serve as a 
disincentive to both work and recovery. This recommendation is 
consistent with the Dole-Shalala Commission's suggestion to add 
quality-of-life payments to compensation.
    Research reviewed by the committee indicates that disability 
compensation does not in general serve as a disincentive to seeking 
treatment. While some beneficiaries will undoubtedly understate their 
improvement in the course of pursuing compensation, the scientific 
literature suggests that such patients are in the minority, and there 
is some evidence that disability payments may actually contribute to 
better treatment outcomes in some programs. The literature on recovery 
indicates that it is influenced by several factors, and the independent 
effect of compensation on recovery is difficult to disentangle from 
these.
    Determining ratings for mental disabilities in general and for PTSD 
specifically is more difficult than for many other disorders because of 
the inherently subjective nature of symptom reporting. In order to 
promote more accurate, consistent, and uniform PTSD disability ratings, 
the committee recommended that VA establish a specific certification 
program for raters who deal with PTSD claims, with the training to 
support it, as well as periodic recertification. Rater certification 
should foster greater confidence in ratings decisions and in the 
decisionmaking process.
    At VA's request, the committee addressed whether it would be 
advisable to establish a set schedule for re-examining veterans 
receiving compensation for PTSD. We concluded that it is not 
appropriate to require across-the-board periodic reexaminations for 
veterans with PTSD service-connected disability. The committee instead 
recommended that reexamination be done only on a case-by-case basis 
when there are sound reasons to expect that major changes in disability 
status might occur. These conclusions were based on two considerations. 
First, there are finite resources--both funds and personnel--to conduct 
C&P examinations and determine disability ratings. The committee 
believes that resources should be focused on the performance of 
uniformly high-quality C&P clinical examinations. It believes that 
allocating resources to such examinations--in particular, to initial 
C&P evaluations--is a better use of resources than periodic, across-
the-board reexaminations. Second, as the committee understands it, 
across-the-board periodic reexaminations are not required for other 
mental disorders or medical conditions. The committee's review of the 
literature on misreporting or exaggeration of symptoms by PTSD 
claimants yielded no justification for singling out PTSD disability for 
special action and thereby potentially stigmatizing veterans with the 
disability by implying that their condition requires extra scrutiny.
    I understand that the Veterans Disability Benefits Commission 
subsequently recommended that VA should conduct PTSD reevaluations 
every 2-3 years to gauge treatment effectiveness and encourage 
wellness. Since the Commission report was released after the end of our 
work, my committee did not address the disparity in our 
recommendations. I know that our committee and the Commission both want 
veterans to receive fair treatment and the finest care, and I consider 
this to be an honest difference of opinion on how to best achieve those 
goals. There are advantages and disadvantages to the approaches that 
our two groups put forward, and the important thing is for VA to give 
these careful consideration when they formulate their policy. I believe 
that--if periodic reexaminations are implemented--this should not be 
done until there are sufficient resources to insure that every veteran 
gets a first-rate initial C&P exam in a timely fashion.
    To summarize, the committee identified three major changes that are 
needed to improve the compensation evaluation process for veterans with 
PTSD:

     First, the C&P exam should be done by mental health 
professionals who are adequately trained in PTSD and who are allotted 
adequate time to conduct the exams.
     Second, the current VA disability rating system should be 
substantially changed to focus on a more comprehensive measure of the 
degree of impairment, disability, and clinically significant distress 
caused by PTSD. The current focus on occupational impairment serves as 
a disincentive for both work and recovery.
     Third, the VA should establish a certification program for 
raters who deal with PTSD clams.

    Our committee also reached a series of other recommendations 
regarding the conduct of VA's compensation and pension system for PTSD 
that are detailed in the body of our report. I have provided copies of 
this report as part of my submitted testimony.
    Thank you for your attention. I will be happy to answer your 
questions.
                                 ______
                                 
Response to written questions submitted by Hon. Daniel K. Akaka to the 
    Dean G. Kilpatrick, Ph.D., Distinguished University Professor, 
Director, National Crime Victims Research and Treatment Center, Medical 
    University of South Carolina and Member, Committee on Veterans' 
Compensation for Post Traumatic Stress Disorder, Institute of Medicine 
         and National Research Council, The National Academies
    Question 1. Dr. Kilpatrick, IOM also stated that PTSD can develop 
anytime after exposure to a traumatic stressor. IOM found abundant 
scientific evidence indicating that PTSD can develop at any time after 
exposure to a traumatic stressor, including cases where there is a long 
interval between the stressor and the recognition of symptoms. Can you 
please elaborate further on this topic?
    Response. The National Academies' Committee on Veterans' 
Compensation for Post Traumatic Stress Disorder--of which I was a 
member--addressed this topic in detail on pages 101-105 of our 2007 
report PTSD Compensation and Military Service. Quoting the report:

          Determining whether an apparent case of delayed-onset PTSD is 
        actually delayed poses challenges in both clinical and research 
        settings. The difficulty can be attributed to several factors. 
        Foremost, it is rare that a careful longitudinal assessment has 
        been conducted, with data collection beginning soon after 
        exposure to a stressor and continuing long enough to establish 
        (1) the developmental trajectory of PTSD symptoms, (2) the 
        documentation of diagnostic criteria, and (3) the full 
        diagnostic assessment itself. Such information is needed to 
        determine with some degree of confidence how long after 
        exposure symptoms occurred, which and when individual 
        diagnostic criteria manifested, and when and under which 
        version of the DSM all diagnostic criteria for the PTSD 
        diagnosis were met. Additionally, there exists a subpopulation 
        of veterans with PTSD who do not seek mental health treatment 
        services or compensation from the Department of Veterans 
        Affairs at the time of the onset of the disease. When such 
        veterans present with PTSD symptoms for treatment or 
        compensation evaluation long after their military service, what 
        appears to be ``delayed onset'' PTSD may actually be a delayed 
        diagnosis of a disorder that has been present for a substantial 
        period of time.
          Some individuals exposed to potentially traumatic events, 
        including war zone stressors, develop subthreshold PTSD--that 
        is, they meet some of the [DSM IV-TR] B, C, and D criteria for 
        PTSD * * * but not all, or they fall one or two symptoms short 
        of meeting full diagnostic criteria. Such individuals may not 
        have a history of full PTSD, but with slight increases in 
        symptomatology these cases can cross the diagnostic threshold 
        to become full PTSD. Thus, what appears to be a new, delayed-
        onset case may actually be someone who for years has 
        experienced symptoms just short of the benchmark criteria 
        required for PTSD diagnosis and who becomes a case due to a 
        small increase in symptomatology. (p. 102)
          * * *
          Delayed-onset PTSD is consistently observed, albeit in a 
        fraction of the overall PTSD cases, and data indicate that 
        delayed-onset PTSD is perhaps more common among those exposed 
        to war--related trauma than among those exposed to other kinds 
        of trauma Some cases of delayed-onset PTSD are symptomatic 
        individuals who do not meet all the criteria of PTSD. * * * A 
        number of factors have been found to be associated with the 
        delayed onset of PTSD in previously undiagnosed individuals, 
        including the occurrence of negative life events, decline in 
        self esteem, ethnicity, and negative health changes. These 
        factors have been shown to exacerbate symptoms in those with 
        existing PTSD as well * * *. (p. 104)

    The report elaborates on this information and provides citations to 
several peer-reviewed scientific papers that support these observations 
and conclusions.

    Question 2. Dr. Kilpatrick, can you please explain the importance 
of providing a guaranteed level of benefits that would take explicit 
account of the nature of chronic PTSD by providing a safety net for 
those who might be asymptomatic for periods of time?
    Response. PTSD Compensation and Military Service notes that ``some 
researchers have speculated that veterans may be reluctant to 
acknowledge therapeutic gains because they believe that this may lead 
VA to lower their disability rating and thus lower their benefits'' (p. 
182). VA asked the committee to recommend strategies for reducing 
disincentives and maximizing incentives for achieving optimal mental 
functioning for veterans. Among the responses formulated by the 
committee was a recommendation that the VA consider instituting a set, 
long-term minimum level of benefits that would be available to any 
veteran with service-connected PTSD at or above some specified rating 
level without regard to that person's state of health at a particular 
point in time after the C&P examination. Our report offers this 
reasoning in support of that recommendation:

          Regulation already specifies an analogous approach for other 
        disorders, including conditions whose symptoms may remit and 
        relapse over time. Multiple sclerosis, for example, has a 
        minimum rating of 30 percent without regard to whether the 
        condition is disabling at the moment that the subject is 
        evaluated. However, rather than being limited to a particular 
        minimum rating, the committee suggests that the VA consider 
        what minimum benefits level--where ``benefits'' comprise 
        compensation and other forms of assistance, such as priority 
        access to VA medical treatment--would be most likely to promote 
        wellness. It is beyond the scope of the charge to the committee 
        to specify the particular set of benefits that would be most 
        appropriate or the level[s] of impairment that would trigger 
        provision of these benefits. This would require a careful 
        consideration of the needs of the population, of the new 
        incentives that the policy change would create, of the possible 
        effects on compensation outlays and demand for other VA 
        resources, and of how to maintain fairness with respect to 
        other conditions that have a remitting/relapsing nature.
          Providing a guaranteed minimum level of benefits would take 
        explicit account of the nature of chronic PTSD by providing a 
        safety net for those who might be asymptomatic for periods of 
        time. A properly designed set of benefits could eliminate 
        uncertainty over future timely access to treatment and 
        financial support in times of need and would in part remove the 
        incentive to ``stay sick'' that some suggest is a flaw of the 
        current system. 
        (p. 185-186)

    Chairman Akaka. Thank you very much, Dr. Kilpatrick.
    Now we will hear from Dr. Scott Zeger.

 STATEMENT OF SCOTT L. ZEGER, PH.D., PROFESSOR, JOHNS HOPKINS 
    BLOOMBERG SCHOOL OF PUBLIC HEALTH; ACCOMPANIED BY RICK 
   ERDTMANN, M.D., MPH, DIRECTOR, MEDICAL FOLLOW-UP AGENCY, 
           INSTITUTE OF MEDICINE, NATIONAL ACADEMIES

    Dr. Zeger. Thank you, Chairman Akaka, Ranking Member Burr, 
and Senator Murray. I appreciate the chance to be here with you 
today. I am Scott Zeger, professor of biostatistics at Johns 
Hopkins University, and was a member of the IOM committee that 
recently authored this report, ``Improving the Presumptive 
Disability Decision Making Process for Veterans.'' On behalf of 
the committee members and our Chair, Dr. Samet, I am pleased to 
present a summary of our findings to you.
    Our committee worked for a year with two goals, first to 
describe the current process for making presumptive decisions 
for veterans, and second to propose a more sound scientific 
framework for making those decisions in the future.
    Veterans who have been injured by their service are owed 
appropriate health care and disability compensation. As one of 
the most eloquent VSO witnesses to our committee told us, 
``Americans don't leave their wounded soldiers behind.'' When 
scientific information is incomplete, Congress or the 
Department of Veterans Affairs may elect to make a presumption 
of service connection so that a group of veterans may be 
appropriately compensated.
    Our committee studied past presumptions and identified 
shortcomings in the current process. These include poor 
tracking of soldiers' exposures--sometimes due to secrecy--and 
inadequate surveillance of veterans' illnesses. We detected 
varying approaches to synthesizing evidence on the health 
consequences of military service and a lack of transparency of 
the VA decisionmaking process.
    Our committee has recommended a more scientific approach 
that would include the following components: A new process for 
nominating exposures or health conditions for presumptions that 
would be open to all stakeholders; a revised process for 
evaluating scientific information on whether an exposure causes 
a health condition in veterans; a transparent evidence-based 
decisionmaking process by the VA; better tracking of the 
exposures of military personnel and of the illnesses of the 
veterans; and an organizational structure to support this 
process.
    We specifically proposed the creation of two panels. The 
first would be called the Advisory Committee to the VA that 
would assemble and give priority to the exposures and health 
conditions proposed for possible presumptive evaluation. 
Nominations would come from veterans and other stakeholders. 
The second panel would be a Scientific Review Board, an 
independent body not unlike the IOM, that would evaluate the 
strength of the evidence that the health condition is caused by 
the military exposure.
    The VA would then use explicit criteria to render a 
decision to establish a presumption or not, and since better 
data is the means to achieve better decisions, the Scientific 
Review Board would also be responsible to monitor DOD and VA 
information on the health of veterans as it accumulates over 
time and to nominate new exposures or health conditions for 
consideration for presumptions.
    In proposing causation as the target for inference, the 
committee recognizes that both causation and association have 
been used in recent practice. Our focus on cause rather than 
association is to identify the right target, not to set a 
higher evidentiary standard. Also, by focusing on the causal 
target, the committee calls for a broad interpretation of all 
sources of evidence, not only empirical evidence usually relied 
on when establishing association. The committee recommends that 
the VA decide in favor of a presumption when a causal 
relationship is more likely than not as assessed by the Science 
Review Board.
    The committee recognizes that action by Congress is needed 
to implement our plan to create the two panels and to assure 
that we fulfill our commitment to veterans by more accurately 
tracking their military exposures and their health outcomes 
after their distinguished service on behalf of us all.
    Thanks for the opportunity to speak to you today and I 
would be happy to address questions that you might have.
    [The prepared statement of Mr. Zeger follows:]
   Prepared Statement of Scott L. Zeger, Ph.D., Member, Committee on 
 Evaluation of the Presumptive Disability Decision-Making Process for 
    Veterans, Board on Military and Veterans Affairs, Institute of 
  Medicine, The National Academies and Frank Hurley-Catharine Dorrier 
  Chair and Professor, Department of Biostatistics, The Johns Hopkins 
                   Bloomberg School of Public Health
    Good afternoon Senator Akaka and Members of the Senate Committee on 
Veterans' Affairs. I am Scott L. Zeger, Professor of Biostatistics from 
Johns Hopkins University in Baltimore, Maryland, a member of the 
Institute of Medicine Committee who recently authored the report, 
Improving the Presumptive Disability Decision-Making Process for 
Veterans. On behalf of Dr. Jonathan Samet, our Committee Chair, and the 
rest of the 16 members who represent a diversity of scientific and 
medical disciplines, I am pleased to present a summary of our key 
findings to you today.
    Our Institute of Medicine Committee worked for a year to describe 
the current process for making presumptive decisions for veterans who 
have health conditions arising from military service and to propose a 
more sound scientific framework for making such presumptive decisions 
in the future.
    To address its charge, the Committee met with many stakeholders: 
past and present staffers from Congress, the Veterans Administration 
(VA), the Institute of Medicine, veteran's service organizations, and 
individual veterans. The Department of Defense (DOD) gave the Committee 
information about how it tracks exposures and health conditions of 
personnel. The Committee attempted to formally capture how the current 
approach works and completed a series of case studies to identify 
``lessons learned''. The Committee also considered how information is 
obtained on the health of veterans and how exposures during military 
service can be linked to any health consequences via scientific 
investigation. It gave substantial attention to the process by which 
information can best be synthesized to determine if a particular 
exposure causes a risk to health.
    Veterans who have been injured by their service, whether their 
injury appears during service or afterwards, are owed appropriate 
health care and disability compensation. For some medical conditions 
that develop after military service, the scientific information needed 
to determine that the health condition was caused by their service may 
be incomplete. In such a situation, Congress or the Department of 
Veterans Affairs (VA) may elect to make a ``presumption'' of service-
connection so that a group of veterans can be appropriately 
compensated. Presumptions are made in order to reach decisions in the 
face of unavailable or incomplete information.
    Presumptions were first established in 1921. More recently, several 
presumptions have been made about Agent Orange exposure during service 
in Vietnam and around the health risks sustained by military personnel 
in the first Persian Gulf War.
    The present approach to presumptive disability decision-making 
largely flows from the Agent Orange Act of 1991, which started a model 
for decision-making that is still in place. In that law, Congress asked 
the VA to contract with an independent organization, the Institute of 
Medicine, to review the scientific evidence for the health effects of 
Agent Orange. Subsequently, the Institute of Medicine has produced 
reports on Agent Orange, evaluating whether there is evidence that 
Agent Orange is associated with various health outcomes. The Institute 
of Medicine provides its reports to the VA, which then acts through its 
own internal decision-making process to determine if a presumption is 
to be made.
    The case studies conducted by the Committee probed this process. 
The case studies pointed to a number of difficulties that need to be 
addressed in any future approach:

     Lack of information on exposures received by military 
personnel and inadequate surveillance of veterans for service-related 
illnesses.
     Gaps in information because of secrecy.
     Varying approaches to synthesizing evidence on the health 
consequences of military service.
     In the instance of Agent Orange, classification of 
evidence for association but not for causation.
     A failure to quantify the effect of the exposure during 
military service, particularly for diseases with other risk factors and 
causes.
     A general lack of transparency of the presumptive 
disability decision-making process.

    The Committee discussed in great depth the optimum approach to 
establishing a scientific foundation for presumptive disability 
decision-making, including the methods used to determine if exposure to 
some factor increases risk for disease. This assessment and the 
findings of the case studies led to recommendations to improve the 
process:

     As the case studies demonstrated, Congress could provide a 
clearer and more consistent charge on how much evidence is needed to 
make a presumption. There should be clarity as to whether the finding 
of an association in one or more studies is sufficient or the evidence 
should support causation.
     Due to lack of clarity and consistency in congressional 
language and VA's charges to the committees, IOM committees have taken 
somewhat varying approaches since 1991 in reviewing the scientific 
evidence, and in forming their opinions on the possibility that 
exposures during military service contributed to causing a health 
condition. Future committees could improve their review and 
classification of scientific evidence if they were given clear and 
consistent charges and followed uniform evaluation procedures.
     The internal processes by which the VA makes it 
presumptive decisions following receipt of an IOM report have been 
unclear. VA should adopt transparent and consistent approaches for 
making these decisions.
     Adequate exposure data and health condition information 
for military personnel (both individuals and groups) usually have not 
been available from DOD in the past. Such information is one of the 
most critical pieces of evidence for improving the determination of 
links between exposures and health conditions. Approaches are needed to 
assure that such information is systematically collected in an ongoing 
fashion.

    All of these improvements are feasible over the longer term and are 
needed to ensure that the presumptive disability decision-making 
process for veterans is based on the best possible scientific evidence. 
Decisions about disability compensation and related benefits (e.g., 
medical care) for veterans should be based on the best possible 
documentation and evidence of their military exposures as well as on 
the best possible information. A fresh approach could do much to 
improve the current process. The Committee's recommended approach (see 
Figure GS-1 attached) has several parts:

     an open process for nominating exposures and health 
conditions for review; involving all stakeholders in this process is 
critical;
     a revised process for evaluating scientific information on 
whether a given exposure causes a health condition in veterans; this 
includes a new set of categories to assess the strength of the evidence 
for causation, and an estimate of the numbers of exposed veterans whose 
health condition can be attributed to their military exposure;
     a consistent and transparent decision-making process by 
VA;
     a system for tracking the exposures of military personnel 
(including chemical, biological, infectious, physical and psychological 
stressors), and for monitoring the health conditions of all military 
personnel while in service and after separation; and
     an organizational structure to support this process.

    To support the Committee's recommendations, we suggest the creation 
of two panels. One is an Advisory Committee (advisory to VA), that 
would assemble, consider and give priority to the exposures and health 
conditions proposed for possible presumptive evaluation. Nominations 
for presumptions could come from veterans and other stakeholders as 
well as from health tracking, surveillance and research. The second 
panel would be a Science Review Board, an independent body, which would 
evaluate the strength of the evidence (based on causation) which links 
a health condition to a military exposure and then estimates the 
fraction of exposed veterans whose health condition could be attributed 
to their military exposure. The Science Review Board's report and 
recommendations would go to the VA for its consideration. The VA would 
use explicit criteria to render a decision by the VA Secretary with 
regard to whether a presumption would be established. In addition, the 
Science Review Board would monitor information on the health of 
veterans as it accumulates over time in the DOD and VA tracking 
systems, and nominate new exposures or health conditions for evaluation 
as appropriate.
    This Committee recommends that the following principles be adopted 
in establishing this new approach:

    1. Stakeholder inclusiveness
    2. Evidence-based decisions
    3. Transparent process
    4. Flexibility
    5. Consistency
    6. Causation, not just association, as the target for decision 
making.

    The last principle needs further discussion, as it departs from the 
current approach. In proposing causation as the target, the Committee 
had concern that the approach of relying on association, particularly 
if based on findings of one study, could lead to ``false-positive'' 
presumptions. The Committee calls for a broad interpretation of 
evidence to judge whether a factor causes a disease in order to assure 
that relevant findings from laboratory studies are adequately 
considered. The Committee also recommends that benefits be considered 
when there is at least a 50 percent likelihood of a causal 
relationship, and does not call for full certainty on the part of the 
Science Review Board.
    The Committee suggests that its framework be considered as the 
model to guide the evolution of the current approach. While some 
aspects of the approach may appear challenging or infeasible at 
present, feasibility would be improved by the provision of appropriate 
resources to all of the participants in the presumptive disability 
decision-making process for veterans and future methodological 
developments. Veterans deserve to have these improvements accomplished 
as soon as possible.
    The Committee recognized that action by Congress will be needed to 
implement its proposed approach. Legislation to create the two panels 
is needed and Congress should also act to assure that needed resources 
are available to create and sustain exposure and health tracking for 
service personnel and veterans. Many of the changes proposed by the 
Committee could be implemented now, even as steps are taken to move the 
DOD and VA toward implementing the model recommended. Veterans deserve 
to have an improved system as soon as possible.
    Thank you for the opportunity to testify. I would be happy to 
address any questions the Subcommittee might have.
FIGURE GS-1 (IOM 2007) Proposed Framework for Future Presumptive 
Disability Decision-Making Process for Veterans.


    a Includes research for classified or secret activities, 
exposures, etc.
    b Includes veterans, Veterans Service Organizations, 
federal agencies, scientists, general public, etc.
    c This committee screens stakeholders' proposals and 
research in support of evaluating evidence for presumptions and makes 
recommendations to the VA Secretary when full evidence review or 
additional research is appropriate.
    d The board conducts a two-step evidence review process 
(see report text for further detail).
    e Final presumptive disability compensation decisions 
are made by the Secretary, Department of Veterans Affairs, unless 
legislated by Congress.
                                 ______
                                 
Enclosure: Improving the Presumptive Disability Decision-Making Process 
                              for Veterans


































                                 ______
                                 
  Responses to Written Questions Submitted by Hon. Daniel K. Akaka to 
     Scott L. Zeger, Ph.D., Member, Committee on Evaluation of the 
 Presumptive Disability Decision-Making Process for Veterans, Board on 
  Military and Veterans Affairs, Institute of Medicine, The National 
   Academies and Frank Hurley-Catharine Dorrier Chair and Professor, 
  Department of Biostatistics, The Johns Hopkins Bloomberg School of 
                             Public Health
    Thank you for the opportunity to speak to your Committee on 
February 27, 2008 on the important question of how to use the best 
available science in the VA's presumption process as detailed in our 
Institute of Medicine report of the Committee on Evaluation of the 
Presumptive Disability Decision-Making Process for Veterans. I am 
writing in response to your letter of March 3, 2008, that provided two 
questions in follow-up of my testimony. Attached, please find my 
responses.
    I appreciated the opportunity to speak to the Committee. Please do 
not hesitate to contact our Committee's Chair, Dr. Jonathan M. Samet, 
or me if we can be of further assistance as you consider and use the 
report.

    Question 1. Dr. Zeger, I am interested in hearing about your 
Committee's recommended new process for VA to follow in establishing 
presumptions. To aid the Committee in its understanding of this 
proposed approach, please take an existing issue--establishment of a 
presumption in the case of possible Agent Orange exposure for veterans 
who served off the coast of Vietnam--and describe how the Committee's 
recommended approach would be applied.
    Response. The Committee calls for a prospectively implemented 
evidence-based approach that could have provided needed data and 
information on Agent Orange exposure in the Vietnam War, had it been in 
place at the time. The Committee's report calls for improved exposure 
surveillance during wartime deployment. Had such a system been in place 
during the Vietnam War, we might have the relevant data about the level 
and duration of exposures on board ship, as well as other locations in 
Vietnam, rather than having to speculate about them half a century 
later and make an exposure presumption. Having established a legal 
presumption regarding exposure to Agent Orange, the issue of shipboard 
exposure is less of a scientific question and more one of legal 
construction of the law and implementing regulations
    The first step in the process would be for a specific issue or 
concern (i.e., potential exposure and potential resulting health 
condition) to be presented to the Advisory Committee. This could come 
from two general sources. (1) surveillance data and/or research results 
produced by VA, DOD, public health agencies or academicians and (2) 
nominations from an individual (e.g., veteran, veteran's family), a 
group (e.g., VSOs), Federal agencies, academicians or general public. 
VA staff serving the Advisory Committee would quickly compile as much 
information as they could to present to the Advisory Committee. The 
Advisory Committee is envisioned as a screening group and would review 
the available information to make a determination whether there was 
enough evidence to request a full scientific review by the Science 
Review Board. If the Advisory Committee determined there was not enough 
evidence, it could recommend additional research be conducted to 
establish the strength of a causal relationship between the potential 
exposure and potential resulting health condition. If the Advisory 
Committee determined there was enough evidence, it would recommend to 
the VA Secretary that a full scientific review of the evidence be 
conducted by the Science Review Board.
    The next step in the process would be for the VA Secretary to issue 
a specific charge to the standing Science Review Board. In addition, 
the VA Secretary may decide that additional research and/or 
surveillance data should be generated for the specific potential 
exposure and potential resulting health condition.
    The Science Review Board (SRB), with the assistance of its 
associated staff, would conduct a comprehensive evidence review of the 
strength of the causal relationship between the potential exposure and 
potential resulting health condition. The SRB would make a 
determination and classify the strength of causal evidence into one of 
four categories: Sufficient, Equipoise and Above, Below Equipoise or 
Against. The category of Equipoise and Above signifies that the health 
condition was at least as likely as not to be caused by the potential 
exposure. If the SRB classified the strength of causal evidence as 
Sufficient or as Equipoise and Above, the SRB would then move to the 
calculation of the service-attributable fraction. The calculation of 
the service-attributable fraction is independent of the classification 
of the strength of evidence for causation, would be of value in 
decision-making by the VA, and can only be accomplished when required 
data and information are available. In an instance in which data and 
information were not available to calculate service-attributable 
fraction, the SRB would only report its classification of the strength 
of causal evidence between the potential exposure and potential 
resulting health condition. The SRB would report its findings to the VA 
Secretary.
    The VA Secretary would initiate the VA's presumption consideration 
process following receipt of the SRB report. VA would make a 
compensation decision, and the final decision would be made by the VA 
Secretary (unless legislated by Congress).
    The Committee believes that this process would be more efficient 
and consistent than the current one. The Advisory Committee, VA staff 
to the Advisory Committee, Science Review Board and its associated 
staff would all be established entities. The current process requires 
that new scientific review committees are assembled each time a new 
concern or study charge is given by VA. As evidenced by presumptions 
established to date, there have been different approaches in evidence 
evaluation and classification as well as how and which scientific 
evidence has been used in establishing presumptions.

    Question 2. Dr. Zeger, with respect to presumptive disability 
decision-making, IOM recommended a standard of ``causal effect.'' In 
some cases, servicemembers may have been subjected to multiple 
potential exposures of uncertain dosage. If causation is unclear, does 
your Committee believe that a showing of increased incidence of certain 
disabilities in the subject group should be a basis for a presumption 
of service-connection?
    Response. Our committee recommends that the presumptive process 
focus on the question: does the exposure cause the disease or condition 
in question. Empirical association such as an increased incidence of 
disease in an exposed group is one source of evidence in favor of 
causation, but so is relevant biological knowledge about the mechanisms 
by which an exposure might cause the disease is also relevant. Our 
recommendation to focus on cause rather than association is not raising 
the evidentiary bar for a presumption. Rather, it broadens the scope of 
relevant evidence to be considered. The committee further recommended 
that presumptions be found when all of the relevant evidence, carefully 
considered by a panel of experts, leads them to conclude that the 
causal connection is at least as likely as not. This relatively low 
threshold of evidence accommodates many of the uncertainties that exist 
in presumption cases. By refocusing on the question of cause, by 
considering all of the relevant evidence and by establishing a 
threshold of at least as likely as not together with available service-
attributable fraction data, the Committee believes that the VA can 
achieve the appropriate if delicate balance between society's 
commitment to its veterans and the use of public's resources.
    The charge to our Committee did not specifically ask the Committee 
to address ``multiple potential exposures of uncertain dosage'' in 
establishing causation and, as such, this is not specifically addressed 
in the Committee's report. The current presumptive disability decision-
making process establishes presumptions for individual health 
conditions related to exposure from one specific agent (with the 
exception of Congress' Gulf War presumptions of undiagnosed illnesses). 
However, our Committee recognized that each Servicemember will be 
exposed to different agents during their service in garrison and in the 
field. The Committee's approach could be used to evaluate multiple 
potential exposures. If the Science Review Board (SRB) determined that 
the evidence demonstrated that it was at least as likely as not that 
multiple potential exposures caused a specific health condition, then 
the SRB would classify that specific, defined situation as Equipoise 
and Above. The SRB would submit its report to the VA Secretary, and the 
VA would make compensation and final decisions to establish or not 
establish a presumption in such an instance.

    Chairman Akaka. Thank you very much, Dr. Zeger.
    Now we will have rounds of questions by the Committee.
    My first question is directed to Dr. Kilpatrick. Dr. 
Kilpatrick, IOM found that disability payments may actually 
contribute to better treatment outcomes. Can you please explain 
that further?
    Mr. Kilpatrick. Well, there is sort of a lore out there 
that basically says, veterans who get compensation for PTSD 
have no incentive to seek treatment and they have no incentive 
to get better because they are, in essence, being compensated 
for being sick. The committee received testimony from several 
individuals and reviewed research that indicated that basically 
there was not any strong evidence to suggest that.
    There were anecdotes to that, but actually some of the 
research that we reviewed indicated that, first of all, there 
was no difference between people who got compensation versus 
not in terms of responding well to treatment, and something 
that people don't look at sometimes is that it appeared that 
maybe some veterans might seek compensation to be able to 
access treatment. In other words, the VA, as we understood it, 
has to prioritize eligibility based on some criteria. One of 
those criteria is: that if you were service-connected for PTSD 
or other things above 50 percent, I believe it is, that puts 
you at a higher priority to receive treatment.
    So, on one level, people might have to seek out disability 
just to be able to get treatment. On the other hand, there was 
some testimony that we got that was done of veterans who said 
that they felt validated when they were having a problem and 
they went to the VA and the VA said, we agree that you have a 
service-connected problem, and so in that case, they might feel 
better about themselves in addition to being able to access the 
treatment.
    Chairman Akaka. Thank you. Dr. McMahon, you heard the IOM's 
response to my previous question. I now turn to you. You 
surveyed veterans about how disability payments impact their 
willingness to follow medical treatment. Can you describe for 
the committee the results of this survey? What do the results 
suggest about the relationship between disability compensation 
and medical treatment, especially treatment for PTSD?
    Ms. McMahon. I will certainly try to shed some light based 
on the survey questions that we used. We approached this 
through a series of indirect questions. We didn't just directly 
ask veterans if they did not seek treatment or if they had 
terminated treatment because they were perhaps fearful of 
losing their benefits. So we set up a series of indirect 
questions to ask them about their treatment plans and ask them 
about the therapy they might receive and then approach this in 
an indirect manner.
    The substance of our finding was we found virtually no 
evidence of any systematic desire on the veterans' parts to 
avoid treatment or to curtail treatment because of the fear of 
losing their benefits. And in fact, if you want to address 
this, the exact number----
    Mr. Christensen. Yes. The actual number was less than half 
of one percent of all veterans essentially had behavior that 
reflected not following treatment or not getting treatment or 
not seeing it through to the end because they were concerned 
about their benefits.
    Chairman Akaka. Thank you for that response, Dr. 
Christensen.
    Dr. Bristow, one significant recommendation made by the 
Commission is to expand the concept of disability to include 
limitations in daily living and loss of quality-of-life. Please 
describe IOM's evaluation of these concepts.
    Dr. Bristow. The rating schedule as it was originally 
developed was framed in a society that was largely agrarian and 
so the emphasis was upon whether or not an individual's 
physical limitations impeded their ability to work, often in 
farm work. Society has changed considerably over the almost 100 
years since the schedule began to evolve and it is clear that 
when an individual suffers a disability, there is more impact 
on their life than just their ability to earn a living. Such 
things as their ability to interact with their family, with 
their loved ones, with their neighbors, and to enjoy the 
everyday living activities that most of us sort of take for 
granted can be severely hampered.
    When we talk about quality-of-life, we are talking about 
the individual's perception of their well-being in several 
domains--the physical, the psychological, social and economic. 
What do we mean by that? We are talking about how an individual 
sees themselves in terms of, ``Am I fitting in with what I 
would normally expect to be able to do.''
    Now, there has been social scientific research in this area 
for almost 20 years, in evaluating a person's quality-of-life. 
If I may take a moment, a study was done in Ontario, Canada, 
involving some 12,000 disabled workers in a workers' 
compensation program. They made a series of approximately 84 
videos of individuals who had various disabilities going 
through the ordinary activities of daily life. These videos 
depicted the impact of being blind, for example, on being able 
to prepare your own breakfast, being able to get about in your 
home.
    They made a series of 84 such videos, and then they showed 
four or five of those videos to each of these 12,000 
individuals, never showing a video that contained the same 
disability that the disabled person had, but other 
disabilities. Then, they asked those individuals to rate what 
sort of impact on their perception of life it would be if you 
had that type of disability--from zero, which they considered 
to be perfectly normal, up to 100, which was death. They also 
took at the same time some 300 normal individuals in Ontario 
who had no disability and put them through the same process of 
viewing four or five of these videos each and saying, ``What 
would it mean to you if you were blind and had to try to 
shave,'' as depicted on the videos. From that, they were able 
to construct a measure of the loss of quality-of-life for 
various disabilities in those particular workers' compensation 
programs.
    Now, what we need in the VA is a similar approach--not for 
workers' compensation, but--for the impact on a veteran's life, 
and we need to have comparable studies that would assess how 
veterans who are disabled perceive themselves and how veterans 
who are not disabled perceive themselves if they were to have 
this disability and to be able to construct from that measures 
of the impact on the quality-of-life for veterans who are 
disabled.
    What my committee is recommending is that once that has 
been done, then go back to the rating schedule to see how well 
the rating schedule is, in fact, reflecting that impact on 
quality-of-life for the various disabilities that veterans 
have. And, if it turns out that the rating schedule is 
already--as Dr. McMahon said, factoring that in in some way--
fine; all well and good. But, if it is not, then we believe our 
Nation needs to take steps to include that factor; because 
quality-of-life is recognized now to be much more important to 
a person than we were able to perceive 80 years ago.
    Chairman Akaka. Thank you very much, Dr. Bristow.
    Senator Burr?
    Senator Burr. Thank you, Mr. Chairman.
    Dr. Kilpatrick, I want to make sure I understood you 
correctly in something that you said, because I thought it was 
a little bit different, maybe, from the testimony. You stated 
that somebody needed to have a disability established before 
you felt they would get the proper treatment within the VA 
system. Did I accurately reflect what you said?
    Mr. Kilpatrick. Well, let me tell you what I meant. What I 
meant to say is that it was our understanding that the VA does 
prioritize treatment if there are not enough resources in the 
health care system for the VA to treat all veterans, if they 
all came forward at the same time for treatment. There would 
not be sufficient resources to do that. Therefore, there is a 
priority system, which differs for veterans of different wars; 
but, it also filters in the level of service connection that 
you have, which is one thing that moves you up or down the 
priority list in terms of getting you in for treatment.
    So therefore, it is possible that some of the recent 
veterans may have--I mean, they are first priority to get in; 
but, for example, some Vietnam veterans might not be first 
priority to get in, yet they would have a higher priority 
depending on the level of disability for PTSD that they had.
    Senator Burr. Clearly past veterans have gone through 
disability ratings. They filed their disability claims. They 
have probably been re-rated numerous times, and I think we are 
certainly focused on this new starting point for today's 
warrior and how the system needs to reflect not only technology 
in the delivery of care, but their expectations.
    The challenging thing, especially as it relates to PTSD and 
other mental disabilities, is that I think most clinicians know 
that the first 6 months is the most crucial time of intense 
rehabilitation, of intense treatment, yet it is proven within 
the system you don't even get a disability determination in 6 
months, at the earliest, and likely it extends much past that.
    The focus of our attention is how do we take these young 
warriors and put them in intense rehabilitation in hopes that 
when they come out the other end, the disability is better or 
it is gone. As a matter of fact, I am troubled because the 
Inspector General's report in 2005 found that, generally, once 
a PTSD rating was assigned, it was increased over time until 
the veteran was paid 100 percent. Now, I have got to be clear. 
My objective is to make sure that the initial rating after 
treatment goes down, hopefully; and if it doesn't, we have a 
system that, in the future, will account for quality-of-life 
and for loss of work.
    I have difficulty with the VA model today, because it seems 
like you come in one side and you go out another side sicker 
than when you came in. That is not health care. Health care is 
designed to make one better. So, I would only caution you on 
that statement. I think I am less concerned with what their 
rating is for disability when that disability determination is 
made. I am more concerned that when they are seen, if they 
believe that there is a need for mental health services, that 
we get them in that program; that we do everything to keep them 
in that program; that we make sure any financial challenges 
that a family has, we overcome, so that the service personnel's 
focus is on treatment. The most important thing for me right 
now is treatment; and on the back end, we can make a more 
accurate evaluation of the disability, the degree of the 
disability, and consequently, what the compensation should be.
    Clearly, I am alarmed at what the Inspector General found, 
and that is, if we enter them into the system, if we don't get 
them the type of services that they need up front, the outcome 
today is that eventually they become 100 percent disabled. I 
think our objective ought to be to make sure that nobody 
reaches 100 percent, because we have got the services in place 
to change their course, yet 100 percent is there in case 
everything that we collectively try fails.
    Let me move to you, Dr. Bristow, for a second because I am 
curious as to where Chairman Akaka went, and I am having a 
difficult time distinguishing. I see the two areas, quality-of-
life and the work disability, and I am having a hard time 
separating quality-of-life from the non-work disability, 
because I guess I put myself in a category that I am not 
disabled. When my wife says, ``Change that light bulb,'' 3 
weeks later when I haven't changed that light bulb--if I were 
disabled, it is a quality-of-life issue: that I see that I 
can't physically do it. There are some things that I am limited 
in doing, non-work-related, that had I not had the disability, 
I could do. I could respond.
    Help me distinguish these two, because I think my concern 
is that the more you split the categories, the more difficult 
it is for us to come to a system and to design something that 
is reflective of the balance that we need.
    Dr. Bristow. Yes, sir, Senator. Let me try to do that. I 
would say that the non-work-related disabilities that we are 
referring to are measurable disabilities--how much time does it 
take you to climb a flight of stairs? How well can you carry 
out certain functions that are common to everyday life? Those 
are measurable, as I said, speed, dexterity, that sort of 
thing.
    When we speak of quality-of-life, we are speaking instead 
of the individual's perception of themselves, and as I said, 
how they fit into this world. That is not the same thing as 
whether or not you can lift a 50-pound load from the floor 
repetitively over the course of 5 minutes.
    So, one is non-work-related. It is not something that you 
are engaged in in your occupation, but it impacts how quickly 
can you get to work if you have difficulty with ambulation, how 
much difficulty is there in getting dressed in the morning. 
Those are the non-work-related disabilities. I would consider 
them measurable or at least estimable.
    The quality-of-life issues, on the other hand, are such 
things as, ``I can't put my arms around my kid who is growing 
up because I don't have an arm.'' That is not measurable; it is 
a self-perception. What we are saying is that in the modern 
world's concept of disability, it is recognized that that is 
something that should be taken into consideration. Workers' 
compensation systems in a number of areas are attempting to 
take into consideration quality-of-life changes as a result of 
a disability. I believe it can be safely said that the Veterans 
Administrations in Canada and in Australia are attempting to 
take into account the quality-of-life impact from a disability 
and to develop some form of compensation for that.
    Senator Burr. I appreciate your comments, as I do from all 
of you, and I hope you understand why we are going into such 
depth. We have got a system that hasn't changed in 50 years. 
The historical precedent that is set is that we may not change 
this for another 50 years. So, hopefully we design it in a way 
that it accommodates those things that we can't anticipate we 
are going to run into, but also that it reflects where we are 
technologically, where we are from a standpoint of our 
commitment, our promise, our obligation. My hope is that we get 
it right or that we come as close as humanly possible, and that 
is why I commend the Chairman and his willingness to take on as 
much input into this, because it is an extremely important 
course that we take.
    I apologize. My time has run out and I think the Chair is 
going to have another round, I feel certain.
    Chairman Akaka. Thank you very much, Senator Burr.
    Dr. Zeger, let me just move back to more of the structure. 
Can you please explain the relationship between the Advisory 
Committee, the Science Review Board, and VA? Should VA be 
required to follow the recommendations of these new panels?
    Dr. Zeger. Thank you, Mr. Chairman. The committee was not 
so bold as to recommend that the VA must do something, because 
it recognizes that the VA and Congress have the responsibility 
for establishing the exact process and the decision about a 
particular presumption. What we did ask, however, is that a 
more scientific basis be put in place so that the best evidence 
is brought to the decision that the VA and Congress make. There 
are two parts of the process we see opportunity for revision.
    The first is a way to prioritize the many potential 
presumptions that arise. The committee believes that we should 
encourage affected veterans to come forward with their health 
or exposure concerns; we need a place where VSOs may bring 
concerns of the community. So, the first Advisory Committee 
would be a place that would receive a range of potential 
nominations for presumptions, would prioritize them, and put 
some into a scientific process.
    The Science Review Board would be the place where the best 
available evidence would be gathered and assessed and then 
recommendations would be made to the VA. The VA would have the 
responsibility for the ultimate decision about the presumption, 
or Congress in the cases where it is involved.
    Chairman Akaka. Thank you very much.
    Dr. McMahon, CNA's quality-of-life study found that mental 
disability does appear to lead to lower physical health, but 
physical disability does not lead to lower mental health. To 
some, this might seem counterintuitive. We generally understand 
that physical disability is often associated with lower mental 
health. Is this true for veterans and non-veterans alike?
    Ms. McMahon. We looked at the issue of the health scores 
separately for physical and mental health scores from the 
results of the survey, and what we found for those who had a 
primary physical disability--and let me just back up and 
clarify. Veterans may have a number of different disabilities. 
We categorize them by the primary disability being physical or 
mental. So, for those who had a primary physical disability, 
what we found is that for those with a reasonably low rating of 
disability, up to, say, 50 percent, they did not appear to have 
a mental score that was different from the norm of the 
population in general. So, they did not have a mental score 
that reflected a difference from the general civilian 
population.
    On the other hand, for those who were severely disabled 
with a primary physical disability--say an 80 percent or 100 
percent disability--they did show that they had below average 
mental health scores, as well. So, it is their disability on 
the physical side was associated with a loss of the mental 
score, as well.
    On the other hand, for those who had a primary mental 
disability, we were surprised to see that at every rating 
category, there was a loss in both the physical and the mental 
health scores compared to the overall population norms. That 
was not something we anticipated.
    Chairman Akaka. Dr. McMahon, CNA's analysis found that a 
higher number of those designated as individually unemployable 
suffer from disabilities such as PTSD. CNA's report states that 
this suggests a failure of the VA rating schedule. In your 
opinion, what changes should be made to the rating schedule to 
correct the over-reliance on IU? What changes should be made to 
the criteria for IU?
    Ms. McMahon. Well, we did look at IU and one of the 
findings we had is that, overall, 8 percent of those receiving 
VA disability compensation have IU, but 31 percent of those 
with PTSD as their primary diagnosis had an IU designation. We 
concluded from this that there was an indication that the 
rating schedule was not working well for PTSD and that many of 
the people who had PTSD were having to come back and say, we 
have an inability to work and we need a higher rating. So, that 
suggested to us that the rating was not working well enough for 
that group of people and possibly for others, as well.
    What you would do to address that, I think, could occur in 
a number of ways. One suggestion is that if people are unable 
to work, even though they don't have a 100 percent rating in 
this area, that possibly they are not being rated correctly. I 
am not a clinician. I can't say exactly how I would rate 
someone with PTSD to do this, but I can say that we did review 
this issue. With the survey of our raters and VSOs, we asked 
these people how they felt about the rating process, and they 
particularly indicated that they found the claims becoming more 
complex. They found that it was much more difficult to rate a 
mental disability than a physical disability, other things 
being equal, and in particular, PTSD was the hardest to be 
objective about. There was a subjectivity to the evaluation 
that troubled them, that led to some inconsistencies, perhaps. 
And so they spoke up for the need for more time and especially 
more clinical input from physicians and mental health 
practitioners to assist them in making that determination for 
PTSD.
    And I think when you weave these stories together, it is an 
indication that the process needs to be addressed, that the 
raters are not comfortable with what they are being asked to 
do. They need more assistance. They need more time to consider 
this kind of claim in particular and that might lead to a 
better outcome.
    Chairman Akaka. Senator Burr?
    Senator Burr. Dr. McMahon, thank you very much. I was 
fascinated with your statement that physical disabilities 
didn't lead to mental deficiencies, but mental disabilities did 
lead to physical deficiencies. I think that is sort of at the 
heart of what I have tried to drive, and that is: with that 
known, the focus--especially on mental disabilities--should be 
treatment as quickly and as effectively as we possibly can. 
Because I think the data proves and your study proves that that 
leads to a physical deficiency if, in fact, we don't thoroughly 
address the mental disability that exists. And as we look at 
one, a primary objective of making a veteran better when they 
leave than when they came in; and two, how do we eliminate the 
slide in the future of one who continually gets worse. Well, 
clearly to inject the physical side into it, you now have a 
veteran that is affected in multiple ways.
    You mentioned that veterans who become severely disabled at 
a young age may have a long period of lost earnings. I 
mentioned Sarah Wade earlier, and as she put it, ``Ted will 
never again get a pay raise.'' For these young severely 
disabled veterans, you found that they are substantially below 
parity in terms of compensating for their lost earnings. Would 
you walk us through your suggestions for how you would make 
sure that young severely wounded warriors, like Ted, are being 
adequately compensated in the future?
    Ms. McMahon. I would be happy to do that. I believe that 
when we looked at the parity of the disabled veterans, we found 
that the average age of entry into the VA system is about at 
age 55, and to put it as simply as possible, someone coming in 
at that point has had a fairly long job history so far in their 
lives and now the disabling condition has become something that 
they can no longer cope with quite so well. And so they come 
into the VA system and then we look at what that says for the 
compensation over their expected lifetime. This is a lifetime 
look that we took in terms of the compensation.
    So, for the young veteran who has become severely disabled 
at a young age, they are facing an entire lifetime of having an 
inability to completely participate in the workforce as 
compared to their peers that are able to do this in a normal 
fashion. So, they are looking at a long period of years when 
they are disadvantaged in terms of their work capabilities, and 
that is what leads to some of the disparity that we see. It is 
not a system that expects you perhaps to come in at age 25 and 
be there for the rest of your life.
    As for the question of how you would deal with that, it is 
possible that you could deal with it partly by having a 
compensation that would depend on the age of entry. Another 
possibility would be to have a special compensation element for 
those people who came in at a very young age to reflect that 
condition.
    I think another thing that I would want to say is that I 
also view that the better solution is treatment and getting the 
person to be well-adjusted to life and able to contribute as 
much as they can. It does seem to me that you don't want to 
simply say, well, we will give you more money if, in fact, what 
you can do is give more treatment to help people. And I think 
in particular with PTSD, that treatment is crucial and getting 
treatment that is thorough and adequate as well as you can to 
give people the best chance as possible to return to a normal 
life is a very important aspect of it.
    Senator Burr. Let me ask you, about 30 percent of our 
veterans with service-related disabilities are also military 
retirees who by definition would be eligible for DOD retirement 
benefits, including an annuity, health insurance for their 
entire family, access to tax-free shopping at commissaries and 
exchanges. Now, specifically for those retirees with less 
disabling conditions: did your study address whether they, on 
average, work less than veterans who do receive these benefits? 
I hope you understand what I am trying to analyze.
    Ms. McMahon. I do understand, and we did not look at that 
issue. I can't give you an answer on that.
    Senator Burr. Is that something important for us to look at 
as we try to construct something that truly reflects what fair 
compensation is, and by the way, to eliminate disincentives 
that may exist in the system? I am not suggesting to take 
things away from people, but to identify disincentives that 
need to be balanced.
    Ms. McMahon. Partly, I would say that this becomes a policy 
issue, and my comments on this are not based so much on an 
analysis of findings but just in terms of other kinds of policy 
assessments that have been made over time. If you view your 
retirement benefit as being something that you have earned, 
then it is something that is yours, that you own--it is sort of 
like you have paid into a system and received it. It is 
somewhat like having a retirement system in the civilian market 
where you may have paid into a fund and then that money is 
yours at the end. And so in that sense, it is not really a 
compensation, it is a retirement fund that you have built up.
    In that sense, what we looked at in the study was strictly 
based on income-earning ability and compensation. We did not 
address, and I can't think how we could have addressed the 
issue of various retirement funds that individuals acquire in 
various ways other than the obvious one with the military. So, 
that is just not something that we were able to bring into the 
picture.
    Senator Burr. Dr. Bristow, do you want to add something to 
that?
    Dr. Bristow. Yes, sir. Thank you, Senator. Our committee 
was quite interested in this issue but from the other end of 
the spectrum, in that, particularly in the IU program, the 
Veterans Administration is prohibited from taking into account 
the age of the individual who applies and does not make any 
allowance for how long this person would be expected to be able 
to be employed in the future. Our committee, in fact, has 
recommended that research studies should be done to see whether 
or not that is an appropriate policy, and I think what I have 
heard today suggests to me even more so that it really should 
be done. There should be some reasonable accounting taken for 
the age of the individual and what is projected to be their 
likelihood of employability over a period of time.
    Ms. McMahon. And I would follow up with that. We also 
looked at unemployability that way and one of the things we 
noted is that this payment, once achieved, can be received 
indefinitely, whereas most people have retired by a certain 
age. And so this concept of considering the age of the 
individual with regard to the benefit received is something 
that we addressed, as well.
    Senator Burr. Well, I genuinely want to say how grateful I 
am to all of you for your willingness to be here. The Chairman 
has been very gracious with me on the clock. I want to ask all 
of you, I will have additional questions----
    Chairman Akaka. We will do another round.
    Senator Burr. The Chairman says he is going to do another 
round. I will probably have additional questions beyond that, 
as well, and they may not all be tomorrow. They may be as we 
work through the construction of where it is we need to go. And 
I hope all of you will make yourselves available to help us as 
we try to construct what we believe is the most appropriate 
path forward.
    Chairman Akaka. Thank you very much, Senator Burr. We will 
have another round here.
    Dr. Kilpatrick, IOM recently published a report on the 
effectiveness of the best approaches for treating PTSD. Did IOM 
reach any conclusions on whether or not cognitive therapy is 
readily available to veterans?
    Mr. Kilpatrick. That was not our committee, but I am 
generally familiar with that report and my recollection is that 
in terms of cognitive behavioral therapy, they identified one 
treatment, which was prolonged exposure, that said that it 
really met the gold standard test of having then multiple 
studies that were replicated for effectiveness for PTSD. I 
think there are some other treatments that some of us think are 
probably very close to that level of gold standard, as well, 
and I believe that the committee determined that many VA mental 
health professionals have not been trained in those particular 
treatments.
    And so to that extent, I believe they would say that there 
is a shortage of trained clinicians to provide those treatments 
in the VA, which the VA, in fairness, is working on and I know 
has training programs and is also trying to hire new mental 
health professionals. But I think where we stand right now is 
that the most effective treatment that was identified is not 
readily available to every veteran at every VA.
    Chairman Akaka. Dr. McMahon, CNA found that service-
disabled veterans with serious mental disabilities earn less in 
every age group and rating group than veterans with physical 
disabilities. What do you believe accounts for this difference? 
Should veterans with mental disabilities receive higher ratings 
to compensate for their lower earnings?
    Ms. McMahon. I am not completely certain, of course, what 
makes the difference, but I can speculate a little bit about 
what I think is a reasonable interpretation of that finding. I 
think with physical disability, it is often something that can 
be compensated for, not in money terms in this context, but 
compensated for in other ways. It may be that there is an 
artificial limb that is provided. It may be that there is an 
accommodation of a workspace that is changed or stairs are 
replaced by an elevator or something like that which allows a 
person to be able to work more effectively. In addition, people 
can recognize what the physical limitation is and perhaps find 
ways to work around it in a fairly straight-forward fashion. I 
didn't say that well.
    When you are dealing with a condition that is a mental 
disability, I don't think it is as easy to understand how to 
accommodate the person in that circumstance. I don't think it 
is a visible thing, such as I have lost a limb or I need to 
have someone help me come up the stairs or something of that 
nature. And so I think it is harder for the accommodation to be 
made for that person. It is just not easily recognized what is 
needed to make them fit well into the work environment so 
readily.
    In terms of compensation, should there be extra 
compensation, I would say that I view it as one of two things. 
Either you find a way to treat the person so that they are able 
to be accommodated into the workforce in a better fashion or 
you have to recognize that we are not able to make that 
accommodation, and then in that sense, yes, they would need an 
additional compensation.
    Chairman Akaka. Dr. Bristow----
    Dr. Bristow. Yes, sir?
    Chairman Akaka [continuing]. Can you please explain the 
importance of VA beginning to use the ICD and DSM 
classification systems that are used in today's health care 
systems?
    Dr. Bristow. Yes, sir, I would be happy to. In fact, this 
will apply to the last question that you raised with Dr. 
McMahon.
    The ICD coding system and the DSM coding system allow for 
the most precise definition of a state of disease in a given 
individual. What VA is currently using is extraordinarily 
imprecise and, in fact, even when they acknowledge what the 
diagnosis correctly is, in the area of mental illness, which is 
a glaring example, administratively, VA has decided we will 
decide all mental illness in terms of its disability using the 
same set of criteria, and those criteria that have been 
selected do not fit well with many mental illnesses. They may 
fit very well with a person who has got schizophrenia, but they 
have very minimal application to a person who has PTSD.
    If they were using DSM as a coding system, DSM provides and 
identifies where the problems are being manifested in that 
given individual. It would then be a lot easier to say, well, 
if the person is having these manifestations, that indicates a 
severer level of disability than using a broad-brush which has 
very little application to where the problems are for this 
specific illness.
    So, it is imperative, in my opinion and in the opinion of 
our Committee, that VA move to using the same coding 
classification that is being used all over the world--that is 
being used within the VA's health care system itself. It is 
just that when they leave VA's health service and transfer the 
information over, it is recoded into something terribly 
archaic, and that negatively impacts the ability of the 
disability system, which wants to do the right thing; but it 
makes it very hard for them to do the right thing when they are 
using the wrong tool.
    Chairman Akaka. Thank you very much, Dr. Bristow.
    I will call on Senator Burr, though I have one more 
question to ask all of our witnesses. I will do that after he 
is done.
    Senator Burr. Dr. Bristow, I want to call on your 
Presidency of the AMA to ask you, is it healthy for the 
Chairman to drink such a large cup of Starbuck's coffee? 
[Laughter.]
    I am not sure I can figure out how you could make it 
through this hearing having drunk that whole thing.
    You know, I am reminded as I sat here that we have done a 
tremendous job with homelessness in this country, and that is 
both sides, the veterans' side but also the general public 
side. There is one thing that we learned extremely early in it 
and we are still having a difficulty implementing. We can do a 
great job at providing a roof and walls to an individual, but 
without the wrap-around services, you can't put somebody 
permanently in housing. It takes the wrap-around services to 
treat the other conditions that they run into that make them 
permanent from a standpoint of being in a home.
    So, I hope all of you understand why I have been so 
insistent about making sure that we provide the services. It is 
not just, how do we get the disability right. It is how do we 
provide the level of health care so that, hopefully, the 
disability goes down over time, if that is possible.
    Dr. McMahon, I want to ask you one last question. The VDBC 
noted, and I quote them, ``it is commonly acknowledged that the 
disability compensation program compensates for injuries and 
diseases that do not impair earnings capacity but have negative 
consequences for veterans,'' and I would only ask you, were you 
able to draw any conclusions along those lines?
    Ms. McMahon. I am going to be very candid and say I am not 
exactly certain what context that is taken from. Our mandate 
was to look for those things that had an impact on the ability 
to earn and to look at what compensation consequences there 
were, and that was really the thing that drove our 
considerations. I suspect that this is something that I would 
understand better if I could read more of the context 
surrounding the statement.
    Senator Burr. We will ask it in a written follow-up 
question and try to point to you----
    Ms. McMahon. That would be better. Thank you.
    Senator Burr [continuing]. Exactly the context that it was 
in, and again, I want to--yes, sir, Dr. Bristow?
    Dr. Bristow. Very quickly, I think that a good example of 
the VA's efforts, good faith efforts in that direction would be 
compensation for loss of procreative organs, which have 
obviously nothing to do with a person's earnings capacity, but 
it is a recognition once again of an attempt to go into the 
area of quality-of-life, which is important.
    If I can sneak in one last little quick statement? Our 
committee felt it is going to be important as we go forward to 
give each applying veteran a more complete evaluation than they 
currently have been receiving; not only a compensation and 
pension evaluation, and a medical evaluation, but they really 
should have a vocational evaluation when they first apply, so 
as to be able to inform that veteran and help that veteran 
decide how can they emphasize the ``ability'' part of 
disability rather than the ``dis'' part. Find out what they can 
do to help them return to normal, to as much normalcy as 
possible, and that can only be done if we provide that type of 
service when they first apply. Yes, you have these impairments, 
but you also have these potentials, and maybe we can help you 
go to school to work on some of your strengths. If we can do 
this, it will help that veteran get the most out of life.
    Mr. Kilpatrick. Senator Burr, I just wanted to clarify, as 
well, that our committee, whereas it was focusing on the 
disability process, noted that there was a separation between 
the disability determination and encouragement and involvement 
in just what Dr. Bristow was talking about. And as a mental 
health professional who treats PTSD, I would say that we all 
think that veterans should get access to the best mental health 
services possible. There might be a difference of opinion about 
whether being involved in a disability for PTSD would affect 
that or not. I don't think our committee felt that it would.
    But clearly, we are in agreement that services in the VA 
should change its procedures and what not, and laws if 
necessary, to make sure that everybody does have access to the 
best mental health services because it benefits society, 
obviously, not just the veterans, to be in a situation where 
they improve as much as they can, where they get over the 
terrible things that have happened to them and that they can 
live as productive a life and as happy a life as possible.
    Senator Burr. I appreciate that, and I hope you understand 
where I am getting that. I am not sure that it is good enough 
for us to say, it is available. I think our policy has to 
facilitate people to take advantage of it. It is not just about 
access. It is about accepting that pathway of treatment and 
rehabilitation.
    I am somewhat passionate about it because I look at the 
data and the data suggests the model we currently have, which 
provides access for many if not a majority of the veterans, 
does not work. I am not suggesting that that is something that 
is reflective of something we have done wrong or the system has 
done wrong. It is the fact that veterans for possibly a host of 
reasons have not entered into the system with the intent that 
the system will make them better. I truly believe if they 
believed that, they would be in it.
    So, shouldn't we try something different? Shouldn't we 
create the incentive to get them in, because you--the medical 
professionals--tell us that if we are in there, you know what? 
The outcome is different. So, I think this is a process of how 
do you get the disability side correct, but also how do you 
take the delivery side and make it work for veterans.
    Again, I thank each and every one of you.
    Chairman Akaka. Thank you, Senator Burr.
    Here is my last question. I am continuing to try to get 
from the source--which you are--to VA, to find out whether 
everything was done that needed to be done in this area. So, my 
question to the four of you is, is there anything--anything at 
all, either in your report or from your overall work for the 
Commission--which is not included in the report or is not 
reflected in the way you intended it to be? Dr. McMahon?
    Ms. McMahon. I believe that the Commission was extremely 
receptive to the work that we did and I do not believe that 
there is anything that they did not consider that we put 
forward to them. It was a remarkable experience--dealing with 
13 Commissioners who had their own points of view--but I think, 
in the end, we were able to give them what they asked for and 
they reflected that very well in their report.
    Chairman Akaka. Thank you. Dr. Bristow?
    Dr. Bristow. Thank you, Mr. Chairman. I believe the 
Commission did an outstanding job. I would say that I am not 
certain that the Commission quite grasped one aspect that my 
committee was trying to put forward, and that is the Veterans 
Administration has available to it an enormous mine of 
information upon which we can, when properly mined, base 
evidence-based decisions, evidence-based programs that best 
serve our veterans. It currently would be enhanced if we had 
the right sort of coding system, and once that is in place, 
begin to utilize the information that is right there. We have a 
treasure trove of potential information which needs to be mined 
that will allow us to best use our resources. We can find out 
what is the best way to provide services by utilizing the 
research opportunities that are just begging to be used.
    Chairman Akaka. Thank you. Mr. Kilpatrick?
    Mr. Kilpatrick. I would say that our committee did a very 
thorough job of identifying areas of difficulty and then coming 
up with, I think, some common sense ways to reform the process 
of compensation and, as I mentioned previously, to further 
integrate the disability part of the VA with the health care 
and treatment delivery and rehabilitation part of the VA.
    I think that although our committee sort of tangentially 
discussed this, I mean, what I see as one of the big challenges 
is that for PTSD, we do have some effective treatments now. We 
always need more research. I mean, I couldn't be a researcher 
and not say that we need more research, but we need more--we do 
need more research, but we do have some things that work now. I 
think we need more studies to look at--to evaluate efficacy and 
effectiveness. I think we also--the VA is going to need to do 
even more than it is doing now to make sure that we have well-
trained mental health professionals who are up to date in 
evidence-based treatments and assessment procedures.
    Chairman Akaka. Thank you. Dr. Zeger?
    Dr. Zeger. Yes. Thank you. I would like to report that our 
committee was very impressed by the degree to which General 
Scott and the Commissioners were interested in our committee 
process. We had the good fortune of meeting with some of them 
in San Antonio when we had open hearings for VSOs and veterans. 
It would have been much better had it been in Hawaii, of 
course, but it was very nice to be with them in San Antonio. I 
am particularly pleased--I know the committee is--that the 
Commission has accepted all of the recommendations that we have 
put forward to them and we are now looking forward to seeing a 
transition toward a more scientific basis for presumptions.
    Chairman Akaka. Well, thank you so much for your responses. 
This has been a great hearing, and as I mentioned, I look upon 
all of you here as a source that will help VA do its job 
better. We are looking forward to trying to support what needs 
to be done to improve the programs that we have to help our 
veterans.
    So, in closing, let me say thank you very much, all of you, 
for appearing before us today.
    The hearing is adjourned.
    [Whereupon, at 11:03 a.m., the committee was adjourned.]



  

                                  
