[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
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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
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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
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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
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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.]