[House Hearing, 112 Congress]
[From the U.S. Government Publishing Office]
REEVALUATING THE TRANSITION FROM SERVICEMEMBER TO VETERAN: HONORING A
SHARED COMMITMENT TO CARE FOR THOSE WHO DEFEND OUR FREEDOM
=======================================================================
HEARING
before the
SUBCOMMITTEE ON DISABILITY ASSISTANCE
AND MEMORIAL AFFAIRS
of the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED TWELFTH CONGRESS
SECOND SESSION
__________
WEDNESDAY, MARCH 28, 2012
__________
Serial No. 112-53
__________
Printed for the use of the Committee on Veterans' Affairs
----------
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COMMITTEE ON VETERANS' AFFAIRS
JEFF MILLER, Florida, Chairman
CLIFF STEARNS, Florida BOB FILNER, California, Ranking
DOUG LAMBORN, Colorado CORRINE BROWN, Florida
GUS M. BILIRAKIS, Florida SILVESTRE REYES, Texas
DAVID P. ROE, Tennessee MICHAEL H. MICHAUD, Maine
MARLIN A. STUTZMAN, Indiana LINDA T. SANCHEZ, California
BILL FLORES, Texas BRUCE L. BRALEY, Iowa
BILL JOHNSON, Ohio JERRY McNERNEY, California
JEFF DENHAM, California JOE DONNELLY, Indiana
JON RUNYAN, New Jersey TIMOTHY J. WALZ, Minnesota
DAN BENISHEK, Michigan JOHN BARROW, Georgia
ANN MARIE BUERKLE, New York RUSS CARNAHAN, Missouri
TIM HUELSKAMP, Kansas
MARK E. AMODEI, Nevada
ROBERT L. TURNER, New York
Helen W. Tolar, Staff Director and Chief Counsel
______
SUBCOMMITTEE ON DISABILITY ASSISTANCE AND MEMORIAL AFFAIRS
JON RUNYAN, New Jersey, Chairman
DOUG LAMBORN, Colorado JERRY McNERNEY, California,
ANN MARIE BUERKLE, New York Ranking
MARLIN A. STUTZMAN, Indiana JOHN BARROW, Georgia
ROBERT L. TURNER, New York MICHAEL H. MICHAUD, Maine
TIMOTHY J. WALZ, Minnesota
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
official version. Because electronic submissions are used to prepare
both printed and electronic versions of the hearing record, the process
of converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
current publication process and should diminish as the process is
further refined.
C O N T E N T S
__________
March 28, 2012
Page
Reevaluating The Transition From Servicmember To Veteran:
Honoring A Shared Commitment To Care For Those Who Defend Our
Freedom........................................................ 1
OPENING STATEMENTS
Chairman Jon Runyan.............................................. 1
Prepared Statement of Chairman Runyan........................ 40
Hon. Jerry McNerney, Ranking Democratic Member................... 2
Prepared Statement of Hon. Jerry McNerney.................... 40
Hon. Russ Carnahan............................................... 4
Prepared Statement of Hon. Russ Carnahan..................... 42
WITNESSES
John Medve, Office of VA-DoD Collaboration, U.S. Department of
Veterans Affairs............................................... 5
Prepared Statement of John Medve............................. 42
Mr. Jim Neighbors, Director, Requirements and Strategic
Integration, U.S. Department of Defense........................ 6
Prepared Statement of Jim Neighbors.......................... 44
Executive Summary of Jim Neighbors........................... 52
Dr. Gail Wilensky, Senior Fellow, Project HOPE................... 17
Prepared Statement of Gail Wilensky.......................... 53
Executive Summary of Gail Wilensky........................... 56
Mr. Ken Fisher, Chief Executive Officer, Fisher House Foundation,
Inc............................................................ 19
Prepared Statement of Ken Fisher............................. 56
LTG James Terry Scott USA (Ret.), Chairman, Advisory Committee on
Disability Compensation........................................ 21
Prepared Statement of LTG James Terry Scott.................. 58
Mr. John Wilson, Assistant Legislative Director, Disabled
American Veterans.............................................. 27
Prepared Statement of John Wilson............................ 60
Mr. Phil Riley, Senior Benefits Liaison, Wounded Warrior Project. 29
Prepared Statement of Phil Riley............................. 64
Overview of Wounded Warrior Project Testimony................ 72
Mr. Eric Greitens, Chief Executive Officer, The Mission Continues 31
Prepared Statement of Eric Greitens.......................... 72
REEVALUATING THE TRANSITION FROM SERVICEMEMBER TO VETERAN: HONORING A
SHARED COMMITMENT TO CARE FOR THOSE WHO DEFEND OUR FREEDOM
----------
Wednesday, March 28, 2012
U.S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Disability Assistance
and Memorial Affairs,
Washington, D.C.
The Subcommittee met, pursuant to notice, at 10:05 a.m., in
Room 334, Cannon House Office Building, Hon. Jon Runyan,
[Chairman of the Subcommittee] presiding.
Present: Representatives Runyan, Stutzman, McNerney, Walz,
Carnahan.
OPENING STATEMENT OF CHAIRMAN JON RUNYAN
Mr. Runyan. Good morning and welcome, everybody. The
Oversight Hearing of the Subcommittee on Disability Assistance
and Memorial Affairs will now come to order.
We are here today to examine the current framework in the
ongoing efforts to streamline the transition process between
active duty soldier to veteran. The streamlining of this
process has been the implementation of the Integrated
Disability Evaluation System, otherwise known as IDES. This
program was created in December of 2007, following the
recommendations of the Veterans Disability Benefits Commission
and the President's Commission on Care for American Returning
Wounded Warriors, otherwise known as the Dole-Shalala
Commission.
The IDES goal was to improve the timeliness, effectiveness
and transparency of the former legacy DES review process which
has been in place for over 60 years. In October of 2010, the VA
and the DoD worked in concert to begin the permanent shift to
IDES around the country in 139 locations.
The ultimate objective remains to fully close the gap which
occurs between the separation from active duty service to the
receipt of VA benefits and compensation.
I am pleased to see the process being made to meet this
objective under the new system, specifically helping to cut the
transition time between active duty and veteran status.
However, there are several issues and unforeseen problems which
need to be addressed. First, issues with the processing times
remain problematic; whereas some recovering warriors experience
lengthy delays in their attempt to navigate through the IDES
system, others are rushed through without receiving the proper
medical attention that they need.
Secondly, many recovering warriors reported that they find
the IDES process to be extremely confusing and difficult to
understand. Further efforts must be made to work directly with
our recovering warriors to ensure that they are making the
right decision for themselves, their families and their
futures.
Finally, IDES is not as simple in practice as the various
Commission reports were hoping it would be when it was first
proposed. Now, nearly five years after its inception, it is
important for both the VA and the DoD to continue evaluating
the system and their efforts to achieve its goals of increasing
transparency, improving consistency and eliminating duplicate
processes.
As a new generation of active duty servicemen and women
return home from conflicts overseas, we must be prepared to
meet our commitment to see that their transition to civilian
and veteran life is as efficient and as simple as possible.
This is our duty to see that their service is honored as best
as our resources will permit.
It is my hope that this Oversight Hearing will shed some
light on some of the problems that we have encountered in the
implementation of IDES so we may work together to find the best
solution possible.
I want to thank the VA, the DoD, and the present VSOs, Dr.
Wilensky, Mr. Fisher and General Scott for their valuable input
as we work together to find important solutions.
We welcome today's witnesses and we now call on the Ranking
Member for his opening statement.
[The prepared statement of Chairman Jon Runyan appears in
the Appendix]
OPENING STATEMENT OF HON. JERRY MCNERNEY,
RANKING DEMOCRATIC MEMBER
Mr. McNerney. Thank you, Mr. Chairman. I would like to
thank you for holding today's hearing.
The purpose of this hearing is to focus on the transition
process of servicemembers to veterans, with a particular focus
on the implementation of the Integrated Disability Evaluation
System, also known as IDES, which is a joint VA/DoD examination
and records integration effort initiated in 2007 as a result of
the fallout from deplorable conditions and disjointed care
found for our wounded warriors at the Walter Reed Army
Hospital.
This hearing will allow us to not just to assess the
effectiveness of the Integrated Disability Evaluation System,
but other components of the Pre-Discharge Program established
by the Departments of Defense and Veterans Affairs to
streamline servicemembers' transition from active duty to
veterans' status.
Today's discussion on IDES also follows up on our work
implementing the Veterans' Benefits Improvement Act of 2008,
Public Law 110-389, which also paved the way for a number of
initiatives targeting the VA claims backlog.
In 2007, the Dole-Shalala Commission, set recommendations
for the care of wounded warriors, and concluded that it is not
nearly enough to patch a system for transition to civilian
life, as has been done in the past. The experiences of our men
and women returning home complaining about lack of a clear
outline of access to care, benefits, and services available to
them highlighted the need for fundamental changes in the care
management and disability systems.
The Dole-Shalala findings marked the siren call for the
creation of a joint effort between DoD and VA to move to a one-
exam platform which today we know as the Integrated Disability
Evaluation System or IDES.
We must make every effort to focus our resources toward
assisting transitioning servicemembers with the comprehensive,
coordinated care and benefits that they deserve. This must
occur at the very beginning of a servicemember's reintegration.
To this end, any member of the Armed Forces who has seen
active duty, including those in the National Guard or Reserves,
is eligible to apply for VA disability benefits prior to
leaving military service through the Benefits Delivery at
Discharge, Quick Start, or IDES pre-discharge programs.
During the application process, servicemembers can get help
in completing forms and preparing other required documentation
from VA personnel located at their bases. Additionally, IDES
combines the health exam required by the DoD upon exiting the
military and the VA Disabilities Assessment Exam into a single
process, albeit for different purposes.
In the meantime, in an effort to provide even greater
transition assistance, more elements and players, like the
Federal Recovery Coordination Program, have been added to
assist our wounded warriors.
I know the intent of these programs are well meaning and
have helped numerous veterans across our country, but I still
hear from veterans in my district who have gone through these
programs and continue to experience significant delays,
confusion and other problems with effective reintegration.
In fact, to that end, I would like to mention that Mr.
Barrow, my colleague, has a helpful bill pending before the
Health Subcommittee, H.R. 3016, that would improve
reintegration efforts and require that the Federal Recovery
Coordination Program operate jointly under the DoD and VA.
Since its full implementation at the end of 2011, IDES has
been expanded from 3 military bases to more than 139 sites
globally and nationally.
With the draw down of troops over the next few years, I am
particularly concerned by the fact that the average processing
time takes 400 days and that there are about 200,000
servicemembers already in the system. We don't need another
backlog and want to avoid that kind of outcome at all costs.
I look forward to having an open dialogue with the panels
here today, and with my colleagues, on ways to overcome
challenges within the IDES system, and to accelerate processing
without sacrificing quality. Separating servicemembers should
not wait more than a year for assessments and benefits.
It is my hope that through our examinations of the IDES and
other pre-discharge programs today, coupled with the electronic
integration and other business reformation efforts accomplished
over the last few years, we will continue to improve and
transform today's VA claims processing system and help our
servicemembers successfully transition back into our
communities, and not into another backlog.
I look forward to hearing from our esteemed witnesses, and
I thank you, Mr. Chairman. I yield back.
[The prepared statement of Hon. McNerney appears in the
Appendix]
Mr. Runyan. Thank you, Mr. McNerney. With that being said,
in the order of business I would like to welcome our colleague,
Mr. Carnahan, here. I ask unanimous consent that he participate
in this hearing.
Hearing no objection, so ordered.
Do any other Member wish to make an opening statement?
Mr. Carnahan is recognized.
OPENING STATEMENT OF HON. RUSS CARNAHAN
Mr. Carnahan. Thank you, Mr. Chairman and Ranking Member
McNerney. I am pleased to be sitting with the Subcommittee
today and especially proud to have an organization from my
district in St. Louis that has grown nationally. I had the
pleasure of working with them. Testifying for them today will
be their CEO, Eric Greitens of The Mission Continues.
The Mission Continues is truly a remarkable organization
that empowers veterans to transform their lives and the lives
of others by participating in community service fellowships.
The Mission Continues fellows serve six months as community
nonprofit organization and afterwards either obtain full-time
employment, pursue higher education or permanent roles in
service.
This is truly a remarkable program that not only gives
veterans a much needed sense of purpose following military
service, but also eases an often extremely difficult transition
to civilian life and is an organization that is run by a Navy
SEAL and many former members of the military. The Mission
Continues has a keen understanding of the many challenges
facing our servicemembers when they return home.
As this organization continues to make this model more
accessible and available to veterans across our country, my
colleagues and I stand ready to continue to support them and
their work in this life-changing mission for our veterans.
With that, Mr. Chairman, again, I want to thank you for
allowing me to join in the Subcommittee today. I look forward
to hearing the testimony, not only of The Mission Continues but
the other organizations who are here today to talk about these
important issues.
I yield back.
[The prepared statement of Hon. Russ Carnahan appears in
the Appendix]
Mr. Runyan. Thank you very much. I would like to welcome
panel one, now. First, we will be hearing from Mr. John Medve
with the Office of VA-DoD Collaboration and the Department of
Veterans Affairs. And next we will hear from Mr. Jim Neighbors
who is the Director of Requirements and Strategic Integration
of Department of Defense.
Your complete written statements will be entered into the
hearing record. And Mr. Medve, you are now recognized for five
minutes for your oral statement.
STATEMENT OF JOHN MEDVE, OFFICE OF VA-DOD COLLABORATION, U.S.
DEPARTMENT OF VETERANS AFFAIRS; JIM NEIGHBORS, DIRECTOR,
REQUIREMENTS AND STRATEGIC INTEGRATION, U.S. DEPARTMENT OF
DEFENSE.
STATEMENT OF JOHN MEDVE
Mr. Medve. Thank you, Mr. Chairman.
Good morning, Chairman Runyan, Ranking Member McNerney, and
Members of the Subcommittee. My name is John Medve, Executive
Director of the Department of Veterans Affairs Office of VA-DoD
Collaboration within the VA's Office of Policy and Planning. I
am pleased to be joined by Mr. Jim Neighbors from the
Department of Defense, as well as Mr. Michael McDonald from the
Federal Recovery Care Coordination Program, Ms. Debbie Ender
from the VHA, Mr. Tom Murphy from VBA.
I ask that my complete statement be included in the record.
The Subcommittee asked that I focus my testimony on the
status of the transition process from DoD to VA, with an
emphasis on the Integrated Disability System, IDES, and the
Federal Recovery Coordination Program, FRCP, as well as VA's
Veterans Affairs Schedule for Ratings Disabilities, VASRD,
modernization efforts.
With respect to IDES, much has been accomplished to improve
the DoD disability process in the wake of the issues identified
in 2007 at Walter Reed Army Medical Center.
In early 2007, VA partnered with DoD to make changes to
DoD's legacy Disability Evaluation System, which resulted in
the implementation of IDES. IDES is now the standard process
for all servicemembers who are being medically transitioned out
of their respective service.
The goals of the joint process were to eliminate the
benefits gap, increase transparency for servicemembers, reduce
the processing time and improve the consistency of ratings for
those who are ultimately medically separated. We have
accomplished those goals. We are now focused on continuing
improvement to that process.
With respect to the Federal Recovery Coordination Program,
FRCP, it was created in October 2007 in direct response to the
Dole-Shalala Commission's recommendation for improved care
coordination for wounded, ill and injured servicemembers.
Federal Recovery Coordinators, FRCs, are located in 12
facilities across the country, including four military
treatment facilities, two VA Medical Centers, three VA poly-
trauma centers, and three Wounded Warrior Program offices.
FRCs assist severely wounded, ill, and injured
servicemembers, veterans and their families through each
client's recovery, rehabilitation, and reintegration. The FRC
creates a Federal Individual Recovery Plan for each client
based on the goals expressed by the client, with input from his
or her family and/or caregiver and health care team.
FRCP is unique to other programs in that once an FRC is
assigned to a client, the FRC is the constant point of contact
for that client throughout all transitions.
With respect to the Veterans Affairs Schedule for Ratings
Disabilities, the VASRD, it is a regulatory framework through
which VA provides veterans with compensation for diseases and
injuries they incur while serving our Nation. It is this rating
schedule that guides the disability rating personnel of VA and
DoD in making the correct determination of the compensation
benefit level applicable for Veteran's service-connected
conditions.
VA has partnered with DoD and the academic community to
collaborate on revisions to the rating schedule. The
collaboration involves public forums in which medical experts,
members of the Advisory Committee on Disability Compensation,
DoD officials, Veterans Service Organizations, and other
stakeholders provide input and subsequently form working groups
to substantively revise the rating schedule.
The VA remains fully committed to meeting the needs of our
Nation's heroes and their families. VA and DoD are partners and
will continue to work together diligently to resolve transition
issues while aggressively implementing improvements and
expanding existing programs.
Thank you again for your support of our wounded, ill and
injured servicemembers, veterans and their families. This
concludes my testimony and I will be happy to respond to any
questions.
[The prepared statement of John Medve appears in the
Appendix]
Mr. Runyan. Thank you, Mr. Medve.
Mr. Neighbors, you are now recognized for your oral
testimony.
STATEMENT OF JIM NEIGHBORS
Mr. Neighbors. Good morning, Chairman Runyan, Ranking
Member McNerney and Members of the Committee. My name is Jim
Neighbors and I am the new Executive Director for DoD-VA
Collaboration Office within the Office of Personnel and
Readiness.
It is my pleasure to be here with my friend, John Medve, to
testify on the transition of our servicemember to veterans
status. I would also like to take this opportunity to thank
John publicly for helping to bring me up to speed on our very
important work.
Taking care of our servicemembers is the highest priority
of the Department of Defense. Over the past five years, DoD and
VA have worked together with assistance and guidance from
Congress to reform the cumbersome and often confusing
bureaucratic processes which provide care and benefits to our
servicemembers when and where they need them.
Working closely, deliberately and collaboratively, our
departments have established governance at the highest levels
to facilitate continuous improvements and to achieve our goal
of seamless transition from servicemember to veteran. The duty
of VA to an executive council co-chaired by the Deputy
Secretary of Veterans Affairs and the Under Secretary of
Defense for Personnel and Readiness is the body created by
Congress to formalize the collaboration between our departments
ensuring interagency oversight to streamline, deconflict and
expedite efforts to improve health care, disability processing
and the seamless transition of servicemembers to veteran
status.
Additionally, the Secretary of Defense and the Secretary of
Veterans Affairs meet on a quarterly basis to discuss high
priority matters that span both departments such as the
Integrated Disability Evaluation System and electronic health
records. They will continue the dialogue toward resolving any
issues and critical areas of collaboration between our
departments.
There are three areas I would like to particularly
highlight on our work and focus on servicemembers. First,
Recovery Care Coordination Program was established by Congress
to provide recovery care coordinators or RCCs whose
responsibilities include ensuring servicemembers' non-medical
needs are met during recovery, rehabilitation, reintegration
and in addition to assisting with the development and
implementation of individual comprehensive recovery plans.
Currently, there are 171 RCCs and 198 Army advocates in 84
locations worldwide within the service Wounded Warrior
Programs. More than 3,800 servicemembers and families have
received the assistance of an RCC.
Second, the Integrated Disability Evaluation System,
streamlining the DES process with servicemembers receiving a
single set of physical disability examinations conducted
according to VA examination protocols, proposed disability
ratings prepared by VA that both DoD and VA can use and
processing by both departments to ensure the earliest possible
delivery of disability benefits.
The IDES is in use at 139 locations across all services.
The Department is continuously monitoring statistics on IDES
and exploring ways to improve the system and drive down
processing time to reach our 295-day goal. As long as one
servicemember is in the system longer than perceived helpful,
we are obligated and committed to do all that we can to enhance
the experience and make improvements.
Finally, DoD and VA spearhead numerous interagency
electronic health data-sharing activities and delivering IT
solutions that significantly improve the secure sharing of
appropriate electronic health information. Interagency health
information exchange capabilities that levers the existing
electronic health records of each department are in use today,
and as both departments work to address the need to modernize
our EHRs, we are working together to synchronize planning
activities and identify a joint approach to modernization.
To date, DoD has transmitted health data on more than
5,800,000 retired or separated servicemembers to VA. Of those,
approximately 2,300,000 have presented to VA for care,
treatment or claims to termination.
Mr. Chairman, I cannot overstate how far DoD has come in
partnership with VA in recent years and we realize there is
still more to do on these extremely important efforts. We will
continue work with all of our partners to do anything and
everything we can to provide our servicemembers with the
absolute best care in treatment that they so rightfully deserve
in return for their service to our Nation.
Thank you again for the opportunity to be with you today. I
look forward to your questions.
[The prepared statement of Jim Neighbors appears in the
Appendix]
Mr. Runyan. Thank you very much. And with that, we will
begin questioning in the order of arrival, which I think
everybody here was at gavel call, or sitting in.
First of all, Mr. Neighbors, according to the DoD
Recovering Warrior Task Force 2011 Report, there is still work
to be done identifying the recovery team and acknowledging the
role VA has in the system. In previous hearings and testimony
before this Committee, veterans seem to be confused on what
part of the process is VA and what is DoD. Can you really
explain why this is happening because I'm going to drill into
many avenues of confusion? This is just the first one.
Mr. Neighbors. I understand. Mr. Chairman, I apologize. The
Recovery Care Coordination Program that we have within DoD and
then the FOC program that VA has, we consider them very
complementary programs. We see different things that are
involved with what DoD brings to this process and what the VA
brings to the process.
As I stated in my oral remarks, we look at non-clinical
kinds of care things to help both the servicemember and the
family. Now, if I could, I would like to kind of put a
philosophy or a statement that we take very seriously and that
is never alone known, as a servicemember who has come through a
very, very traumatic happening obviously with some traumatic
injury that has occurred to their body and even their mind, we
take the efficacy very, very important to be very efficient,
excuse me, very effective in what we are doing. And we realize
that does, at times, appear to be-- what is the word--redundant
within our own selves and even across the boards but we are
going to look at the things that we provide to a servicemember
all along this continuum as that approach and philosophy
``never alone,'' so there may be some things there where we are
making very good warm handoffs to the person, which I think is
very true between not only the DoD entities and the VA, but
there may be times when the person thinks they have four or
five people, but we will err on the side of being very, very
effective to that person 24 hours a day, seven days a week,
always to have somebody that they can call on even if it is one
or two or three levels deep within the points of contact that
they have.
And we also ensure that there is a warm handoff. And what I
mean by that is there is notification through a number of
channels that VA knows very directly every servicemember goes
from a RCC to an FRC. Thank you, sir.
Mr. Runyan. And just talking to the FRC and the RCC, I have
experienced, through the veterans I have talked to, a lot of
confusion on who is the go-to guy, where do I go when I have a
problem if something is not working as I anticipated and/or the
lack of the communication throughout that process. Can you
touch on that because that obviously, is going to come up in a
later panel with some of the VSOs that have a lot more
experience with it.
Mr. Neighbors. I understand, sir, and I will obviously
yield over to my VA counterpart to talk about the FRC piece of
this since this is obviously within their daily work.
I grant you and we have within the DoD continuous process
improvements efforts that are always ongoing and looking at
different things, not only within just the specific area, but
with electronic records and everything else in transition that
we are talking about. So I do recognize and agree that there
are better ways to do things. We do take inputs and we work
those regularly with VA. In fact, I think we have one coming up
on Friday in which we are meeting again to discuss outputs from
some of the things we have had in this area, so I agree, I
guess, from my point of view as we are working these
continuously and moving forward.
Mr. Medve. Mr. Chairman, clearly if somebody is assigned a
Federal Recovery Coordinator, that person should be the prime
individual for the veteran or servicemember to go to and should
be the one directing them across the whole set of issues that
they are dealing with.
The advantage of an FRC, clearly, is they handle both
clinical and nonclinical issues. They are masters trained,
nurses, social workers, and so part of the issue has been that
the services want to ensure that they got kind of activity with
that servicemember, and so the team of having an FRC and an RCC
is complementary. In talking to the program directors in the
field, this seems to be working better, that there is better
coordination between the two, that the Federal Recovery
individual recovery plan that is developed is now aligning
better so there isn't confusion for the servicemember on what
the plan is since it is their plan.
So there have been confusions in the past. We believe we
are seeing improvement and we are working, obviously, to
continually improve that.
Mr. Runyan. And how are you actually educating them--
obviously we are talking about servicemember and veteran in
transition, how are you educating them to the process so they
can understand it more when these problems do arise?
Mr. Medve. If you don't mind, Mr. Chairman, I would defer
to Mr. McDonald who is here from the program to answer that
question because he has got more hands-on experience than I do.
Mr. Runyan. Okay.
Mr. McDonald. Mr. Chairman, the purpose of the FRC to work
with the individual is to let them know what responsibilities
the FRC will handle. Being both clinical and non-clinical, they
can work on both sides there. They can work on the DoD side and
the VA side and what they try to do is to let the servicemember
know, the servicemember and the family in some cases, know what
they can do and what they can assist them with, and if they
need that assistance, they can reach out and touch them. They
will, at a minimum, stay in contact with their folks every 30
days and a lot of time when they are working on specific
issues, that will be much more often obviously. Does that
answer your question, sir?
Mr. Runyan. Somewhat, but it goes back, just to make a
point, with what Mr. Medve said, who the point of contact
should be. I think that part of the confusion is who is the go-
to guy as we move through this process, and I think making that
definition clear to everyone, because you said it three times
in your answer to that question.
Mr. McDonald. The problem, the reality is, sir, sometimes
we will tell them we are available to reach out and they will
sometimes call someone else. That's the reality. What we try to
inform them is, if they have an issue, let us know so we can be
working on it with all the members of the team, which will
include the RCC, the treatment team, the various case managers,
such as that.
One of the things that the FRC does is a continuous
availability in terms of if they are assigned a client whether
in the medical treatment facility, they will stay with that
client using various transitions to other MPFs to PA poly-
traumas, sometimes to private treatment centers, and the same
MRCC stays with that person so that they are familiar, build a
trust with the individual so that they know that that is the
person to come back and advise us.
In the first part, as with any relationship, is it is a
developing thing and sometimes it is not clear. We can explain
to please let us know what the issue is, but if they don't come
back to us, then that is difficult sometimes to manage that
relationship.
Mr. Runyan. Thank you. And I obviously, in dealing with it
by speaking to veterans, know that clarity in the way we move
forward in the process is essential--the process a lot of times
is the issue. The process is unclear to a lot of people and
obviously it falls on all of us not only to educate veterans,
servicemembers and their families, but to have the system as a
resource to where, we can access it and understand how we move
through it, so thank you.
And with that I will recognize the Ranking Member, Mr.
McNerney for his questions.
Mr. McNerney. Thank you, Mr. Chairman. I think we made a
little progress here in your questioning, so good work there.
I think the goal is to make it seamless for the
servicemember, obviously that is the goal. Are there technical
issues, like communication between computers or any of that? Is
that a problem at all? Can we just put that one to bed now, or
do we need to talk about that for a little while?
Mr. Medve. So, Congressman, thanks for the question. We are
working on that. You know, I am sure you are familiar with that
word, trying to develop or out on the boards developing an
integrated electronic health record which once that comes into
fruition, will, I think, be a great asset for us. In terms of
the Integrative Disability Evaluation System and moving people
through that process, we have one system called the Veterans
Tracking Application that we use to manage where people are in
the process so that we have the metrics and understand where
they are at.
We monitor those things every two weeks at the VA. The VA
Chief of Staff holds a biweekly performance meeting with every
senior executive that manages a part of that process down to
the local level. As part of those discussions, if there are
issues that we are having in terms of transmissions of data or
anything like that, he immediately calls our Office of
Information Technology to bore in on the problem and to fix it.
Mr. McNerney. Well, that sounds good. Except, I want to get
an idea of when these medical records are going to be
standardized so that we can get this transition, that part of
it, out of the way. So do you have an idea about when that can
be expected to be finished?
Mr. Medve. Sir, I know the two secretaries, as Mr.
Neighbors alluded to, meet every quarter. At the last meeting
at the end of February 27th, one of the marks on the wall is
that we are putting the Integrated Electronic Health Record at
the James A. Lovell Federal Health care Center. That's the
pilot site for it. They have required that there be two
additional sites be in place by 2014 in order to build this,
and so it is going to be a rolling development over the next
several years.
Mr. McNerney. That is not good enough. That is just not
even good enough. Yes, Mr. Neighbors.
Mr. Neighbors. Sir, if I could chime in and thank you for
your question. DoD and VA are actually sharing more health
information right now than any two organizations in the Nation.
If I could just give you some statistics, please, on what that
sharing is.
Servicemembers' data, again, that has been shared with VAs
over a million times already, and what that turns into is for
laboratory results. We have shared 23,000,000 of them to date,
and these are in IT form. This is machine readable things that
we push for, so they are not paper in this area-- radiology,
3,600,000 million reports; pharmacy, 24,000,000 records. And
patients have engaged on their medication, allergy information
from what was about 27,000 to now 1,200,000, which is a
significantly improving patient safety.
Those are just some areas. It is an entire IEHR.
So between our organizations, we actually are doing some of
the sharing already. And if I could, there are actually four
locations pilot-wise which we are including private providers,
such as a Kaiser Permanente or something, what we would bring
to them into the fold here to.
So between governmental entities, we have that actually
going on right now. So you are right. We are not where we need
to be. We are not completely there, absolutely, but there is
stuff going on that is servicing our veterans.
And the second thing I would like to say, sir, if I could,
please, that is entity to entity. As far as giving a VA, excuse
me, a veteran, or even a servicemember their health records, we
can do that right now. We are working very closely with VA to
enroll our servicemembers as they come in the door, into a
platform, an IT platform called the E-Benefits Platform, that
allows--we have got 1,400,000 of them already signed up right
now, but at any point in time after that from anywhere in the
world, 24/7, they can actually download their medical records
and hand them off to a private provider or anybody that they
are involved with through that continuum right now, and that's
called the blue button capability. Maybe you have heard that or
not.
Mr. McNerney. No, I haven't heard that. One of the things
that Mr. Medve was saying is that you can track an individual
through the process, but is there an advocate for that
individual or does that get passed on and the individual finds
himself or herself calling in and getting the runaround.
I mean, what we need is an advocate, whether it is DoD or
VA or the joint effort--Mr. McDonald started going into that--
but an ombudsman or an advocate or some coordinator that that
person can go to when they are in trouble from start to finish.
Mr. Medve. Sir, yes. Thank you for your question, again,
Congressman. In IDES, when someone is enrolled in it, there is
the PEBLO, the Physical Evaluation Board Liaison Officer. When
that individual is referred is who greets them at the entrance
to that process. That is the single point of contact that will
shepherd them through IDES. As they are in each different
stage, they are briefed by that person where they stand,
whether they are medical, when their medical evaluations are
done, when they are supposed to appear before any boards, all
that.
Once we get to a point where they are going to be
determined to be separated, we, the VA sitting with the DoD
PEBLO, we call the military service coordinators, that then sit
down with the individual as a team and explain to that
individual what their VA benefits are, so that is what happens
inside the IDES.
Mr. McNerney. Does the servicemember or former
servicemember get to check off on that and say that they are
okay with that transition?
Mr. Medve. I will defer to Mr. Neighbors since that gets
into the military's administrative process.
Mr. Neighbors. Absolutely, sir. At any point in time when
an evaluation takes place, that servicemember has reclama
capability at a number of venues. Each one of the services has
a local board that does exactly what we are talking about here,
which is the evaluation of their disability and the rating.
They can then take that to a department-wide--excuse me, let me
say this again. The service-wide board is more of a formal
activity in which they make sure that the rulings have been
applied equally across from the local board itself.
If the servicemember doesn't believe that is equitable,
they actually can go to another level and they can actually go
to what is called the Board of Correction for Military Records
level, also. So there are a number of points that the person
can say, you know what, this wasn't fair, I need another look,
and they can be reversed or they can be upheld as any kind of
board would do, but yes, sir, there is.
Mr. McNerney. Okay. I am going to yield at this point.
Mr. Runyan. I thank the gentleman. Mr. Walls.
Mr. Walz. Thank you, Mr. Chairman, for holding this
hearing. Thank you both for being here. This issue of singles
transition, like you, I feel like I have spent most of my adult
life talking about it and trying to get us there and I am
please to see both of you sitting here. It certainly is a move
forward where we have both DoD and VA, and I know the things
you have talked about and trying to get us there through
electronic records, through the coordination and collaboration.
It is not only the right thing to do. It will save us resources
and money in the long run preparing for our veterans, and so I
appreciate what both of you do, and I know that you are two
representatives sitting there and if the Chairman will indulge
me a bit, I am going to--I am very thankful, I think, listening
to the name of this hearing, honoring the Shared Commitment to
Care for those who defend our freedom.
I am thinking about this and watching the two of you set
this idea of a handoff or whatever, there was some more news
this week again. And those of you on this Committee, I have
been here long enough, I certainly don't turn to the
sensational to highlight this, but I am going to highlight this
issue of the discharges from DoD on personality disorder.
I am truly troubled by this. If this is truly about
honoring the Commitment to Care, this is the third hearing I
have set here where we have talked on something like this. In
2007 we were going to get this fixed. We were going to get it
fixed in 2010, September 15th, and there is a report today and
my friends over at the Vietnam Veterans of America, through a
Freedom of Information Act, were at it again.
So we got soldiers. They go to war, they come back and they
are being diagnosed with adjustment disorder or personality
disorder. It gets stamped on their discharge papers,
``Discharge for Personality Disorder.'' They are denied VA
benefits and that is on their permanent record to follow them
for employment.
So Mr. Neighbors, I know this is not your area of
expertise, if I could say. I am not putting you on the spot for
the entire Department of Defense, but I would like you to--what
do you think when you hear this again because all the issues
you are talking about, I don't want to distract us from this
very, the broader issue, but I do feel like I need to speak up
for these 31,000. I do need to try and figure out how we right
this wrong because the idea that you would be diagnosed with an
adjustment disorder after being in Afghanistan, I don't know,
if I could just turn it over to you, and I thank you, and I
know it is very general but it just troubles me.
Mr. Neighbors. I understand and I really appreciate the
question. It is a very important issue. I am going to go out on
the limb a little bit here and try to narrow it a little bit. I
think what you are referring to is what has happened maybe at
Madigan out on the West Coast. Am I correct on that or is it--
--
Mr. Walz. Well, there was a new--I had the thing, we just
had a Freedom of Information Act request and the study was put
together on this from Vietnam Veterans of America. I will make
sure we get a copy to you----
Mr. Neighbors. Okay.
Mr. Walz. --to let you see that. But it is pretty much we
are on the same pace as we have been in the last 10 years,
releasing these folks. This came to our attention when Joshua
Kors wrote the piece, ``The Disposable Soldiers in the
Nation.''
We had three hearings on it again. Vietnam Veterans brought
it up again, and it is probably the most striking example for
me of how somebody does fall through the cracks or how we are
not seamlessly to handing off folks and I am just curious on
your part.
Mr. Neighbors. Okay. And I appreciate that, sir.
Mr. Walz. Yeah.
Mr. Neighbors. If I could, I would like to yield back to
one of my SMEs that I have brought that I think can more, give
you much----
Mr. Walz. That would be greatly appreciated.
Mr. Burdett. Councilman, I think you are calling an issue--
I am Phillip Burdett. I work with----
Mr. Runyan. Would the gentleman, please, speak into the
microphone, please.
Mr. Burdett. Councilman, I am Phillip Burdett and I am Mr.
Neighbors' colleague and we work in the IDES system. And
particularly, I think the behavioral health issue that you've
highlighted is a critical one for us. As we have made non-
visible injuries a priority, we have seen them skyrocket in
diagnosis, we struggle to hire behavioral health professionals,
and I think the answer to your strategic question is how do we
train those behavioral health professionals correctly and then
how do we administer the policies and regulations, and we have
made some great steps in 2010, think we had this issue fixed,
and when it flares up, I think it comes back to training those
behavioral health professionals, making sure we have the right
and adequate ones at our bases' posting stations, give them the
diagnoses.
Mr. Walz. Are we benchmarking now because my question, I
think what the public comes up to is how do you know that
person came in with a preexisting condition of a personality
disorder? How are you making that judgment?
Mr. Burdett. I think two issues come to mind here. It is
such a new science in so many areas. We have talked of PTSD,
directly the TBI, and then the manifestation of both of those
conditions with the incredible physical problems at the same
time, so as our diagnoses have skyrocketed, we have invested a
tremendous amount, especially with our Assistant Secretary of
Health Affairs. The investments in that have been significant.
Now, we need to then recognize are we using some good
medical standards across the board, are we then making sure
that our doctors are using those diagnoses, following the
regulations that we have implemented in the accordance with the
laws that you have passed. We owe that. I think we have made a
great effort in acknowledging what we know and don't know about
behavioral issues and then putting together solid policies and
regulations.
Mr. Walz. And I appreciate that and I do acknowledge the
progress we have made and this is a difficult area. And I guess
my question is how do we right what I think is an egregious
wrong for some for these folks? I think they went in and the
horrific experience they experienced, they are coming out with
what others have, which I would say in some cases is a normal
reaction. They have been diagnosed with this, which is
basically a black ball to them, that they are not welcome at
the VA, they are not welcome at the employers.
Do you have a suggestion? And I appreciate your candidness
from both of you on this issue of trying to address it.
Mr. Burdett. I think, Congressman, I would say that I think
that Mr. Neighbors highlighted is we have made this a
servicemember centric policy and regulations since the
beginning and the ability for a servicemember either on the VOD
side of the equation or the VA side to then challenge and come
back and open these cases and say I would like you to look at
it again. Those have not been abridged. They have been
extended. And the opportunity for those servicemembers to
recognize, you know, I may have gotten out in 2004 and then had
this condition that I need to have reevaluated.
The VA has done fantastic work at making those avenues
available to those veterans to come back and say, let us look
at that case again.
Mr. Walz. You think it is too harsh where VVA (Vietnam
Veterans of America) is just point blank calling these illegal
discharges?
Mr. Burdett. I think the role of the VSOs is critical. I
sometimes refer to them as our conscience, making sure, holding
us accountable to make sure that we understand things. I
appreciate their flexibility and also understanding that the
behavioral health issue is such a new area of science for the
medical community, for the policy makers, and then for the----
Mr. Walz. Well, I am going to try and figure out a route to
figure out how we get these folks back, how we give a fair
shake at them because I think we got folks--and I say this
again from the moral perspective, but also from an economic
perspective. They are probably not working. Our suicide rates
can be tied to some of this. There are just different issues
that we have got to go back and capture them with the new data
that has gone--and I will be the first to tell you that I think
in the ten years in seeing what we were first doing in the war
zones, what we are doing now, great kudos to everybody
involved, behavioral health and integration.
Mr. Neighbors. I just want to add one other thing, Mr.
Congressman, to what Mr. Burdett said, and that is the basic
military training, you touched a little bit on preexisting
conditions. There is a vast array of medical diagnoses--not
diagnoses, evaluations that take place even as a person is
coming in the door for basic military training in which you
alluded to preexisting conditions. Those are all documented.
Mr. Walz. Why did we keep them then?
Mr. Neighbors. Oh, no, no. There is a wash out period there
also, sir.
Mr. Walz. But you know, we got some of these folks that
went, they served their time, some up to eight years, went to
Iraq, came back and then they were stamped on their as a
preexisting condition for personality disorder. Why the heck
did we keep them if that was the case? Why didn't we get them
out otherwise? I mean, how do I respond to those people? You
see where this is going?
Mr. Neighbors. I do.
Mr. Walz. And we are this close to a class action suit
against DoD on this. You feel that coming. My case is I just
want to correct the problem and make sure it doesn't go
forward.
Mr. Neighbors. And I understand completely, sir. Again,
they have multiple avenues to go back to up to include Board of
Corrections for military records, which I sat on for the Air
Force. I saw many of those kinds of cases and saw some actually
overturned also, so there are avenues for people. You are
absolutely correct. There is more that needs to be done, and
there are more things that I believe we can do and we are
working on those with the services to move forward, but I do--
--
Mr. Walz. You think the avenues exist without us getting--
my take is is to help and figure out a channel through the
proper existing process of appeals or rectifying these. You
think those set out there and are ready to go?
Mr. Neighbors. I will be happy to work with you. Obviously,
I----
Mr. Walz. Yeah, and we will be following up with others,
but I thank you, Mr. Chairman. I know you gave me extra time,
but I want to thank both of you for your candidness and attempt
to get out this. I appreciate it.
Mr. Runyan. I thank the gentleman. Mr. Carnahan.
Mr. Carnahan. Thank you, Mr. Chairman. I really just had
one quick question I wanted to ask our two witnesses. I
understand there have been some informal sessions for
demobilized and separating National Guard and Reserve members.
Can you talk about some of the unique challenges associated
with educating and processing these servicemembers and do you
have any thoughts on how to deal with them more effectively? Go
ahead. Jump in.
Mr. Neighbors. I apologize. Sir, a great question. There is
no doubt that there are differences, especially in timeliness
as far as how servicemembers from the Guard Reserve come
through the IDES specifically, but I do know that we are
taking, as for us, especially Recovery Care Coordinators, and
things have a standardized training regime. They all receive 40
hours of training or more to make sure that they are engaging
with servicemembers, not only active duty, but Guard and
Reserve, so that they understand all the processing the same.
There is no doubt, as far as transition is concerned,
servicemembers that are Guard Reserve have issues of employment
that are in and out of their employment. There is a large--in
fact, thank you, gentlemen, for the VOW Act that you graciously
gave to the DoD last year. As far as transition is concerned,
we are working very hard. Some of, I think, what answers what
you are saying there is an involved in implementing that Act
which we are working with the White House on right now.
Many issues in making sure that Guards and Reservists get
that exact same training that is funding, that it's moving
forward in the same way that the active duty is getting. We are
working very hard with the VA in ensuring that that transition
takes place. Does that kind of get to what we are talking here?
Mr. Carnahan. Yeah.
Mr. Neighbors. Okay. All right, sir.
Mr. Medve. Congressman, again, thanks for the question. In
terms of overall in the process of demobilization, I know that
we have VA reps at the de-mobe sites there to work people
through to ensure they understand what they are eligible for.
In terms of IDES, you know, we currently have a major effort
going down on Pinellas Park with a number of Reservists'
records that are being gone through to determine whether or not
they had profiles that had to be validated to see if they were
such a level to require medically being separated from the
service. We are working hand in hand with DoD.
We have a number of Reservists and National Guard who do
collect VA benefits when they are off of active duty, and as
part of that process we share with the DoD as they are looking
at these records in terms of medically separating people to
validate conditions that exist and all that, so we have got
good information sharing between the departments on that.
But a Reservist going through IDES gets the same attention
going through the process because they are still on active duty
when they are going through IDES, so the PEBLO that I talked
about before, they are walking them through the process. They
have access to the military's service coordinators that go
through the process, so they are treated no different from our
point of view, than active duty, somebody who is on active duty
all the time. servicemen are going through the process.
Mr. Carnahan. Thank you, gentlemen. I yield back.
Mr. Runyan. Thank you, gentlemen--and on behalf of this
Subcommittee, I thank you for your testimony and your time.
Obviously, we have a lot of work ahead of us trying to make
sure that we take care of our warriors, our true heroes of this
country, so with that being said, I look forward to working
with you on that and continuing to make this process what it
truly deserves and needs to be.
So with that being said, both of you are excused. Thank
you.
I want to call the second panel to the witness table at
this time. At this time I welcome Dr. Gail Wilensky, a Senior
Fellow with Project HOPE. Dr. Wilensky also served as a
Commissioner on the Dole-Shalala Commission. And next we will
hear from Mr. Ken Fisher, Executive Officer of the Fisher House
Foundation. Mr. Fisher also served as a Commissioner on the
Dole-Shalala Commission. And finally we will hear from
Lieutenant General James Terry Scott who served on the Advisory
Committee on Disability Compensation.
We appreciate all of your attendance here today. Your
complete and written statements will be entered into the
hearing record.
And Dr. Wilensky, you are now recognized for five minutes
for your oral statement.
STATEMENTS OF DR. GAIL WILENSKY, SENIOR FELLOW, PROJECT HOPE;
KEN FISHER, CHIEF EXECUTIVE OFFICER, FISHER HOUSE FOUNDATION,
INC.; LIEUTENANT GENERAL JAMES TERRY SCOTT USA, (RET.),
CHAIRMAN, ADVISORY COMMITTEE ON DISABILITY COMPENSATION.
STATEMENT OF GAIL WILENSKY
Ms. Wilensky. Thank you, Chairman Runyan and Ranking Member
Mr. McNerney and Members of the Subcommittee.
I am pleased to be here to talk about the transition from
servicemember to veteran with particular emphasis on the
Integrated Disability Evaluation System.
As you mentioned, I am currently a Senior Fellow at Project
Hope, an International Health Education Foundation. I also
serve as a regent for the Uniformed Services University of the
Health Sciences, USUHS. I have had the honor and privilege of
being on the Dole-Shalala Commission as you mentioned. I was
also a Co-Chair of the congressionally mandated study on the
future of military health care and earlier in the decade I co-
chaired the President's task force to improve health care
delivery for our Nation's veterans, initially with your
colleague, Gerald Solomon, who unfortunately died early in that
period, and then with John Paul Hammerschmidt. The views I am
going to express are my own, however, not those of these other
organizations.
Before the introduction of the IDES, servicemembers needed
first to separate from his or her service and then to enter the
VA process, requiring as you have mentioned, two different
exams. The process and criteria for determining fitness
differed across services. They differed between the services
and the VA. The result was real and as important, perceived
differences, in equity across the services and between the
services.
It was frequently a lengthy process, as you have mentioned.
It was also frequently a contentious process which was equally
bound to have happen.
The difference now with the IDES is that there is a single
exam done by a VA certified physician that serves both as the
basis for determining fitness to serve and also by the VA to
establish a level of disability. The services continue
importantly to determine fitness to service and the VA, the
disability level.
The time has been reduced substantially, although not as
much as it should be. The goal that was talked about this
morning of 295 days is a substantial improvement. Initially,
there has been some discussion of a goal of 100 days. That is
obviously still a long way out.
And there are some lengthy and inexplicable delays that
occasionally reported. Last summer at a Senate hearing there
was a discussion of a marine who had been in Afghanistan in
2010, lost both his arms and legs and had his papers sitting on
someone's desk for 70 days; clearly, not something acceptable
to anyone.
There are some questions that remain in my mind as somebody
who had run Medicare and Medicaid in the early 1990s, as to why
it is taking quite so long to fully roll out the IDES, until
the fall of 2011. It has now happened and I am glad, but that
length of time is inexplicable to me.
There are also questions about what are the real goals of
the program, and that means not just reducing time but what
actually is it that you are trying to do.
I also want to talk for a minute about another area where
we had recommended change and that was the Disability and
Compensation System, trying to make sure that it was speedy
with, reduced inequities and, most importantly, helped veterans
return to their productive lives as fully and completely as
possible.
We recommended a transition payment be made while
individuals are receiving rehab and training, and that this was
to be followed up by an earnings-loss estimate which may remain
after training, but in our service-oriented information economy
may not remain. There was also to be a quality-of-life payment
recognizing that even if there was a loss, there was not a loss
of earnings capability, there may well be a real quality of
life decrement which should be compensated.
Two of the young men on our Commission really fit into that
role. One was getting an MBA at Harvard. One was having a
double major at George Mason. Both of them would probably not
experience earnings losses, but they had major injuries that
would result in quality of life decrements.
We also need to make sure that other recommendations that
we made in Dole-Shalala are carried out, making sure that care
is available for those needs of PTSD and TBI services. We
recognize that is going to be a challenge because of the
shortage of mental health providers and professionals in the
country in general and, therefore, afflicting those services as
well.
And we have recommended extending respite care and
extending the FMLA, the Family Leave Act, for up to six months
for spouses and parents of seriously injured people. This, of
course, is going to be difficult in our fiscally challenged
environment, but it is one that is important.
Let me just end on a positive note. While the
recommendations we made are important and we are glad to see
some of them being carried out, we also noted that the problems
were not quality-of-care problems, but rather problems with the
handoff, the transitioning from inpatient to outpatient, from
active duty to veteran.
We, of course, need to make sure that both are appropriate
for our returning wounded warriors, but I would hate to have
people think that it was a quality of care that we found
wanting after 2007. It was not. It was these other processes
which we are pleased that you are taking on.
Thank you.
[The prepared statement of Gail Wilensky appears in the
Appendix]
Mr. Runyan. Thank you very much. Mr. Fisher.
STATEMENT OF KEN FISHER
Mr. Fisher. Chairman Runyan, Members of the Committee, on
behalf of Co-Chairs Dole and Shalala who could not be with us
today, the Members of the Commission, and my fellow
Commissioner Gail Wilensky, I appreciate the opportunity to
appear before you today.
Both as a Commissioner and as Chairman of the Fisher House
Foundation, I have devoted the last 12 years of my life towards
improving both the care and the quality of life of our
military, those wounded, veterans and their families. Today's
hearing on the DES and the seamless transition are critical to
this Nations' security and I am proud to discuss my work on the
Commission, recommendations and action steps, and how this
system must be made simple, easily understandable and easier to
navigate.
But I must admit to being a bit confused. This is the
greatest Nation on earth, with the greatest equipped and best
trained military in the history of the world. What puzzles me
is we are here five years after the roll out of this report.
Before I begin, I feel compelled to preface my statement by
explaining our mission. We were charged by President Bush to
examine, evaluate, and analyze the care and process related to
our returning wounded global war on terror servicemen and
women. We looked at the system through the eyes of the wounded
service people. We were solution driven. We held numerous field
hearings, interviewed wounded, interviewed commanders, doctors,
family members as well as others who played a role in the
recovery process.
We not only examined problems and inadequacies but also
looked for best practices that might help improve their care.
Our goal was to simplify and help eliminate the log jam, which
was the result of fighting lengthy two front wars with a VA
that was already challenged by the weight of an intolerable
bureaucratic system. And by doing this, we sought to eliminate
the backlog and claims that had reached at the time
approximately 800,000 to 900,000.
While the living conditions at Walter Reed were indeed
horrendous, this was only the tip of a massive iceberg. We
found hundreds of troops waiting months for follow up
appointments or awaiting the ratings process. This gap in
benefits caused massive problems known to but a few.
The Commission was given six months to evaluate the entire
disability evaluation system and our findings were thoughtful,
inclusive, and implementable. It was not our intention to put
forth hundreds of recommendations that would have been
difficult to implement or too expensive as a whole.
And by the way, as a side bar I would like to join my
colleague and say that I want to compliment this Nation's
military health care professionals whose work and use of the
latest technologies resulted in a battlefield survivor rate of
better than 95 percent, which is unprecedented.
Today, five years after our report was made public, there
has been progress, to be sure, but with all due respect, not
nearly fast enough, and with not nearly enough sense of
urgency. Tracking the results of the Commission has been
difficult, as admittedly I would not expect the process to be
transparent. But again, the task we were given with that of
OEF/OIF, and I hope of its adoption would have moved the system
along faster.
Now, rather than go in and be redundant on points already
covered, I would like to--we have heard about disability and
the new IDES, although I feel that there are staffing problems
which are causing problems in the implementation of IDES. I
also am confused as to why a VA doctor would be doing a DoD
physical, but I don't want to get into that either at this
point.
What I would like to discuss is the--pardon me--is the PTSD
and I would like to remove the word or the letter ``D'' because
I don't believe that post-traumatic stress is a disorder. We
recommended lifetime treatment for post-traumatic stress. These
men and women have endured multiple deployments, have been in
intense urban fighting, often against civilian insurgents who
too often hide behind innocent women and children. They have
seen horrific injuries caused by IEDs. And the stigma
associated with coming forward and asking for help leaves too
many to suffer in silence, and if they are home, their families
to suffer as well.
We believed this was a major problem when our report was
made public, and it has been for any servicemember who has
fought in battle be it World War II, Korea, Vietnam or today.
Today it is evident why this was a major recommendation.
Five years after our report was made public, there have been
well over 1000 suicides, outpacing the civilian population,
domestic violence, and divorce, drug and alcohol abuse,
homelessness, joblessness, all at unacceptable levels.
Just the other day in USA Today, an article appeared
discussing alcohol within the ranks of the Army and the fact
that they have delayed for three years a confidential counsel
program for treatment. They had begun a pilot program in 2009,
but it was ended after a high dropout rate. According to the
article, 25 percent had a drinking problem.
In the interest of time, Mr. Chairman, I will end my
statement there, and I thank you for the opportunity to appear
here and look forward to your asking questions.
[The prepared statement of Ken Fisher appears in the
Appendix]
Mr. Runyan. Thank you, Mr. Fisher.
General Scott.
STATEMENT OF LIEUTENANT GENERAL JAMES TERRY SCOTT (RET.)
Lieutenant General Scott. Chairman Runyan, Ranking Member
McNerney and Committee Members, it is a pleasure to appear with
you today representing the Advisory Committee on Disability
Compensation and the Veterans Disability Benefits Commission
that met from 2005 to 2007 and reported out to you in October
of that year.
It is also a distinct honor to serve on a panel with Mr.
Kenneth Fisher whose contributions to servicemembers and
veterans are known and appreciated.
Mr. Fisher. Thank you.
Lieutenant General Scott. The Advisory Committee is
chartered by the Secretary of Veterans Affairs in compliance
with Public Law 110-389 to advise the Secretary with respect to
the maintenance and periodic readjustment of the VA Schedule
for Rating Disabilities. Our charter is to, ``Assemble and
review relevant information relating to the needs of veterans
with disabilities; provide information relating to the
character of disabilities arising from service in the Armed
Forces; provide an on-going assessment of the effectiveness of
the VA's Schedule for Rating Disabilities; and to provide
ongoing advice on the most appropriate means of responding to
the needs of veterans relating to disability compensation in
the future''.
Your letter asked me to testify on the Advisory Committee's
views regarding the transition from servicemember to veteran,
with a particular focus on the implementation of the IDES.
At the time the Veterans Disability Benefits Commission was
created by the National Defense Appropriations Act of 2004 it
was already apparent that the peacetime system for
transitioning sick and injured servicemembers to veteran status
was overwhelmed. From the outset, and well before the
reprehensible situations at the Walter Reed Barracks and other
locations were recognized, the Commission saw the need for a
rapid and seamless process that protects the servicemember
while he or she progressed to veteran status. Transition became
one of the major issues studied by the Commission. Interim
recommendations addressing transition issues were offered as
deliberations progressed.
The VDBC examined the policies and processes within the
Departments of Defense, Veterans Affairs, Labor, Health and
Human Services, and the Social Security Administration that
affected separation or retirement. Each of these entities plays
a significant role in the transition of veterans and their
families.
Of the many recommendations the Commission made, many of
them pertained to improving the transition process. I am
providing for the record a list of the key transition
recommendations and the status of their implementation as I
understand it.
Of the recommendations pertaining to transition of both the
Veterans Disability Benefits Commission and the Advisory
Committee on Disability Commission have offered, the one with
the most potential to reduce the time to process claims and
improve accuracy and consistency is the ongoing plan to revise
the VASRD, the rating schedule. This complex, multi-year
revision will incorporate current medical knowledge and
technology as well as streamline the diagnosis, evaluation, and
adjudication processes.
Another key recommendation with potential long term
positive effect is the movement to an electronic claims record.
This is another example of an extremely complex challenge that
VA has accepted and is working on. When fully implemented, it
will simplify and expedite the claims process. As well, the
Integrated Electronic Health Record which was mentioned in the
previous testimony.
The Advisory Committee on Disability Compensation took up
where the VDBC left off on making recommendations for
improvements to the systems and processes to transition
servicemembers to veteran status. Particular emphasis has been
on the injured and the ill servicemembers who are eligible for
the IDES program. However, the scope of our activities, it
covers all servicemen transitioning to veterans.
Our recommendations have included specific statutory and
regulatory changes such as increased family support services,
educational, vocational training and rehabilitative support.
Many of these recommendations have been adopted in whole or in
part. We have recommended the VA undertake an in depth
longitudinal and independent evaluation of the VR&E Program as
soon as possible to determine the effectiveness of the program
in serving disabled veterans. We believe there are significant
opportunities for improving access offerings and management.
We have offered recommendation for reducing a number of
contact points a veteran must touch in order to understand and
receive benefits, also mentioned in previous testimony. We are
in the process of reviewing the availability of mental health
programs for veterans. The Committee is also tasked to look at
unique Reserve and National Guard transition issues and we
recently added a U.S. Air Force Reserve medical officer to the
Committee to assist us in that regard.
The current IDES program incorporates many of the
recommendations of the Veterans Disability and Benefits
Commission and the Advisory Committee on Disability
Compensation. It represents a tremendous effort on the part of
VA and DoD to focus on the transition of members who are sick
or injured to veteran status.
All parties, including the Congress, are frustrated by the
average time still required to complete the transition. From
the perspective of someone who has the opportunity to work on
this effort over the last eight years, I do believe that
progress is significant and more importantly that the progress
will continue.
On behalf of the Advisory Committee, thank you for the
opportunity to testify on this important matter.
[The prepared statement of Lieutenant General James Terry
Scott appears in the Appendix]
Mr. Runyan. Thank you very much, General Scott, and I thank
you for your service to this country and your continuing
service to our heroes. I appreciate it.
With that, we will begin a round of questioning. My first
question is for Dr. Wilensky. In your testimony you mentioned
the importance of recognizing that there are different
functions that medical exams can serve and there are many
different goals. How would you incorporate your suggestion of
the ongoing periodic medical evaluations into a single
disability exam process?
Ms. Wilensky: It is a good question, Mr. Chairman. The
reason I mention that is having spoken with many medical
officers, those currently and previously in the military, they
reminded me of the different functions that a medical exam can
fill, a physician maybe determining the diagnosis or the
process of treatment and then the progress in terms of that
individual over time, which may be on an ongoing basis. When it
comes to an exam that is done in order to determine fitness to
serve or a disability status, that is a moment in time. I mean,
it is an important moment in time. It needs to be on a single
basis as is being done. But it needs to be recognized within
the context that there will be ongoing periodic evaluations,
both in order to be able to treat the individual, whether he or
she returns to duty or becomes a veteran, and also periodically
should be done in order to establish whether or not the
disability is continuing as it was initially established.
It's important to recognize that a single exam may include
different components, it will be a snapshot and a moment in
time, but it doesn't mean that it is the only medical exam that
will be occurring over time. If you have a medical problem, you
would want to have your medical professional seeing you when
carrying out the course of treatment. It is to recognize that
the focus on having this one exam done by a VA certified
physician is appropriate for the particular purpose of
establishing fitness to serve or a VA disability as of that
moment, but there will be, should be continuing medical exams
over time for these other purposes.
It's really to remind people this is not once and never
again will you have a medical exam because that would not
provide optimal care.
Mr. Runyan. Thank you for that. And also, talking about
disability and payment steps as we begin to deal with the
transition and then loss of earnings and finally quality of
life, can you give your assessment of the current state of
these steps and how we can improve that process?
Ms. Wilensky. Thank you very much, Mr. Chairman. This is an
area that for me as an economist was particularly important. We
on our Commission recognize that the payment, the orientation
and thinking of the disability payment was heavily tied to
post-World-War-II thinking where the loss of a limb or a
certain type of injury could have very major impacts on
earnings-potentials of individuals of post World War II, Korean
and Vietnam eras.
We were recognizing that we are now in an information and
service oriented economy. And what that means is that with the
help of the VA, the GI bill and others, even seriously injured
individuals can be helped to reach a higher functioning state
with the proper support, both VRA for those who need
vocational, but higher education for those who are in a
position to do so, and may be able to reduce or eliminate any
earnings loss per se. Even for those individuals, they may well
merit a quality of life decrement payment such as was the case
for two out of the three injured on our Commission.
I mentioned in my testimony that the wife of a third
individual, Tammy Edwards, her husband is not somebody who is
ever going not to have a major earnings loss as well as a
quality of life decrement, no matter how much training and
education was provided because of the severity of his injuries,
including brain injuries as well as major burns.
So it is important to recognize that even in an information
and service society, there will be people who will continue to
have significant earnings losses and quality of life
decrements. But for people, like, two of our members, they
would not have earnings losses. They would require a lot of
support, payments while they were going to school, as well as
what was as expensive support for their education.
To the best of my knowledge, we have not made much progress
in this area, although as you know, there has been a
significant improvement in the educational support to people
post service.
Mr. Runyan. I have one question for Mr. Fisher quickly. I
assume you have communication insight into the world of Wounded
Warrior support, obviously through your organization. What is
the general feel in this area pertaining to how the DoD and the
VA utilize and communicate to organizations such as The Fisher
House? Obviously, a lot of what we are talking about today
deals with the lack of communication or lack of knowing the
pathway forward.
Mr. Fisher. Thank you, Mr. Chairman, and I would say in
general we have maintained a very, very good dialogue with both
the DoD and the VA. It is necessary for us to do so because the
way we determine where a house is located is by dealing with
the VA or the Surgeons General. So communication for us is
absolutely essential so that we don't waste money. Every
donation we get is precious. So we can't afford to have a house
built where it doesn't belong.
So the communication with the VA and the DoD has been
fairly good in terms of our ongoing dialogue.
Mr. Runyan. Thank you very much. With that, I recognize Mr.
McNerney.
Mr. McNerney. Thank you, Mr. Chairman.
Mr. Fisher, I would just like to thank you for dedicating
so much of your life to the service of other people.
In your experience, what if anything can be done to ensure
a better continuity of care for wounded warriors before they go
home to live with their families, especially ones without PTSD
and traumatic brain injuries? I know this is a tremendous
burden on the families. Is there anything we could do or that
the DoD or the VA could do to make that transition easier so
the families can deal with this enormous burden?
Mr. Fisher. Thank you, sir. I would, I think in my prepared
statement I suggested that there potentially could be kind of a
spousal education program upon deployment or as they entered
the military and if a serviceman or woman enters the military
as a single person and gets married while in the military, that
their spouse at the time join a program.
I think it is essential for the spouses to learn what the
signs are or what to look for. They don't always manifest
themselves with violence off the bat or the screaming and mood
swings and so forth. I think that sometimes it could be just,
you know, something as simple as not sleeping at night after
deployment.
So I think some kind of a spousal educational program that
would kind of educate them, let them know what the signs or
what the early warning signs are when they come home.
Mr. McNerney. So this education would have to start before
they come home basically.
Mr. Fisher. Well, in terms of the spousal program, I would
like to see something like that happen upon deployment before
they leave, and I mean the first time, not if we are talking
about multiple deployments.
Mr. McNerney. Thank you. Ms. Wilensky, I was struck by
something you said, the starkness of your statement that the
problem is in the handoff, not in the quality of care, but then
you also said that the IDES exam is just a single point in
time. Things change and so I would like to get your idea of how
we could make this work better. I mean, you must have a vision
of how this would work.
Ms. Wilensky. The good news, as I indicated, was that our
observations, and that is supported by others as well, is that
the actual quality of care being delivered. Once the person is
in the place they are supposed to be, either active duty
military or in the VA system, has been very good, and that the
problems have occurred whenever they are making a change. There
is not a single handoff.
When they move from inpatient to outpatient care, there
were major problems. It was why the Wounded Warrior Recovery
Program was so important to put in place. And while that has
reportedly helped, there are still concerns about whether it is
completely getting the job done, whether those transitions and
handoffs are occurring for the especially very seriously
wounded as well as they need to be and whether that will
continue as we go out because we are still seeing very
seriously wounded individuals coming out of Afghanistan and
other places.
So it is not even there a single handoff. It is every time
somebody moves to a different part of their care is when the
problems have been occurring and those are the places where we
remain vulnerable.
With regard to the point in terms of evaluation, something
like a three year evaluation of a disability is appropriate, so
that there can be an assessment as to how the person is
progressing and the kinds of needs that they have at that
point, and again it was the emphasis that this is not anything
other than a snapshot. It needs to be a really good snapshot
because you are making a decision about fitness to serve and
disability for the person who is leaving the service, but it
has to be a series of follow-on snapshots, and three years is
the time that was recommended to us.
Mr. McNerney. Thank you.
Ms. Wilensky. We did, by the way with respect to your
question to Mr. Fisher, specifically recommend for the families
of those who are severely wounded that the legislation be
passed to allow them a six month family leave period as well as
extended respite care to the parents or spouse of the severely
injured.
Mr. McNerney. Okay. I want to yield back to the Chairman.
Mr. Runyan. I apologize to everyone. We just had a bill
called in Natural Resources and I don't have any other Members
on my side, so we are going to have to go into a recess for
about a half an hour and reconvene at that point. I apologize
and we will be back shortly. Return at noon.
[Recess.]
Mr. Runyan. The Committee will again come to order and I
apologize for the delay and appreciate your patience in working
with this. I have a question for General Scott. Based on what
you heard this morning in respect to DoD and the VA's testimony
on the progress of IDES as this point, generally how would you
grade their progress with the recommendations of the Veterans
Disability Benefits Commission?
Lieutenant General Scott. Well, I think that both
departments picked up on the problem after it was brought to
their attention. As I said, it was pretty clear early on that
some peacetime arrangement where the VA and the DoD was not
satisfactory for large numbers of returning soldiers.
Again, like you, sir, I was present when there was nothing,
you know, when the VA and DoD essentially were not
communicating at all about how to transition particularly
injured or ill servicemembers, but all servicemembers to VA.
It was basically, it was, well, here are your discharge
papers, period. So I would say that I would give them a B to
B+, and to get to an A they have got to reduce the average
time, understanding that there are always going to be some
cases that are just really complex, that are going to take an
inordinate amount of time, and that makes the average, that
runs the averages up.
But I am pretty sure from what I heard this morning and
from what I know from working with the VA in particular, that
they are working to get these numbers down. And of course,
numbers are not everything because we have got to be sure that
we are taking care of the servicemember. As was said earlier,
you have to be careful about trading off efficiency for
effectiveness of speed for accuracy.
Having said that though, I think that anyone who was
testifying here or the backups would agree that we can do
better and I can't tell you what the right number is, but I
believe that these two departments are going to get it lower in
that regard, so I give them a B to a B+ for progress certainly
higher than that for an effort.
Mr. Runyan. Thank you. Just one final question. Mr. Fisher,
you talked about how the communication back to the departments
is good. Are they providing you with the right amount of
information and access to the wounded warriors to fulfill your
mission? Or are there other things that you would like to be
able to help?
Mr. Fisher. No. We are being provided with the information
and the access to the wounded warriors, absolutely. We are
doing fine in terms of our interaction on that front.
Mr. Runyan. Thank you for that. Okay. With that being said,
again I apologize for the delay and I thank the panel for their
testimony and look forward to continuing to have these
discussions as we work to help our warriors transition into
their life, so with that being said, the panel is excused.
Thank you very much.
I call the third panel up at this time. First we will hear
from Mr. John Wilson, Legislative Director from Disabled
American Veterans, and then we will be hearing from Mr. Phil
Riley, the Senior Benefits Liaison for the Wounded Warrior
Project, and then, Mr. Eric Greitens, the Chief Executive
Officer from The Mission Continues.
We appreciate your attendance today, and your complete and
written statements will be entered into the hearing record. And
Mr. Wilson, you are now recognized for five minutes for your
oral statement.
STATEMENTS OF JOHN WILSON, ASSISTANT LEGISLATIVE DIRECTOR,
DISABLED AMERICAN VETERANS; PHIL RILEY, SENIOR BENEFITS
LIAISON, WOUNDED WARRIOR PROJECT; ERIC GREITENS, CHIEF
EXECUTIVE OFFICER, THE MISSION CONTINUES.
STATEMENT OF JOHN WILSON
Mr. Wilson. On behalf of the Disabled American Veterans and
our 1,200,000 million members all of whom are wartime and
disabled veterans, I am pleased to be here today to testify
before the Subcommittee on Disability Assistance and Memorial
Affairs about the Integrated Disability Evaluation System or
IDES.
IDES is the result of a recommendation of several
commissions, as we know, with the goal of DoD and VA creating a
single, comprehensive standardized medical exam that the DoD
administers serving DoD'S purpose of determining fitness and
VA's of determining initial disability ratings.
A comparison between the DES pilot that was launched in
2007 by the DoD and the VA, and the legacy DES found Active
Component military members completed the pilot in an average of
289 days, and Reserve Component military members completed it
in an average of 270 days, compared to the legacy DES average
of 540 days.
Surveys revealed significantly higher satisfaction among
DES pilot participants from those in the legacy system, and on
July 30, 2010, the DoD Senior Oversight Committee Co-Chairs
directed that IDES expand worldwide and it was by October of
2011.
While the DAV is generally pleased with the IDES, there are
two topics I wish to address in my oral testimony. First, we
are concerned about the military members going through the IDES
not having ready access to representation from a veteran
service organization as they did under the legacy DES.
The issue of access to counsel to advise military members
on the disability claims process is a concern of DAV and other
VSOs and is also cited as a concern by the Recovering Warrior
Task Force. The Task Force conducted surveys to determine the
effectiveness of DoD programs and policies of for Recovering
Warriors to include IDES. Their survey results reinforce the
importance of providing legal counsel for the Medical
Evaluation Boards as well as Physical Evaluation Boards. And
even though the surveys clearly demonstrate the value of having
legal counsel available throughout the disability evaluation
process, the majority of Task Force focus group participants
said they do not have any personal experience with or knowledge
of these specialized legal services.
As a result, they may be accepting PEB decisions that are
not in their best interest, and the benefits they receive, may
be less than what they would received have had if they
understood the long term consequence of their acceptance of a
particular PEB decision.
We believe that all those going through the IDES process
should have a clear understanding about it. That understanding
would be best provided if they had access to the free
assistance from certified representatives of VSOs who can not
only explain the process and their rights, but can also act as
their advocates.
There has been some positive movement in this area that
partially addresses VSO representation. The VA's Integrated
Disability Evaluation System Implementation Guide issued in
December of last year states that VA Military Services
Coordinators will ``explain the availability of Veterans
Service Organizations and provide a VA Form 21-22, Appointment
of Veterans Service Organization Claimant's Representative, if
the servicemember expresses interest.''
While this is an improvement, we find it too passive. We
recommend this guidance be modified so the Military services
Coordinator explain the option of VSO representation whether or
not the military member ``expresses an interest.''
The second area to address is the effectiveness of the
Physical Evaluation Board Liaison Officers or PEBLOs, who are
supposed to guide servicemembers through IDES on the DoD side
of the process, to ensure they are aware of their options.
The Task Force found that many participants had limited
knowledge about the role of PEBLOs. More often than not,
comments about PEBLOs were negative and military members seemed
to expect them to be more of an advocate than they are. That is
not their role.
While DAV has received information from the field that
indicates the performance of PEBLOs has improved generally,
there have been occasions when PEBLOs have incorrectly advised
members. Recently, a PEBLO advised a member that he could not
personally appear before the Formal Physical Evaluation Board
to appeal the Informal Physical Evaluation Board's decision.
This is clearly in error. But one of DoD's National Service
Officers was able to provide the correct information to the
member.
And another case, a PEBLO incorrectly advised a master
sergeant that he would received 10 percent as his retirement
pay as a result of the IDES decision, even though he had been
in the military 22 years. We clarified for the member that, in
fact, he would be eligible for 55 percent of his base pay due
to his 22 years of service, and that 10 percent that he would
receive was his VA disability rating, not his retirement pay,
and that would be offset.
In order to prevent these types of errors and improve
satisfaction levels, we believe it is imperative that training
and quality control be reviewed and strengthened to make sure
that VA is getting the rating decision right for the first
time.
As stated earlier, military members expect PEBLOs to be
more of an advocate. The role of advocacy is key. Most
servicemembers may not realize how complex the disability
adjudication process is and have little time to learn, given
the new time constraints. DAV believes that military members
best interests would be served with greater access to the free
assistance from representatives of VSOs who not only help them
understand the claims' process, but will also act as their
advocates.
Mr. Chairman, that concludes my testimony. I would be glad
to answer any questions you may have.
[The prepared statement of John Wilson appears in the
Appendix]
Mr. Runyan. Thank you very much.
Mr. Riley.
STATEMENT OF PHIL RILEY
Mr. Riley. Chairman Runyan, Members of the Board,
Subcommittee, rather, Wounded Warrior Project welcomes this
opportunity to share our views in the Integrated Disability
Evaluation System, IDES.
As a Senior Benefits Liaison with Wound Warrior Project, it
is my privilege to represent wounded, injured and ill as they
go through the IDES leading to military retirement, separation
or possible return to duty.
Wounded Warrior Program recognizes that VA and DoD staffs
have worked hard to improve disability evaluation process. We
have seen some improvement, but much more work needs to be done
to realize the goals set for IDES.
As we see it, VA is meeting its commitments to IDES, but
DoD has more work to do. IDES was created as a streamlining
effort to replace separate DoD and separate VA medical
evaluations and disability ratings. The goals were to create a
less complex non-adversarial system that was faster, produced
more consistent evaluations and compensation and led to a
seamless transition from military to civilian life. In large
part these critical and important goals have not yet been
achieved.
IDES begins with the warrior being referred to a Medical
Evaluation Board or MEB for short. A board of several medical
officers charged with evaluating, if the warrior is able to
meet medical retention standards and return to full duty. When
MEB determines that the warrior does not meet retention
standards, it makes recommendation to the final deciding
authority, the Physical Evaluation Board or PEB.
The MEB's findings are documented in a narrative summary
called the NARSUM. That summary (NARSUM) becomes the most
important evidence the PEB uses. But in doing its work, the MEB
does not examine or usually does not even meet with the
servicemember.
In our experience the critical summary the MEB prepares is
often incomplete and inaccurate, and the servicemember has
limited time to review and challenge the MEB summary. As a
result, critical errors frequently go uncorrected.
Allow me to share a case study from case experience of one
of many wounded warriors we have worked with to illustrate some
of these problems. The Army officer sustained a penetrating
head injury in Iraq. Early in the course of his rehabilitation,
he and his wife were pressured into signing papers and rushed
him into the MEB and cut short some treatment.
The NARSUM ultimately prepared by the MEB failed to include
any description of the officer's day-to-day functional
impairment. Instead, it simply listed medical conditions. Even
at that, one of those conditions, loss of the use of an arm was
omitted from the critical document.
Later, the warrior transition unit he was assigned to
actively discouraged him from appealing the PEB decision as
``that would slow the process down.'' Their experience
illustrates that IDES is subject to troubling, disruptive
pressures.
Overall, this profoundly wounded officer was prematurely
pushed into a Medical Board process that produced a deeply
flawed decision document that led to an erroneous decision and
ultimately a lengthy but fortunately successful appeal.
A less experienced young warrior with similar injuries and
without the expert representation this officer secured might
have fared much differently. It would be a mistake to judge
IDES solely by reference to timeliness. That would overlook the
dangers of moving too quickly, focusing only on the major
unfitting conditions, at the expense of all medical conditions.
Moving quickly often results in erroneous rating decisions and
in servicemembers not getting needed medical care.
IDES is highly vulnerable to quality control issues,
incomplete exams, exam reports that fail to include new
diagnosis, incomplete or insufficient NARSUMs and missing
critical documentation.
MEBs often don't have the time to review a warrior's
medical records or do needed research on depth. The NARSUMs too
often are not fully developed, not comprehensive and
inaccurate, and too often fail to identify and fully document
all of the warrior's medical conditions or minimizes them.
These problems are often due to pressures to move cases along
but errors ultimately prove harmful to the warrior. Wounded
warriors and caregivers themselves generally are both poorly
informed and under represented in navigating IDES.
In theory, the PEBLO, that is Physical Evaluation Board
Liaison Officer, should close any information gaps. In reality
some of those liaison officers don't fully understand the
system themselves and have such large caseloads that they can't
provide adequate assistance to everyone.
Also, there is considerable variability in the JAG's
expertise on the IDES and there are just not enough JAG
officers with necessary expertise.
For recommendations, the Wounded Warrior Project has a
number of recommendations to offer to more fully realize the
goals set for IDES. We urge the Committee to work with Armed
Services Committee to spur the executive branch to make needed
changes.
High among the recommendations in our written submission,
we urge that DoD be directed to re-engineer and institute
quality controls on its part of the IDES process.
In conclusion, today, almost five years after the
bipartisan commission called for streamlining the complicated
Disability Evaluation System, the goals and vision for that
system have yet to be realized.
Thank you for this opportunity to testify.
[The prepared statement of Phil Riley appears in the
Appendix]
Mr. Runyan. Thank you very much.
Mr. Greitens, you are now recognized.
STATEMENT OF ERIC GREITENS
Mr. Greitens. Thank you. Mr. Chairman, Congressman
Carnahan, Members of the Subcommittee, thank you for the
opportunity to testify this morning as the Founder and CEO of
The Mission Continues. The Mission Continues is a national
nonprofit organization that challenges veterans to serve and
lead in communities across America.
We believe that any system that is designed to create
successful transitions for veterans, will only work if veterans
are recognized for the immense abilities that they bring back
to their communities. We have learned that by focusing on these
strengths, despite some of the most severe disabilities, we can
facilitate successful transitions from warrior to citizen.
As a Navy SEAL, I served four tours in the Global War on
Terrorism. On my last deployment in Iraq, my unit was hit by a
suicide truck bomb. I was treated at the Fallujah surgical
hospital and returned to full duty 72 hours later, but some of
my friends--some of whom were standing an arms length from me--
were hurt far worse than I was.
When I returned home, I visited them and went to Bethesda
Naval Hospital to visit other wounded servicemembers. When I
asked them, ``What do you want to do when you recover,'' each
one of them said, ``I want to return to my unit.'' Their bodies
had been injured, but their spirit of service had endured.
My experience at Bethesda that day was not unique. In a
recent survey of post-9/11 veterans, 92 percent strongly agreed
or agreed that serving their community is important to them.
At The Mission Continues we create successful transitions
by challenging veterans to continue their service and engaging
them in six-month fellowships at nonprofit and public service
organizations in their communities. Today, an Army specialist
from the 82nd Airborne now trains service dogs for the
disabled; an airman now serves at a women's shelter; a Marine
Corps sergeant now builds homes with Habitat for Humanity.
During their fellowships, our veterans are provided with
stipends and mentors, and are engaged in a comprehensive
curriculum designed to achieve one of three post-fellowship
goals. They go on to full-time employment, full-time education,
or participate in an ongoing role of service in their
communities. To date, we have awarded fellowships to 255 post-
9/11 veterans, who have served with 168 organizations across
the country.
For example, in Mississippi County, Arkansas, Anthony Smith
served his fellowship working with under-privileged youth. In
2004, Anthony was serving as a major in the Army when he was
hit by a rocket-propelled grenade. After spending 64 days in a
medically induced coma, he awoke to find that he was blind in
one eye, had lost his right arm underneath the elbow, and that
parts of his leg, hip and spinal cord were damaged. Like many
of the veterans that we work with, his transition was
difficult, and he started to doubt whether or not he was needed
here at home.
After Anthony became a Mission Continues Fellow, he found a
renewed sense of purpose. Through his fellowship, Anthony is
using martial arts to mentor at-risk youth. Using pushups,
modeling patience, and teaching self-control, Anthony teaches
character lessons to dozens of students every day.
In two independent research reports, the George Warren
Brown School of Social Work at Washington University has found
that nearly 80 percent of the participants in our program
reported that serving in the community had a positive effect on
their future employability, performance, and promotion; 86
percent of participants reported transferring their military
skills to civilian employment; and 100 percent of fellows
reported that they will probably or definitely stay involved in
volunteer activities and public service in the future.
Mr. Chairman, Congressman Carnahan, the story of this
generation of veterans is still being written. Some have a
tendency to rely on PTSD figures, unemployment statistics, and
suicide rates to tell us how our veterans are transitioning.
But these statistics do not tell the whole story. These
statistics do not capture a veteran's desire to continue to
serve and their willingness to lead in communities upon their
return.
They do not tell the story of Shawn, an Army veteran who is
now a youth football coach in Massachusetts, or April, the Army
veteran who serves as a mentor to refugee children in the
Chicago classrooms.
Across America veterans are serving again. In fact, the
majority of the members in this Committee have Mission
Continues fellows serving in their district or neighboring
districts. And last year, with our fellows as examples, The
Mission Continues engaged over 15,000 Americans to spend a day
of service with veterans in their communities. Our Mission
Continues fellows are enduring leaders who have overcome pain
and turned it into wisdom. They are veterans whose commitment
to our country did not end on the battlefield.
In order for veterans to transition successfully,
communities across America must begin to recognize the service
they still have to give. We believe that when the story of this
generation of veterans is written, it will not only be a story
of the wars they have fought overseas; it will also be a story
of the homes built, the parks restored, the young minds engaged
by veterans whose mission continues here at home.
Mr. Chairman, we are grateful for your support and the
support of this Subcommittee. I would welcome any questions
that you or other Members may have. Thank you.
[The prepared statement of Eric Greitens appears in the
Appendix]
Mr. Runyan. Thank you, Mr. Greitens. I appreciate that. I
thank you for your service and what you are doing to help our
servicemen and women. On a personal note, I am fortunate enough
to have in my district office a wounded warrior. I would say
she is probably one of the top employees we have around there
and she deals with all of our veterans case work.
Mr. Greitens. Yes.
Mr. Runyan. And does a very good job at it. So I agree with
pretty much everything you said.
Mr. Greitens. Thank you.
Mr. Runyan. Especially as to on how motivated these
individuals are, and how giving and service oriented they are.
Mr. Greitens. Yes.
Mr. Runyan. Mr. Wilson, I have a question for you. Do you
think the VA and DoD have adequately taken the recommendations
of the various Commission reports into account and of those
recommendations, which of those recommendations have or have
not been implemented?
Mr. Wilson. There are certainly a number of recommendations
that the Commission has put forward. One of the ones that we
were most concerned about had to do with the single
comprehensive exam, letting the VA, in fact, do what they do
best, which is evaluate disabilities and provide overall rating
examinations. They have now done that and generally it seems to
be an effective program. There continues to be concerns with
the DoD and VA staffing levels for physicians in order to make
sure the exams are being timely that the narrative summaries
are fully developed by the DoD, and again that there are a
sufficient number of physicians on staff to make this as timely
as possible.
The other issue is JAG representation. It is critical for
an individual to know their legal rights. You have to have a
sufficient number of JAG officers, Judge Advocate Generals, to
advise personnel about what those rights are. They may not
fully understand them, and that is a concern to us. The
staffing levels of the PEBLOs is also a concern because they
need to have a certain number of PEBLOs in order to manage the
cases.
PEBLOs are asked to address issues that are cross
functional which leads to some of the problems that I alluded
to in my testimony.
Mr. Runyan. And in talking about knowing your rights,
whether it is getting to a JAG or dealing with a PEBLO, do you
see the possibility of the VSO having a role in that?
Mr. Wilson. Yes, sir. In my written testimony, I highlight
some statistics that we had for DAV exclusively and other
Veteran Service Organizations could provide additional
information I am sure.
We have seen a steady decline in the number of individuals
we have represented over the years since the implementation of
the IDES program. Now, that may be as a result of individuals
thinking that a 30 percent disability rating with VA is good.
It gives me retirement so I move on.
Our concern is that 30 percent may not be an accurate
rating of their disabilities and some of those individuals who
may have gotten a 10 or 20 and severance pay instead, may not
have received an accurate rating of disabilities either. It
depends on what information you provide and how well it is
documented in your medical record, of course.
Veterans Service Organizations can advise military members
on the IDES and are excellent at doing so. That is DAV's forte,
as a matter fact.
Mr. Runyan. Thank you.
Mr. Riley, if you could identify one fundamental problem
with the IDES program that should be addressed immediately,
what would that be?
Mr. Riley. The NARSUM preparation needs much better quality
control by DoD and the Services.
Mr. Runyan. Okay. In dealing with how the VA and the DoD,
and the contrast between recovering warriors that have the long
delays and those others that are expedited right through it,
how do we bring that gap together where it is more consistent,
because obviously some of them do need to be expedited, but
there is always going to be a breakdown there and try to,
obviously cut that down--I think you mentioned or someone in
the other panel mentioned we would like it to be at 100 days if
we could. How do we get there?
Mr. Riley. I think that is a question that the medical
command has to come to grips with but basically if there are
serious conditions, not just unfitting conditions that need
treatment, the treatment should be given, and there should be
some control over that, instead of just pushing them through as
soon as they have gotten identified as unfitting or several
unfitting conditions and making it go fast at that point. The
other thing, of course, is getting good advice to some of the
people to make sure they make the most of their medical
treatment availability, don't miss their appointments and
administrative things of that nature.
Mr. Runyan. Thank you. Mr. Greitens, I just have one
question for you, specifically because you deal with a lot of
these wounded warriors day in and day out. What is the feedback
you get from them about this program?
Mr. Greitens. Sir, generally, with this program there has
been a lot of----
Mr. Runyan. Is your mic on?
Mr. Greitens. Yes, sir. Yes, sir. With this program, what
we have seen from a number of veterans, certainly a broad
spectrum of responses, but I think with many of the veterans
there has been frustrations, though with this process, and the
frustration, sir, is that as they are coming back, it is not
just dealing with the system for getting a solid disability
rating. The larger point is that there is not a clear avenue
for them out of this process, so there in a disability process.
But the question is, of course, for them, what comes next.
Our answer at The Mission Continues is that you can
continue your service to your country as you come back, and of
course we need to have answers to them both around employment
and education.
And what we believe is that in order for this transition
process to be successful, what those veterans have to see very
early on is that there is this light at the end of tunnel, and
one of the things that I would recommend, we found that
oftentimes the very best people who can actually advocate for
and work with wounded veterans are oftentimes wounded veterans
themselves because they have been through the process, they
have lived through it and one of the things that they can also
offer to their colleagues is some hope that at the end of this
process there is a way to turn this pain into wisdom, there is
a way to turn the suffering and the strength, and there is a
way for them to continue their mission of public service to
their country, sir.
Mr. Runyan. Thank you very much.
Mr. Greitens. Yes, sir.
Mr. Runyan. Mr. Carnahan.
Mr. Carnahan. Thank you, Mr. Chairman. I want to start with
Mr. Wilson and Riley and really follow up on the things you
touched on about getting a good advice and to what extent that
you mentioned, Mr. Riley, the shortage of JAG officers, but
also, Mr. Wilson, you mentioned the legal counsel that is
available through your organizations. How are those coordinated
and are there ways that that can begin, try to maximize the
resources that are out there to be sure they are getting that
good advice in the process?
Mr. Wilson. To address the issue of access to Disabled
American Veterans, representatives or other certified Veteran
Service Organizations, we know when we look at the guidance
currently available from DoD and VA, the VA and Military
Services Coordinator, his task, as I said in my testimony, with
the task of letting you know you have an interest, that there
are VSOs who can assist you.
Having an interest is a concern to us. If a person is
rather passive in their discussion, the VA Military Services
Coordinator may not pick up on the fact that, yes, they would
like to know about this, so we would prefer that it would be
very direct information sharing from the VA's Military Services
Coordinator. We also believe strongly that the PEBLO who is
supposed to be key to driving the train on the DoD side of this
process, also clearly lets them know that Veteran Service
Organizations are available to assist them as well. You don't
have to be a veteran in order to get Veteran Service
Organization representation and that shift thinking of someone
on active duty versus thinking of themselves as soon to be
veterans may be a part of a problem. As individuals are going
through this IDES process which is new to them, they are
learning as they go. They get many months of training through
the various military specialties but they don't get very many
months of training when it comes to the IDES process, They are
focused first, getting healthy. Later in the healing process
they focus on, what they are going to do when they get out of
the military. In trying to make that transition they then come
to understand they need legal representation which we can
provide.
Mr. Carnahan. And let me ask Mr. Riley to respond as well.
Mr. Riley. Well, I find that oftentimes when I meet Wounded
Warriors families and the warriors in the wards that they
really want to know something about the benefits process, but
they don't know who to ask, and they don't get information
right up front.
First of all, I think, when you have got seriously wounded
people, you need to get information right up front and we do a
number of bedside briefings and what have you if we are allowed
to.
The PEBLO gives basically a PowerPoint briefing to the
servicemember, and unfortunately most of the time we don't get
engaged until we have been called in by someone who is
concerned about their narrative summary and also they don't
take advantage of the JAGMEB/PEB Officers. There are some good
JAGs and real trusted JAGs out there now, but there weren't a
few years ago, and soldiers tend to resist, thinking that they
have got a lawyer that is not on their side when it is a
government lawyer, but now they actually have MEB and PEB
lawyer JAGs that are very helpful. I have worked several cases
in conjunction with JAG officers and that has worked very well.
So what I would finally say is if the Department of Defense
would encourage and bring us on to do more, we could really
help with the success of the IDES process.
Mr. Carnahan. Thank you. Let me turn to Mr. Greitens. You
mentioned this avenue out of the process which I think
obviously is a critical component. What is the biggest
challenge that you have found for your fellows in being able to
get to that avenue?
Mr. Greitens. Yes, you know, well, Congressman, one of the
challenges is, is to make sure that as a community
organization, that we have the opportunity to work with men and
women who are interested in this program. Over 50 percent of
our recommendations are coming from Mission Continues Fellows
and Mission Continues alumni who are saying to their
servicemembers, saying to men and women who they are in the
hospital with, this really changed my life, you should get in
touch with The Mission Continues.
We have, at present, a number of excellent advocates,
individuals in the VA system who have seen their patients go on
to become Mission Continues Fellows. But one of the challenges
at present is that for an organization like The Mission
Continues or other organizations that offer services to help
veterans make this transition, there is no central way to
become accredited as a high quality service organization that
can actually work within the DoD and the VA.
And so what happens is that for many small nonprofit
organizations who might have a national footprint but don't
have the ability to go to every military base around the
country, right now you would have to get an individual
memorandum of understanding to work on that base.
One of the things that would be incredibly helpful is if
there is a joint VA and DoD process that could accredit
organizations who are often very high quality services. As you
know, Congressman, there also is a great number of veterans
organizations that are out there. Not all of them provide high
quality services, and so if the VA and the DoD create an
accreditation process, it would help these organizations to get
that accreditation. It would kind of serve as a way to certify
organizations who could help with this transition.
Mr. Carnahan. Thank you.
Mr. Greitens. Yes, sir.
Mr. Carnahan. I have got a couple more that I want to ask
you about and that Chairman has given me leave to ask a few
others.
Mr. Greitens. Yes, sir.
Mr. Carnahan. But to your point.
Mr. Greitens. Yes, sir.
Mr. Carnahan. About the VA and DoD, the role that they are
playing in helping to do that now, and sort of where is that
room for improvement, if you could elaborate on what you just
talked about.
Mr. Greitens. Yes, sir. I think just to elaborate and what
I would like to see is a joint process by which the VA and the
DoD come up with a certain criteria that organizations need to
meet in order to be accredited to provide services to
servicemembers and returning veterans. Currently, that process
oftentimes varies from base to base. It can sometimes vary from
hospital to hospital.
And so, in the same way The Mission Continues today, it is
a Better Business Bureau accredited charity. The Better
Business Bureau has 20 standards that we have to meet in order
to get that accreditation. I think there is some room here for
the Secretary of the VA and the Secretary of Defense to put
together a joint Committee which would then say these are the
standards that organizations have to meet in order to be
welcome both on military bases and in VA institutions.
Mr. Carnahan. I think that is a great idea and I think it
is a conversation really worth digging into. And also I wanted
to follow up and ask within what you do, do you see actions
that Congress could do to better assist community-based
organizations like yours to again help with this transition?
Mr. Greitens. Thank you, Congressman. I think there are
probably two things that Congress can do. One is, I think,
because of the sort bully-pulpit power that individual members
have, Congress has, that this Subcommittee has, I think it is
very important for us to get the message out to the public
about the capabilities that this generation of veterans has.
Too often when people think about veterans, if you pulled ten
people off of the street right now and you asked them to give
you their top ten words about veterans, they would certainly
say service, they would certainly say honor. But somewhere in
that list of ten, they would also say post-traumatic stress
disorder, they would say traumatic brain injury, they would say
unemployment, they would say suicide.
And I believe, Congressman, that we have a battle on our
hands right now to determine what the future, what the legacy
of this generation of veterans is going to be. So first, I
think there is a kind of bully pulpit function of individual
congressmen going out and talking about the wounded warriors
who they have, who are doing incredible work, and let us get
that message in front of the public about the capabilities that
these men and women have.
Secondly, my team and some of our other partners in the
veterans service space right now are exploring ways that we
might actually engage with existing Federal programs, existing
Federal dollars that would help to enable veterans to begin to
serve again in their communities.
Our plan is to do this research and then come back to you,
Congressman, and come back to the Subcommittee with a set of
recommendations about how Congress could actually help to
facilitate veterans coming home and continuing to serve in
their communities and executing these successful transitions,
and we welcome the opportunity to follow up with your staff and
the staff of this Subcommittee on those ideas. Thank you so
much.
Mr. Carnahan. Thank you.
Mr. Runyan. I just have one final question, for Mr. Wilson.
In your written testimony, you stated that overall satisfaction
rates are higher in the IDES program than the legacy DES
program. Other than improved processing times, specifically
what else is there that is moving that line?
Mr. Wilson. I think it would be interesting to see what the
individuals who are going through the processes themselves have
thought thus far. If I recall correctly, they would like to
have a better understanding of who their advocate is in this
process, who is that person. How would the DoD and the VA go
about improving this so that it is very clear to an individual
that their advocate is going to be a certain single individual
that they can go to? That is one area, I think, that is of
great interest to us, and we would hope that the briefings are
provided are not death by PowerPoint, but in fact but are given
by PEBLO's who are well trained and understand the process well
enough to explain IDES clearly.
So quality control of the work done by PEBLOs or a Military
Services Coordinators, or others, requires continued review and
assessment.
Mr. Runyan. I was looking to end on a positive note, other
than the speed at which we do it, of the new system, what would
that be, or isn't there one?
Mr. Wilson. Oh, are there positives with new system besides
the speed? Yes, sir. We are very pleased with the fact that we
now have a single comprehensive exam done by VA, since they are
experts in this area of providing disability ratings. It is
much more efficient than it was previously and the combining of
efforts and eliminating repetition or competition between the
DoD and VA. No longer are disability ratings done by the DoD
and then by the VA taking out unnecessary steps in this
process. That has made a significant improvement. Timeliness
has improved as well, and I think satisfaction rates are higher
with this program, as a result of those kinds of modifications.
Mr. Runyan. Thank you. You don't have any questions, do
you?
I want to, gentlemen, on behalf of this Subcommittee, I
want to thank each of you for your testimony and we welcome
working closer with you in addressing these issue that have an
enormous impact on our American veterans and you all are
excused now. I recognize Mr. Carnahan for a closing statement.
Mr. Carnahan. Just again, Mr. Chairman, thank you for your
leadership on the Committee and I want to thank our witnesses,
all three panels today. This is, I think, been a really good
overview. Some really good positive ideas have come out of this
and we really look forward to working with you to be sure we
can get these implemented. Thanks again.
Mr. Runyan. With that, I ask unanimous consent that all
members have five legislative days to revise and extend their
remarks and include any extraneous material.
Hearing no objection, so ordered. I thank the members for
their attendance today, and this hearing is now adjourned.
[Whereupon, at 12:59 p.m. the Subcommittee was adjourned.]
A P P E N D I X
----------
Prepared Statement of Hon. Jon Runyan, Chairman
Remarks
Good morning and welcome everyone. This oversight hearing of the
Subcommittee on Disability Assistance and Memorial Affairs will now
come to order.
We are here today to examine the current framework in the ongoing
efforts to streamline the transition process between active duty
soldier to veteran.
The lynchpin of this streamlining process has been the
implementation of the Integrated Disability Evaluation System,
otherwise known as ``I.D.E.S.'' This program was created in December
2007 following the recommendations of the Veterans' Disability Benefits
Commission, and the President's Commission on Care for America's
Returning Wounded Warriors, otherwise known as the Dole/Shalala
Commission.
I.D.E.S.'s goal is to improve the timeliness, effectiveness, and
transparency of the former legacy DES review process, which had been in
place for 60 years prior. In October of 2010, VA and DoD worked in
concert to begin the permanent shift to I.D.E.S around the country in
139 locations. The ultimate objective remains to fully close the gap
which occurs between separation from active duty service and receipt of
VA benefits and compensation.
I am pleased to see progress being made to meet this objective
under the new system, specifically, helping to cut the transition time
between active duty and veteran status. However, there are several
issues and unforeseen problems which need to be addressed.
First, issues with processing times remain problematic. Whereas
some Recovering Warriors experience lengthy delays in their attempt to
navigate through the IDES system, others are rushed through without
receiving the proper medical attention that they need.
Second, many Recovering Warriors report that they find the IDES
process to be extremely confusing and difficult to understand. Further
efforts must be made to work directly with our Recovering Warriors to
ensure that they are making the right decision for themselves, their
families and their futures.
Finally, IDES is not as simple in practice as the various
Commission Reports were hoping it would be when it was first proposed.
Now, nearly five years after its inception, it is important for both VA
and DoD to continue evaluating the system and their efforts to achieve
its goals of increasing transparency, improving consistency, and
eliminating duplicate processes.
As a new generation of active duty servicemen and women return home
from conflicts oversees, we must be prepared to meet our commitment to
see that their transition to civilian and veteran life is as efficient
and simple as possible. It is our duty to see that their service is
honored as best as our resources will permit.
It is my hope that this oversight hearing will shed some light on
some of the problems we have encountered in the implementation of IDES
so that we may work together to find the best solutions possible.
I want to thank the VA, the DoD, the present VSOs, Dr. Wilensky,
Mr. Fisher, and General Scott for their valuable input as we work
together to find important solutions.
I welcome today's witnesses and would now call on the Ranking
Member for his opening statement.
Prepared Statement of Hon. Jerry McNerney,
Ranking Democratic Member
Thank you, Mr. Chairman. I would like to thank you for holding
today's hearing.
The purpose of this hearing is to focus on the transition process
of servicemembers to veterans, with a particular focus on the
implementation of the Integrated Disability Evaluation System (IDES), a
joint VA/DoD examination and records integration effort initiated in
2007 as a result of the fallout from deplorable conditions and
disjointed care of Wounded Warriors at Walter Reed Army Hospital.
This hearing will allow us to not just assess the effectiveness of
the Integrated Disability Evaluation System (IDES), but other
components of the Pre-Discharge Program established by the Departments
of Defense (DoD) and Veterans Affairs (VA), and to streamline
servicemembers' transition from active duty to veterans' status.
Today's discussion on IDES also follows up on our work implementing
the Veterans' Benefits Improvement Act of 2008, Public Law 110-389,
which also paved the way for a number of initiatives targeting the VA
claims backlog.
In 2007, the Dole-Shalala Commission, set recommendations for the
care of wounded warriors, and concluded that it is not enough to merely
patch the system for transition to civilian life, as has been done in
the past. The experiences of our men and women returning home
complaining about a lack of a clear outline of the access to care,
benefits, and services available to them highlighted the need for
fundamental changes in the care management and disability systems.
The Dole-Shalala findings marked the siren call for the creation of
the Disability Evaluation System--a joint effort between DoD and VA to
move to a one-exam platform, which today we know as the Integrated
Disability evaluation System or IDES.
We must make every effort to focus our resources toward assisting
transitioning servicemembers with the comprehensive, coordinated care
and benefits they deserve. This must occur at the very beginning of a
servicemember's reintegration.
To this end, any member of the Armed Forces who has seen active
duty--including those in the National Guard or Reserves--is eligible to
apply for VA disability benefits prior to leaving military service
through the Benefits Delivery at Discharge, Quick Start, or IDES pre-
discharge programs.
During the application process, servicemembers can get help in
completing forms and preparing other required documentation from VA
personnel located at their bases. Additionally, IDES combines the
health exam required by the DoD upon exiting the military and the VA
disabilities assessment exam into a single process, albeit for
different purposes.
In the meantime, in an effort to provide even greater transition
assistance, more elements and players, like the Federal Recovery
Coordination Program have been added to assist our wounded warriors.
I know the intent of these programs are well-meaning, and have
helped numerous veterans across the country. But I still hear from
veterans in my district who have gone through these programs, and
continue to experience significant delays, confusion and other problems
with effective reintegration.
In fact, to that end, I would like to mention that Mr. Barrow has a
helpful bill pending before the Health Subcommittee, H.R 3016, that
would improve reintegration efforts and require that the Federal
Recovery Coordination Program operate jointly under both DoD and VA.
Since its full implementation at the end of 2011, IDES has been
expanded from 3 military bases to more than 139 sites globally and
nationally.
With the drawdown of troops over the next few years, I am
particularly concerned by the fact that the average processing times
takes 400 days, and that there are about 200,000 servicemembers already
in the system. We don't need another backlog and want to avoid that
outcome at all costs.
I look forward to having an open dialogue with the panels here
today, and with my colleague, on ways to overcome challenges within the
IDES system, and accelerate processing without sacrificing quality.
Separating servicemembers should not wait more than a year for their
assessments and benefits.
It is my hope that through our examination of the IDES and other
pre-discharge programs today, coupled with the electronic integration
and other business reformation efforts accomplished over the last few
years, we will continue to improve and transform today's VA claims
processing system and help our servicemembers successfully transition
back into our communities. And NOT into another backlog.
I look forward to hearing from all of our esteemed witnesses. Thank
you, Mr. Chairman. I yield back.
Prepared Statement of Hon. Russ Carnahan
Thank Chairman Runyan and Ranking Member McNerney for recognizing
me here today.
This isn't the normal Subcommittee that I sit on, but today I am
proud to have an organization from my district that I've had the
pleasure of working with testifying before this Committee. I'd like to
use my opening remarks to recognize and introduce to the Committee Eric
Greitens of the Mission Continues.
The Mission Continues is truly a remarkable organization that
empowers veterans to transform their lives and the lives of others by
participating in community service fellowships. These Mission Continues
fellows serve six months at community non-profit organization and
afterwards either obtain full-time employment, pursue higher education
or a permanent role of service. This is truly a remarkable program that
not only gives veterans a much needed sense of purpose following
military service, but also eases an often extremely difficult
transition to civilian life.
And as an organization that is run by a Navy Seal and many former
members of the military, the Mission Continues has a keen understanding
of the many challenges facing our servicemembers when they return home.
As this organization continues to make this model more accessible and
available to veterans across our country, my colleagues and I stand
ready to continue to support them in this life-changing work.
With that, Mr. Chairman, I again thank you for recognizing me, and
I look forward to hearing the testimony of not only the Mission
Continues, but the other organizations who are present here today to
talk about this important issue.
Prepared Statement of John P. Medve
Good morning Chairman Runyan, Ranking Member McNerney, and Members
of the Subcommittee. My name is John Medve, Executive Director of the
Department of Veterans Affairs (VA) Office of VA-DoD Collaboration
within VA's Office of Policy and Planning. I am pleased to be joined by
Mr. Jim Neighbors from the Department of Defense (DoD). My testimony
will focus on the status of the transition process from DoD to VA, with
an emphasis on the Integrated Disability System (IDES), the Federal
Recovery Coordination Program (FRCP), and Veterans Affairs Schedule for
Ratings Disabilities (VASRD) modernization. I will provide the
Subcommittee with an overview of the status of the IDES, the process
used to transition the wounded, ill, and injured who are unfit for
continued military service. I will also provide an overview of care
coordination efforts designed to assist severely wounded, ill, and
injured servicemembers and Veterans through recovery, rehabilitation,
and reintegration as it relates to the FRCP, and explain how VA and DoD
are communicating about additions and revisions to the VASRD.
Integrated Disability System (IDES)
VA and DoD's joint efforts have resulted in improvements and
created an integrated disability process for servicemembers who are
being medically retired or separated.
Much has been accomplished to improve the DoD disability process in
the wake of the issues identified at the Walter Reed Army Medical
Center in 2007. In early 2007, VA and DoD partnered to develop a
modified, integrated Disability Evaluation System (DES) and a DES Pilot
was launched in November 2007. This new, joint process was designed to
eliminate the duplicative, time consuming, and often confusing elements
of the separate disability processes within VA and DoD. The goals of
the joint process were to: (1) increase transparency of the process for
the servicemember; (2) reduce the processing time; (3) improve the
consistency of ratings for those who are ultimately medically
separated; and (4) reduce the benefits gap that existed between the
point of separation or retirement and before receipt of VA disability
compensation. Authorization for the DES Pilot was included in the
National Defense Authorization Act for Fiscal Year 2008.
The DES Pilot was launched at three operational sites in the
National Capital Region (NCR): Walter Reed Army Medical Center,
National Naval Medical Center, and Malcolm Grow Medical Center on
Andrews Air Force Base. The DES Pilot was recognized as a significant
improvement over the legacy DES process, and, as a result of the Senior
Oversight Committee (SOC) findings and the desire to extend the
benefits of the Pilot to more servicemembers, VA and DoD expanded the
Pilot. By the end of March 2010, the DES Pilot had expanded to 27 sites
and covered 47 percent of the DES population. In July 2010, the co-
chairs of the SOC agreed to expand the DES Pilot and rename it IDES.
Senior leadership of VA, the Services, and the Joint Chiefs of Staff
strongly supported this plan and the need to expand the benefits of
this improved process to all servicemembers. Expansion and full
implementation of IDES was completed by September 30, 2011. Currently,
there are 139 IDES sites operational worldwide, including the original
27 DES Pilot sites.
In contrast to the DES legacy process, the IDES provides a single
set of disability examinations and a single-source disability rating,
used by both Departments in executing their respective
responsibilities. This results in more consistent evaluations, faster
decisions, and timely benefits delivery for those medically retired or
separated. As a result, VA can deliver benefits in the shortest period
allowed by law following discharge thus reducing the ``benefit gap''
that previously existed under the legacy process, i.e., the lag time
between a servicemember separating from DoD due to disability and
receiving his or her first VA disability payment. This also prevents
the servicemember from having to navigate the VA disability system on
his or her own after separation. The DoD/VA integrated approach has
also eliminated many of the sequential and duplicative processes found
in the legacy system. Yet, there is more to be done.
To monitor our overall performance for the IDES process, VA and DoD
track the performance of the core processes on a bi-monthly basis for
the over 25,000 servicemembers in IDES. In addition, VA's Chief of
Staff conducts bi-monthly internal Video Teleconferences (VTCs) with
Central Office and Field Executive staff. VA also has joint monthly
VTCs with both Army and Navy/Marine Corps to discuss site performance
and general collaboration opportunities.
VA is responsible for four core processes within IDES: claims
development, medical examination, proposed rating, and VA benefits. VA
average processing time for VA core processes has decreased from 186
days in February 2011 to 134 days as of February 2012. The VA target
for combined processes is 100 days of the 295 day combined VA-DoD
target. While VA is currently meeting the goals for claims development
and medical examinations, it is still falling short of meeting the
standards for developing the proposed rating and the delivery of VA
benefits. To address these shortcomings, VA assigned additional raters
to Disability Rating Activity Sites (DRAS), increasing the number of
Ratings Veterans Service Representative (RVSRs) to 167 among the three
IDES rating sites in Seattle, Baltimore and Providence, which
represents a 35 per cent increase in personnel. To address the
timeliness of benefit delivery, VA identified a process to receive
servicemember separation data electronically. This functionality is
scheduled to be deployed in May of this year.
Despite the overall reduction in combined processing time achieved
to date, challenges remain and there is room for significant
improvement in IDES execution.
VA and DoD are committed to supporting our Nation's wounded, ill,
and injured Warriors and Veterans through an improved IDES. As such, VA
believes that its continued partnership with DoD is critical and is
nothing less than our servicemembers and Veterans deserve.
Federal Recovery Coordination Program (FRCP)
The FRCP was created in October 2007 in direct response to the
Dole-Shalala Commission's recommendation for improved care coordination
for seriously wounded, ill and injured. The FRCP is designed to work
and interact with existing military and VA health care teams, case
managers, benefit coordinators, other Federal agencies and the private
sector. FRCP provides seamless support from the servicemember's arrival
at the initial Military Treatment Facility (MTF) in the United States
through the duration of his or her recovery, rehabilitation, and
reintegration. The FRCP staff at the policy level coordinates with
their DoD counterparts under the umbrella of the Joint Executive
Council. The FRCP is an integral part of VA and DoD efforts to address
issues raised about the coordination of care and transitions between
the two Departments for recovering servicemembers. Federal Recovery
Coordinators (FRCs) are located in 12 facilities across the country
including four MTFs, two VA Medical Centers, three VA Polytrauma
Centers, and three Wounded Warrior Program offices.
FRCs assist severely wounded, ill, and injured servicemembers,
Veterans and their families through each client's recovery,
rehabilitation, and reintegration. They are Masters-prepared nurses or
clinical social workers who provide high-level care coordination for
their clients. The FRC creates a Federal Individual Recovery Plan
(FIRP) for each client based on the goals expressed by the client, with
input from his or her family and/or caregiver and health care team. To
show greater transparency with servicemembers and Veterans, the FIRP is
available through the eBenefits portal 24 hours a day, seven days a
week. eBenefits is a web-based toll that is now available all
servicemembers and Veterans and currently has over 1.2 million
subscribers. FRCs provide client-centric assistance by coordinating all
clinical and non-clinical care, benefits, and services, that are
aligned with their clients' FIRP goals, regardless of medical
diagnosis, geographic location of injury or illness or place of medical
treatment. Clients remain enrolled in the program as long as there is a
perceived need and benefit to the client. FRCP is unique to other
programs in that once a FRC is assigned to a client, the FRC is the
constant point of contact for that client throughout all transitions.
Veterans Affairs Schedule for Ratings Disabilities (VASRD)
The VA Schedule for Rating Disabilities (VASRD) is the regulatory
framework through which VA provides Veterans with compensation for
diseases and injuries they incur while serving our Nation. It is this
rating schedule that guides the disability rating personnel of VA and
DoD in making the correct determination of the compensation benefit
level applicable for a Veteran's service-connected condition(s). The
VASRD contains disability percentages ranging from 0 to 100% that
translate into monthly compensation for Veterans based, by statute, on
``the average impairments of earning capacity.'' (38, U.S.C., section
1155) VA is proactively updating and comprehensively revising the
entire VASRD, which currently includes 15 body systems. This effort is
the result of an October 2009 Secretarial directive to revise and
update all parts of the VASRD, using current medical science and
econometric earnings loss data. The update process is statutorily
required under Section 1155 of Title 38, which states that ``[t]he
Secretary shall from time to time readjust this schedule of ratings in
accordance with experience.'' VA has partnered with DoD and the
academic community to collaborate on revisions to the rating schedule.
The collaboration involves public forums in which medical experts,
members of the Advisory Committee on Disability Compensation, DoD
officials, Veterans Service Organizations, and other stakeholders
provide input and subsequently form working groups to substantively
revise the rating schedule.
While the public forums and working groups gather input from these
important entities, under title 38 U.S.C., section 1155, VA has
ultimate responsibility for adjustments to the VASRD. The Veterans
Benefits Administration (VBA) has implemented a project management plan
detailing the organizational, developmental, and supporting processes
to modernize the rating schedule by 2016. The plan calls for eight
medical officers and six attorneys to work with the subject-matter
experts and cross-agency working groups as described above. The public
forum and working group system is based on a methodology consistent
with the Institute of Medicine's method of involving medical subject
matter experts across disciplines, agencies, and private sectors.
During this ongoing update process, VBA is engaged in a seamless
partnership with VHA.
The VA remains fully committed to meeting the needs of our Nation's
heroes and their families. VA and DoD are partners and will continue to
work together diligently to resolve transition issues while
aggressively implementing improvements and expanding existing programs.
These efforts continue to enhance the effectiveness of support for
Wounded Warriors and their families. While we are pleased with the
quality of effort and progress made to date with our joint
collaboration, we fully understand our two Departments have a
responsibility to continue to improve these efforts.
Thank you again for your support to our wounded, ill, and injured
servicemembers, Veterans, and their families. This concludes my
testimony and I will be happy to respond to any questions.
Prepared Statement of James G. Neighbors
Chairman Runyan, Ranking Member McNerney, and members of the
Subcommittee, thank you for inviting us to testify before you on the
care and transition of our recovering Service members from the
Department of Defense (DoD) to the Department of Veterans Affairs (VA).
Taking care of our wounded, ill and injured Service members is one of
the highest priorities of the Department, the Service Secretaries and
the Service Chiefs. The 2007 revelations regarding Walter Reed Army
Medical Center were a stark wakeup call for us all. During the past
five years, DoD has worked in tandem with VA to improve policies,
procedures, and legislation that impacts the care of our wounded
warriors.
Due to efforts by both Departments, we have reached important
milestones in improving care for our recovering Service members. These
milestones include a new disability evaluation system and improved case
management that are the result of a programmatic cohesion with VA that
is better than ever before. More so than at any other time in our
Nation's history, separating Service members are greeted by more
comprehensive mental and physical care; by greater opportunity for
education, and by a deeper societal commitment to ensuring their
welfare.
The Department's leaders continue to work to achieve the highest
level of care and management and to standardize care among the Military
Services and with other Federal agencies, while maintaining focus on
the individual.
Disability Evaluation System/Integrated Disability Evaluation System
The genesis of the Disability Evaluation System (DES) was the
Career Compensation Act of 1949, and it remained relatively unchanged
until November of 2007. As a result of public concern and congressional
interest, the joint DoD and VA SOC chartered a DES pilot designed to
create a ``Service member-centric'' seamless and transparent DES. The
DES pilot implemented many of the changes recommended by groups like
the Veterans' Disability Benefits Commission and the President's
Commission on Care For America's Returning Wounded Warriors to the
degree allowed within current law.
The pilot launched at the three major military medical treatment
facilities (Walter Reed Army Medical Center, National Naval Medical
Center, Bethesda, and Malcolm Grow Air Force Medical Center) in the
National Capital Region on November 21, 2007, and successfully created
a seamless process that delivers DoD benefits to wounded, ill and
injured Service members and VA benefits to Veterans as soon as possible
following release from duty. We found the DES Pilot to be a faster,
fairer and more efficient system. As a result, in July 2010, the Deputy
Secretary of Defense and Deputy Secretary of Veterans Affairs directed
worldwide implementation to start in October 2010 and to complete in
September 2011. On December 31, 2010, the pilot officially ended and
the first Integrated Disability Evaluation System (IDES) site became
operational.
The IDES, similar to the pilot, streamlines the DES process so that
the Service member receives a single set of physical disability
examinations conducted according to VA examination protocols, proposed
disability ratings prepared by VA that both DoD and VA can use, and
processing by both Departments to ensure the earliest possible delivery
of disability benefits. Both Departments may use the VA protocols for
disability examination and the proposed VA disability rating to make
their respective determinations. Under Title 10 authority, DoD
determines fitness for duty and compensates for unfitting conditions
incurred in the line of duty, while under Title 38 authority, VA
compensates for all disabilities resulting from disease or injury
incurred or aggravated in line of duty during active military, naval,
or air service for which a disability rating of ten percent or higher
is awarded, and also determines eligibility for other VA benefits and
services. The IDES permits both Departments to provide disability
benefits at the earliest point allowed under both titles. It is
important to point out that Service members who separate or retire
(non-disability) may still apply to the VA for service-connected
disability compensation.
The National Defense Authorization Act (NDAA) for FY 2008, Public
Law 110-181, also required the Department to utilize the VA Schedule
for Rating Disabilities (VASRD). While the Department recognizes that
the VA Secretary has ultimate responsibility and decision authority for
the content of the VASRD, we believe DoD should have more developmental
input, given the direct connection between the VASRD ratings and the
decision to place Service members on the medical retirement list with
annuities, benefits and healthcare. We appreciate VA's outreach to
include DoD in the body system rating update review that began last
year and the Services' participation through their subject matter
experts. DoD plans to continue to participate in VA's public meetings
as DoD and VA leadership continue discussing how to strengthen DoD's
role in the VASRD rewrite process. We look forward to finalizing a
memorandum of understanding with VA, which will formalize DoD's active
voice in the future development and modernization of the VASRD.
In summary, the IDES features a servicemember-centric design, a
simplified process, more consistent evaluations and compensation, a
single medical exam and disability rating, seamless transition to
Veteran status, case management advocacy, and establishment of a
Service member relationship with the VA prior to separation. It also
provides increased transparency through better information flow to
servicemembers and their families and a reduced gap between separation/
retirement from Service to receipt of VA benefits.
As of early this month, IDES enrollment is 24,957 Service members
(66 percent Army, 13 percent Marines, 10 percent Navy, and 11 percent
Air Force). Since November 2007, cumulative enrollment has been 44,451,
with 14,249 completing the process and receiving benefits. Including
Service members who are returned to duty by the process, active
component Service member IDES completion time averages 370 days as of
February 2012, Reserve Component members averaged 358 days, and Guard
members averaged 396 days. These averages are above our targeted goals
but still are significantly lower than the 1940-era legacy system it
replaced.
This past year, the Department partnered closely with the VA to
implement the IDES at all 139 DES sites worldwide; however, we
recognize the need to do better in the areas of timeliness to complete
the process. This year our focus will be on such timeliness
improvements. We have made significant policy adjustments to remove
impediments, implemented procedural improvements, enhanced oversight
and assistance to the Military Departments, and added resources that
should improve Military Department performance in this area, including
increasing legal support to advise and counsel Service members
undergoing disability evaluation. We will continue to enhance our
emphasis on leadership, resourcing and execution of the IDES to handle
increased volume while decreasing the time spent in the process.
The Departments are looking closely at the stages of the system
that are outside of timeliness tolerances and are developing other
options to bring these stages within goal by December 2012 as the
Secretaries of Defense and Veterans Affairs have directed. We are fully
committed to working closely with Congress to explore new initiatives
to further advance the efficiency and effectiveness of the disability
evaluation process.
Recovery Coordination Program
The Recovery Coordination Program (RCP) was established by the FY08
NDAA, and was further defined by the Department of Defense Instruction
(DoDI) 1300.24, entitled ``Recovery Coordination Program.'' The
Department has implemented many of the changes recommended by the
President's Commission on Care For America's Returning Wounded Warriors
to the degree allowed within current law. The FY 2008 NDAA and the DoDI
1300.24 together provide a comprehensive policy on the care and
management of recovering Service members, including the assignment of a
Recovery Care Coordinator (RCC) to help wounded, ill and injured
Service members and families through the phases of recovery,
rehabilitation and reintegration utilizing a Comprehensive Recovery
Plan (CRP) that has been developed in coordination with the Recovery
Team. The policy also provides for standardized training, and a
caseload ratio of not more than 40 recovering Service members per RCC.
Currently, there are 171 RCCs in 84 locations worldwide, placed
within the Army, Navy, Marines, Air Force, United States Special
Operations Command and Army Reserves Wounded Warrior Programs. More
than 3,800 Service members and families have the assistance of an RCC,
whose responsibilities include ensuring the Service member's non-
medical needs are met, and assisting in the development and
implementation of the CRP. An automated solution was developed to
increase efficiencies for RCC's to be able to maximize their time and
service provision to our Service members and their families. Each RCC
receives more than 40 hours of Department-sponsored standardized
training, including information on roles and responsibilities and
concepts for developing the CRP. After the October 2011 training, 90
percent of students rated the instruction and course materials as
``excellent.'' Additionally, we are now beginning to train Army
``Advocates'' in order to bring their program into compliance with the
legislative mandate that every recovering Service member be provided a
DoD-trained RCC. This training is continually enhanced based on
feedback from participants. The Department is committed to ensuring
redundancies are mitigated with other agencies. We believe the Federal
Recovery Coordination Program (FRCP) and the DoD programs are
complementary and if there are perceived redundancies, we do not
believe that is indicative of a problem.
Over the past five years, we have increased the numbers of RCCs
available to provide care coordination to our recovering Service
members, and looking ahead, each Military Service will continue to
identify and resource their requirements for additional RCCs. Following
are descriptions of three priorities that play important parts in
recovering members' recovery process. The RCP has expanded to include
several other portfolios, many of them identified as key priorities for
the non-medical care management of recovering Service members during a
Wounded Warrior Care Coordination Summit held in March 2011.
The Wounded Warrior Education and Employment Initiative (E2I)
operates on a regional basis and engages recovering Service members
early in the recovery process to identify their skills, career
opportunities that match those skills, and any additional skills they
may need for success as they recover and prepare to leave service. The
E2I process relies on collaboration with the Service Wounded Warrior
Programs and the VA, operating under a Memorandum of Understanding to
provide VA's vocational rehabilitation services earlier in the recovery
process than ever before.
The Operation Warfighter program (OWF) works to place wounded, ill
and injured Service members in non-paid Federal internship
opportunities that positively impact their rehabilitation and augment
career readiness by building resumes, exploring employment interests,
obtaining formal on-the-job training, and gaining valuable Federal
government work experience. There are currently more than 500 OWF
interns working in approximately 75 Federal agencies and sub-components
around the country, with a total of more than 2,500 placements in 105
agencies and sub-components since the inception of the program. Going
forward, the Regional Coordinators will continue to focus on local and
regional outreach to strengthen relationships with Federal agencies to
improve and enhance internship and employment opportunities for
wounded, ill and injured Service members.
The Military Adaptive Sports Program engages wounded, ill and
injured Service members early in individualized physical activities
outside of traditional therapy settings, inspiring recovery and
encouraging new opportunities for growth and achievement. This new
initiative is being implemented throughout the Department, in
partnership with the Services and the United States Olympic Committee.
The goals of the program include increasing awareness and participation
in adaptive sports and recreation at the Service-level, preparing
athletes for participation in competitive events such as the Warrior
Games, and providing a seamless transition of participation from this
program into VA's National Veteran's Sports program.
These measures when taken together, substantially and materially
affect the life experience of our men and women in uniform and the
families who support them. Our work to improve the care of recovering
Service members, especially as they transition from DoD to VA, is the
core of our efforts to provide those who have sacrificed so much with
the care and benefits they deserve. Despite the significant
achievements, we should not underestimate what remains to be done as we
care for a new generation of Veterans who have served under very
difficult circumstances for sustained periods. We will continue to work
with our colleagues at VA and throughout the government to provide our
servicemembers with the highest quality care and treatment. Taking care
of our wounded, ill and injured Service members is one of the highest
priorities for the Department, the Service Secretaries, and the Service
Chiefs.
Special Compensation for Assistance with Activities of Daily Living
We recognize the strength of military families and caregivers of
recovering Service members. If a Service member returns home wounded,
ill or injured, the military family and caregiver are the glue that
holds everything together during a Service member's recovery and
transition--which can often be confusing, frightening, and
overwhelming. On August 31, 2011 DoD promulgated policy, authorized by
Public Law 111-84, to compensate all catastrophically wounded, ill, or
injured Service members, with line of duty-related medical conditions,
who needed caregiver assistance to live outside a resident medical
facility or who required supervision to prevent harm to themselves or
others. This policy, enacted through DoDI 1341.12, Special Compensation
for Assistance in Activities of Daily Living (SCAADL), gives qualified
Service members monthly compensation to help offset the economic burden
borne by their primary caregivers providing non-medical care, support
and assistance. As of February 29, 2012, 505 Service members have
received the SCAADL compensation.
Transition Assistance Program (TAP)
Today's Veterans face a number of challenges in making the
transition to civilian life among these is embarking on a productive
post-military career. For every success story of a Veteran who has
turned skills developed in the military into success in the civilian
workplace, there are, as President Obama has said, stories of Veterans
who come home and ``struggle to find a job worthy of their experience
and worthy of their talent.'' We see these struggles most clearly in
high unemployment rates for Veterans. As we draw down from the wars in
Iraq and Afghanistan and we make difficult decisions about our future
force structure in light of the fiscal challenges the Nation faces, the
situation becomes more urgent with the increased number of Service
members--particularly young Service members--departing the military.
Making a firm commitment to employ America's Veterans, in August
2011, the President called for the creation of a Task Force led by the
DoD and VA with and other agencies including the DoL, Department of
Education (DoE), Department of Commerce, Small Business Administration,
and the Office of Personnel Management, to develop proposals to
maximize the career readiness of all servicemembers. In coordination
with our VA, DoL, and DoE partners, DoD's implements and sustains a
comprehensive plan to ensure all transitioning Service members have the
support they need and deserve when leaving the military. This includes
working with other agencies in developing a clear path to civilian
employment; admission into and success in an academic or technical
training program; or successful start-up of an independent business
entity or non-profit organization. The effort is fully aligned with the
VOW to Hire Heroes Act of 2011. It is also consistent with DoD's
commitment for keeping faith with all of our military members and their
families, providing them a comprehensive set of transition tools and
support mechanisms as they complete their service to our Nation.
Interagency Electronic Health Data
The collaborative Federal partnership between DoD and VA has
resulted in increased integration of healthcare services to Service
members and Veterans. DoD and VA spearhead numerous interagency
electronic health data sharing activities and are delivering IT
solutions that significantly improve the secure sharing of appropriate
electronic health information.
Today's interagency health information exchange (HIE) capabilities
leverage the existing electronic health records (EHRs) of each
Department. As both Departments are currently addressing the need to
modernize their EHRs, we are working together to synchronize planning
activities and identify a joint approach to modernization.
Current HIE sharing capabilities do support data sharing between
DoD and VA. The Federal Health Information Exchange (FHIE),
Bidirectional Health Information Exchange (BHIE), and the Clinical Data
Repository/Health Data Repository (CHDR) support continuity of care for
millions of Service members and Veterans by facilitating the sharing of
health care data as beneficiaries move beyond DoD direct care to the
VA. The data shared includes information from DoD's inpatient
documentation system which is in use in DoD's inpatient military
treatment facilities, including Landstuhl Regional Medical Center,
Germany, the evacuation and treatment center Service members pass
through if they have a medical problem while deployed in the current
theater of operations. The health data shared assists in continuity of
care and influences decision-making at the point of care.
Transmission of Data from Point of Separation: At separation, FHIE
provides for the one-way electronic exchange of historic healthcare
information from DoD to VA for Service members who have separated since
2001. On a monthly basis DoD sends: inpatient and outpatient laboratory
results; radiology reports; outpatient pharmacy data; allergy
information; discharge summaries; consult reports; admission/discharge/
transfer information; standard ambulatory data records; demographic
data; pre- and post-deployment health assessments (PPDHAs); and post-
deployment health reassessments (PDHRAs). To date, DoD has transmitted
health data on more than 5.8 million retired or separated Service
members to VA. Of those, approximately 2.3 million have presented to VA
for care, treatment, or claims determination. This number grows
constantly as health information on recently separated Service members
is extracted and transferred to VA monthly.
Access to Data on Shared Patients: For shared patients being
treated by both DoD and VA, the Departments maintain the jointly
developed Bidirectional Health Information Exchange (BHIE) system that
was implemented in 2004. Unlike FHIE, which provides a one-way transfer
of information to VA when a Service member separates from the military,
the two-way BHIE interface allows clinicians in both Departments to
view, in real-time, health data (in text form) from the Departments'
existing health information systems. Accessible data types include
allergy, outpatient pharmacy, inpatient and outpatient laboratory and
radiology reports, demographic data, diagnoses, vital signs, problem
lists, family, social, and other history, questionnaires and Theater
clinical data, including inpatient notes, outpatient encounters and
ancillary clinical data, such as pharmacy data, allergies, laboratory
results and radiology reports.
Use of BHIE continues to increase. As of January 2012, there is
data available on more than 4.3 million shared patients, including over
293,340 Theater patients, available through BHIE.
To increase the availability of clinical information on a shared
patient population, VA and DoD collaborated to further leverage BHIE
functionality to allow bidirectional access to inpatient discharge
summaries from DoD's inpatient documentation system. Use of this
inpatient documentation system at Landstuhl Regional Medical Center
plays a critical role in ensuring continuity of care and supporting the
capture and transfer of inpatient records of care for recovering
Service members. Information from these records including inpatient
consultations, operative reports, history and physical reports,
transfer summary notes, initial evaluation notes, procedure notes,
evaluation management notes, pre-operative evaluation notes, and post-
operative evaluation and management notes are accessible stateside to
DoD providers caring for injured Service members and to VA providers
caring for injured Service members and Veterans. DoD's inpatient
documentation system is now operational at all 59 DoD inpatient sites;
ensuring inpatient documentation is available from all DoD inpatient
beds.
Recent improvements to BHIE include the completion of hardware,
operating system, architecture, and security upgrades supporting the
BHIE framework and its production environment. This technology refresh,
completed in January 2011, resulted in improved system performance, and
reliability.
Exchange of Pharmacy and Allergy Data: The Clinical Data Repository
(CDR)/Health Data Repository (HDR) interface (called ``CHDR'') supports
interoperability between AHLTA's CDR and VA's HDR, enabling
bidirectional sharing of standardized, computable outpatient pharmacy
and medication allergy data. Since 2006, VA and DoD have been sharing
computable outpatient pharmacy and medication allergy data through the
CHDR interface. Exchanging standardized pharmacy and medication allergy
data on patients supports improved patient care and safety through the
ability to conduct drug-drug and drug-allergy interaction checks using
data from both systems.
The Departments have exchanged computable outpatient pharmacy and
medication allergy data on over 1.4 million patients who receive
healthcare from both systems.
Wounded Warrior Image Transfer: To support our most severely
wounded and injured Service members transferring to VA Polytrauma
Rehabilitation Centers (PRCs) for care, DoD sends radiology images and
scanned paper medical records electronically. Walter Reed National
Military Medical Center and Brooke Army Medical Center are providing
scanned records and radiology images electronically for patients
transferring to VA PRCs in Tampa, Richmond, Palo Alto, Minneapolis, and
San Antonio. From 2007 to the present, images for more than 480
patients and scanned records for more than 585 severely wounded
warriors have been sent from DoD to VA at the time of referral.
Virtual Lifetime Electronic Record: The Departments are firmly
focused on enhancing our electronic health data sharing and expanding
capabilities to share information with the private sector through
Nationwide Health Information Network (NwHIN) and the Virtual Lifetime
Electronic Record (VLER). NwHIN will enable the Departments to view a
beneficiary's healthcare information not only from DoD and VA, but also
from other NwHIN participants. To create a virtual healthcare record--
and achieve the VLER vision--data will be pulled from EHRs and
exchanged using data sharing standards and standard document formats. A
standards based approach will not only improve the long-term viability
of how information is shared between the Departments, but will also
enable the meaningful exchange of information with other government
providers and with civilian providers, both of which account for a
significant portion of care delivered to the Departments'
beneficiaries.
VLER is being implemented iteratively through an operational pilot
using incremental sets of functionality. The VLER pilot sites are
demonstrations of exchanges of electronic health information between
VA, DoD and participating private sector providers. The pilot continues
to provide evidence of the power and effectiveness of coordinated
development between the Departments for increasing the secure sharing
of electronic health information while leveraging existing EHR
capabilities. DoD's VLER pilot is underway in San Diego, California;
Tidewater, Virginia; Puget Sound, and Spokane, Washington. In addition,
VA is participating in seven other pilots with the private sector to
expand the VLER capability.
The Integrated Electronic Health Record (iEHR): In 2011, DoD and VA
committed to establishing and refining an integrated electronic health
record (iEHR). The iEHR will enable DoD and VA to align resources and
investments with business needs and programs. Going forward, a joint,
common EHR platform will be implemented. Maintenance of AHLTA and VistA
throughout the deployment lifecycle of the iEHR will ensure continuity
of operations.
DoD and VA will purchase commercially available components for
joint use when possible and cost effective. The iEHR will leverage open
source and traditional approaches to software acquisition to foster
innovation and expedite delivery of products to the user.
The Departments anticipate that iEHR capabilities will evolve from
existing service oriented architecture (SOA) compliant capabilities,
commercial off-the-shelf (COTS), open source, and custom systems. The
use of agile development for the iEHR will allow the Departments to
deliver capabilities to customers at a more rapid pace.
The DoD/VA Interagency Program Office (IPO) serves as a single
point of accountability and execution for the iEHR and VLER Health
initiatives to help ensure synchronization of these efforts.
World-Class Medical Care in the National Capital Region
The Department completed its largest and most complex Base
Realignment and Closure (BRAC) projects in history on time last Fall in
the National Capital Region (NCR). These BRAC projects closed and
transitioned Walter Reed Army Medical Center and inpatient capabilities
at Joint Base Andrews to expanded facilities at Bethesda, establishing
the Walter Reed National Military Medical Center (WRNMMC), and a
replacement hospital at Fort Belvoir (FBCH). Today, wounded, ill, and
injured Service members and their families receive care in 3 million
square feet of world-class new and renovated facilities, with 160,000
new equipment items and the latest medical technologies available.
These BRAC projects were one part of the larger transformation of
Military Medicine in the NCR. The NCR has the largest concentration of
healthcare assets in the Military Health System. It contains a mix of
nearly 40 Army, Navy, and Air Force Medical Treatment Facilities
(MTFs), has 550,000 eligible beneficiaries and 12,000 staff, and runs
on an annual operating budget of almost $1.5 billion. Its primary
medical mission is care for wounded, ill, and injured Service members,
and it receives over 70% of the critical care air transports returning
from theater. In order to reduce redundancies inherent in operating
three separate Service systems and increase effectiveness and
efficiency, the Department directed the establishment of an Integrated
Healthcare Delivery System (IDS) in the NCR to be managed by the Joint
Task Force National Capital Region Medical (JTF CapMed).
JTF CapMed has command authority over NCR MTFs. The presence of
command authority provides a singular authority to drive the
transformational change necessary to control unnecessary duplication
among the Services and to increase interoperability. This improves
responsiveness to our patients by aligning authority, responsibility,
and accountability to a single entity that can make changes necessary
to improve care. As an example, JTF CapMed has consolidated and co-
located appointment and referral processes in the NCR to standardize
appointment and referral processes. This has improved services by
eliminating the confusion of multiple appointment processes at
different MTFs in the NCR and has increased the access to care by
offering appointments at any MTF in the NCR in order to meet patient
needs. The JTF's efforts have saved the Department $109 million through
contract execution and $114 million in cost avoidance through equipment
re-use program. Consolidation of the workforces at WRNMMC and FBCH and
authorities sufficient to implement shared services will enable further
efficiencies and economies of scale that will ultimately result in
contractor and civilian personnel savings of approximately $60 million
per year in fiscal year 2011 dollars.
The NCR also has a specific congressional mandate to provide world-
class healthcare through the NCR IDS. As discussed in the Comprehensive
Master Plan provided to Congress, JTF CapMed is implementing the NCR
IDS to provide more effective and efficient healthcare in the NCR and
is overseeing projects at Bethesda required to achieve the world-class
facility standards required by the NDAA for FY 2010. The President has
fully funded these efforts in his Budget Request for FY 2013.
Post-Traumatic Stress and Traumatic Brain Injury
The VA-DoD Integrated Mental Health Strategy focuses on developing
community organization collaboration and partnerships, such as with the
National Institutes of Health and the American Psychological
Association. Part of this work involves the creation of a network of
experts on mental health issues, to include PTSD, so that there are
coordinated efforts to improve access, quality, effectiveness, and
efficiency of services for servicemembers, veterans and their families
by sharing information and resources that enable partners to stay
current with the changing science base and recommended best practices.
The Substance Abuse and Mental Health Services Administration in
the Department of Health and Human Services (HHS) maintains strong
partnerships with VA and DoD to prepare community behavioral health
care systems to provide trauma informed services that reflect an
understanding of military culture, servicemembers' experiences, the
range of post-trauma effects, and the effects of traumatic brain and
other physical injuries. This is primarily accomplished through
SAMHSA's Service Members, Veterans, and their Families Policy
Academies, through which SAMHSA has provided--and continues to
provide--intensive technical assistance to 23 States, two Territories,
and the District of Columbia to help them enhance their behavioral
health systems.
Additionally, SAMHSA's National Child Traumatic Stress Network
(NCTSN) has developed training materials for behavioral health
providers who encounter veterans or servicemembers with traumatic brain
injury. These materials were developed in collaboration with the VA
Palo Alto Health Care Polytrauma Program. This two-hour comprehensive
training is available through the NCTSN's Learning Center Military
Families.
In addition, to establish a network of public and private sector
expertise in TBI, the Department of Defense has fostered collaboration
with inter-Service working groups (Air Force, Army, Marine Corps, and
Navy) together with other Department centers to include the Defense
Centers of Excellence for PH and TBI and the Defense and Veterans Brain
Injury Center (DVBIC) and the National Intrepid Center of Excellence
(NICoE) and the Department of Veterans Affairs (VA). In addition, other
Federal agencies such as the CDC and NIH have been collaborating
partners to further the field of TBI and leverage expertise held within
each agency. The working groups have further included public sector
expertise through consensus conferences. The collaborative working
group and consensus conference process has worked to define best
practices for diagnosis and treatment of co-occurring disorders
following TBI with focus on mild TBI. The collaborative working group
has developed clinical recommendations for vestibular disturbances,
vision disturbances, and endocrine dysfunction following TBI. These
recommendations are intended to provide guidance to primary care
providers in the MHS regarding the consideration and referral process
for Service members with co-occurring disorders following mild TBI. The
collaborative network efforts also addressed needs in the deployed
setting with the revision of clinical practice recommendations/
algorithms for concussion management in the deployed setting. Finally,
collaborations with professional sports organizations have been
developed to help further common goals of addressing barriers to
seeking care for TBI related issues.
The development of a TBI repository of information for and by
various Federal agencies via the Federal Interagency Committee has
recently been established. This will include the following: mild TBI
Translation (mTBI) Grand Rounds (research to clinical practice) through
collaboration with Johns Hopkins Institutes; development of DoD centric
common outcome measures and/or common data elements in partnership with
US Navy and Marine Corps EpiData Center and the Health Analysis
Department.
The Department and VA have also produced a suite of co-branded
education materials and curricula to train clinicians regarding the
effective use of VA/DoD clinical support tools based on clinical
practice guidelines for disorders such as Major Depressive Disorders,
mild TBI, Co-Occurring Conditions, and Substance Use Disorder.
Additionally, the Department has conducted a needs assessment survey
for Behavioral Health and TBI providers as well as provided guidelines
for training providers in evidence-based best practices for PTSD.
The Department produced materials for insertion into Joint
Professional Military Education based on the Chairman Joint Chief of
Staff's Special Areas of Emphasis. These materials will be used to
provide line leadership with core components for a myriad of topics
including PH and TBI. DoD has added a 60-minute overview of PH and TBI
in the DoD briefing into the DoD APEX Senior Executive Service
Orientation, a two-week requirement for all new executives to the
Department.
The DoD and VA have partnered on the Integrated Mental Health
Strategy, specifically by releasing the Operation Enduring Families
curriculum, information, and support for Afghanistan and Iraq veterans
and their families. The curriculum resides online at VA and Military
OneSource websites. This guide was designed to assist parents, other
family members and health care providers in addressing the mental and
emotional health needs of military children through topic-specific,
age-related, public-domain literature. Additionally, since its rollout
in July 2010, 711 providers have been trained on the Defense and
Veterans Brain Injury Center (DVBIC) family caregiver curriculum, a
congressionally mandated guide that serves as a roadmap for those
caregivers of patients with severe and penetrating brain injury.
In response to the DoD Mental Health Task Force recommendation to
address continuity of care, DoD developed the inTransition program.
This program provides servicemembers experiencing a transition
(location change, change in status or health care system) with a coach
to motivate them to remain in treatment. Available 24/7, these coaches
are master's level clinical staff trained in deployment- and
readjustment- related issues. Between February 2011 and February 2012,
the number of inTransition cases increased from 392 to 1660, an
increase of over 300%. Of the servicemembers referred to the program,
95% accepted the referral and 100% of those who completed a program
survey reported the assistance they received from the inTransition
Program increased the likelihood that they would continue their
treatment.
The Center for Deployment Psychology (CDP), a Uniformed Services
University center, has conducted workshops for civilian providers
throughout the United States. To date over 2300 civilian providers have
attended these weeklong workshops. These workshops include information
on the identification, diagnosis and treatment of PTSD and other
frequently occurring psychological health issues such as depression,
substance use disorders, and suicide. An additional 1200 civilian
providers have attended shorter workshops that train evidence-based
treatments for treating PTSD. TBI is also a topic presented to address
these challenges in Service members and Veterans.
Lastly, the VA and DoD jointly develop Clinical Practice Guidelines
(CPGs) to serve as one means of communicating the state of the evidence
to clinical providers in the field. VA/DoD CPGs are publically
available through either Army Medical Command Quality Management
Division's website (https://www.qmo.amedd.army.mil/pguide.htm) or the
VA's Office of Quality and Safety website (http://
www.healthquality.va.gov/). An expert multidisciplinary panel of VA and
DoD providers developed the VA/DoD CPGs recommendations by conducting a
comprehensive and rigorous review of the currently available studies on
psychotherapy and medication. Since the passage of the NDAA 2008, the
VA and DoD have jointly developed or revised CPGs for Depression, PTSD,
mTBI, Opioid Therapy for Chronic Pain, Substance Use Disorder, and
Bipolar Disorder.
The dissemination of existing TBI clinical guidelines and
recommendations to various involved providers are conducted in various
formats. The most powerful dissemination modality is through the
Service TBI program managers who are leading the 56 Army TBI programs,
6 Navy TBI programs and Air Force TBI teleconsultations and joint
programs. Ongoing resources are provided in the form of a national
level resource fact sheet for military case managers as well as
information and educational opportunities via the Military TBI Case
Management Quarterly Newsletter to promote and advance access to care.
The nationwide dissemination of the Case Management of Concussion/mild
TBI Guidance Document was conducted across the MHS. Technology is
widely utilized to disseminate TBI information as well. The release of
the Mild TBI Pocket Guide mobile application for the iPhone and Android
smartphones and the Co-occurring Conditions Toolkit: Mild TBI
Psychological Health mobile application for the iPhone and Android
smartphones disseminated this information to a new market of users.
Additionally six mTBI web-based case studies via MHS Learn for DoD, the
VA Employee Education System and civilian healthcare professionals have
been released. The web-based case studies use patient vignettes as a
way in which to educate healthcare professionals about the clinical
recommendations contained within the VA/DoD mild TBI/concussion
clinical practice guideline. The technology-based efforts reported more
than 4700 downloads of the Mild TBI Pocket Guide mobile application and
more than 500 downloads of the Co-occurring Conditions Toolkit mobile
application. To improve future efforts of dissemination the Department
utilized the Interactive Customer Service Evaluation to obtain user
feedback.
Conclusion
While we are pleased with the quality of effort and progress made,
we fully understand that there is much more to do. We have, thus,
positioned ourselves to implement these provisions and continue our
progress in providing world-class support to our Service members and
Veterans while allowing our two Departments to focus on our respective
core missions. Our dedicated, selfless Service members, Veterans and
their families deserve the very best, and we pledge to give our very
best during their recovery, rehabilitation, and return to the society
they defend.
Mr. Chairman, thank you again for your generous support of our
wounded, ill, and injured Service members, Veterans and their families.
I look forward to your questions.
Executive Summary
Department of Defense Prepared Statement for House Veterans'
Affairs Committee Disability Assistance and Memorial Affairs
Subcommittee
Hearing on Active, Guard, Reserve, and Civilian Personnel Programs
The IDES features a Service member-centric design, a simplified
process, more consistent evaluations and compensation, a single medical
exam and disability rating, seamless transition to Veteran status, case
management advocacy, and establishment of a Service member relationship
with the VA prior to separation. It also provides increased
transparency through better information flow to servicemembers and
their families and a reduced gap between separation/retirement from
Service to receipt of VA benefits.
As of early this month, IDES enrollment is 24,957 Service members
(66 percent Army, 13 percent Marines, 10 percent Navy, and 11 percent
Air Force). Since November 2007, cumulative enrollment has been 44,451,
with 14,249 completing the process and receiving benefits. Including
Service members who are returned to duty by the process, active
component IDES completion time averages 370 days as of February 2012,
Reserve Component members averaged 358 days, and Guard members averaged
396 days. These averages are above targeted goals but still are
significantly lower than the 1940-era legacy system it replaced.
The Recovery Coordination Program (RCP) was established by the FY08
NDAA. Recovery Care Coordinators (RCC) are assigned to help wounded,
ill and injured Service members and families through the phases of
recovery, rehabilitation and reintegration. Currently, there are 171
RCCs in 84 locations worldwide; more than 3,800 Service members and
families have had the assistance of an RCC.
The Special Compensation for Assistance in Activities of Daily
Living program was established by the FY10 NDAA to provide qualified
Service members with monthly compensation to help offset the economic
burden borne by their primary caregivers providing non-medical care,
support and assistance. As of February 29, 2012, 505 Service members
have received the compensation.
Today's Veterans face a number of challenges in making the
transition to civilian life, and among these is embarking on a
productive post-military career. As a result, the President created a
Task Force led by the DoD and VA to develop proposals to maximize the
career readiness of all Service members. The effort is fully aligned
with the VOW to Hire Heroes Act of 2011 and is consistent with DoD's
commitment for keeping faith with all of our military members and their
families, providing them a comprehensive set of transition tools and
support mechanisms.
The collaborative Federal partnership between DoD and VA has
resulted in increased integration of healthcare services to Service
members and Veterans. DoD and VA spearhead numerous interagency
electronic health data sharing activities and are delivering IT
solutions that significantly improve the secure sharing of appropriate
electronic health information. Today's interagency health information
exchange capabilities leverage the existing electronic health records
(EHRs) of each Department as we both address the need to modernize our
EHRs, by synchronizing planning activities and identify a joint
approach to modernization.
The Department of Defense has fostered collaboration with inter-
Service working groups and Department centers such as the Defense
Centers of Excellence, the Defense and Veterans Brain Injury Center
(DVBIC), the National Intrepid Center of Excellence (NICoE), and the
Department of Veterans Affairs (VA). The collaborative working group
has developed clinical recommendations to provide guidance to primary
care providers in the Military Health System regarding the
consideration and referral process for Service members following mild
TBI and addressed needs in the deployed setting. Collaborations with
professional sports organizations have been developed to help further
common goals of addressing barriers to seeking care for TBI related
issues.
Prepared Statement of Gail R. Wilensky, Ph.D
Mr. Chairman and Members of the Veterans' Affairs Subcommittee on
Disability Assistance and Memorial Affairs: Thank you for inviting me
here to testify about the transition from servicemember to Veteran,
with a particular focus on the implementation of the Integrated
Disability Evaluation System (IDES).
I am currently a senior fellow at Project HOPE, an international
health education foundation that works to make health care available to
people around the globe. I am also a Regent for the Uniformed Services
University of the Health Sciences (USUHS). I have previously served as
a Commissioner on the 2007 President's Commission on the Care for
America's Returning Wounded Warriors (Dole/Shalala Commission), a co-
chair for the Congressionally-mandated study on the Future of Military
Health Care (2007-2008) and also as a co-chair on the 2001-2003
President's Task Force to Improve Health Care Delivery for our Nation's
Veterans. The views I am presenting here reflect my training as an
economist as well as the experiences I have had on these commissions
and task forces. However, my testimony today reflects my personal views
and not necessarily the views of Project HOPE or any of the other
organizations with which I have been associated or continue to be
associated.
I am here primarily to discuss the need for an integrated
disability evaluation system and what has been reported about its early
implementation as well as to remind the Committee about the
restructured compensation system that the Dole/Shalala Commission also
recommended should be implemented. I will also briefly review some of
the other issues that need to be considered in order to facilitate the
transition from active duty servicemember to veteran status. Most of
these are not new issues but rather have been recommended by various
groups over the course of at least the last decade.
The Problem
Before the introduction of the Integrated Disability Evaluation
System, a servicemember needed to first separate from his or her
service, with discharge papers in hand, before entering the VA process.
Thus, two exams were required--one from the military services that
determined fitness to serve and a second exam from the VA to determine
a disability rating for purposes of compensation.
The process and the criteria for determining fitness to serve
differed across services and the process for determining disability
differed between the services and the VA, which raised perceptions of
equity of treatment across the different services. Also, servicemembers
could potentially be rated at one level by their service and at another
level by the VA, again raising questions of equity as well as causing
confusion. In addition, these multiple steps ensured that the process
was long and frequently contentious--averaging some 540 days.
The IDES
Under the IDES, there is a single, comprehensive exam by VA
certified physicians. A single-source disability rating is used that
determines both for the purpose of fitness for continuing military
service and also serves as the basis for the VA to rate the level of
disability. Each military service continues to determine whether
someone is able to continue military service.
Service members who are unable to return to active duty are
referred to a medical evaluation board, assigned a physician evaluation
board liaison officer whose job is to help them through the process.
Each servicemember is also assigned a VA military service coordinator
to help them navigate through the VA system.
The stated goal is to get the process done in 100 days. The
estimates I have seen reported are that the former 540- day process was
closer to 295 days as of mid 2011, indicating a clear improvement but
also a time frame that is not as expeditious as might be desired. There
are also still reports of inexplicable and frustrating delays such as
was reported last summer at a Senate hearing where the application of a
Marine who had lost both his arms and legs in Afghanistan in 2010 sat
on a desk for 70 days, requiring a Senator's personal intervention in
order to get it dislodged.
Preliminary Assessment of the IDES
While the overall process is still relatively early in its
implantation stage--having only gone fully live in the fall of 2011--
there are some observations that can be made at this stage.
First, it is unclear why it has taken so long to get to this stage
of the implementation process. The IDES was developed in 2007 in order
to shorten the process of transition from active duty to veteran
status. It followed from multiple recommendations that the Department
of Defense and Veterans Administration use a single comprehensive
standardized medical exam--including a recommendation from the Dole/
Shalala Commission but certainly not limited to that Commission. While
it is true that the Defense Department published guidance for a
voluntary, expedited Disability Evaluation System in early 2009 for
servicemembers that had sustained catastrophic injuries, the full IDES
was not implemented until later in 2011.
Having run the Medicare and Medicaid programs in the early 1990's,
I would agree that piloting a new system before taking it on-line is a
reasonable and prudent step. Why it should take from 2007 until the
fall of 2011 for a full transfer to the IDES is unclear to me.
Second, shortening the time to process a disability claim is
important but the time involved per se is only part of the issue.
Clearly agreeing on its function and making sure that this is fulfilled
is a necessary step as well. Some ways that would shorten the process
may not improve its fairness, such as eliminating a servicemember's
right of appeal.
Third, while the use of a single disability exam makes sense, it is
important to recognize that there are different functions that medical
exams serve, even though they may provide overlapping data fields. They
can serve to define a course of clinical treatment, providing
information about diagnoses and progress as opposed to a medical exam
that is a single snapshot ``finder of fact'' that determines a level of
disability. Both uses suggest the need for ongoing, periodic medical
evaluations but done for different purposes.
Restructuring the Disability and Compensation System
The Dole/Shalala Commission also recommended a complete
restructuring of the disability and compensation system. The purpose of
the recommendation was to simplify the disability determination and
compensation process, eliminate parallel activities, reduce inequities
and perhaps, most importantly, provide a basis for veterans to return
to productive lives as fully and quickly as possible.
Like the present system, the Commission advocated having the
Defense Department determine fitness to serve. For those who are deemed
``not fit'', the Commission recommended that the DoD provide a pension
that reflects a payment for the years served. The payment should be
determined only by the individual's rank and the length of service.
Those who are not fit because of combat-related injuries should receive
TRICARE as should their dependents.
The VA should continue to have the responsibility for establishing
the disability rating and compensation and benefits that follow from
it. The VA should initiate its education and training programs as early
as possible and adopt a policy of reviewing disability states on a
three year basis.
The proposed restructuring of the VA disability payments was to
work in steps. First, there would be a ``transition payment''. This
payment would be to cover living expenses for injured veterans and
their families. It would be defined as three months of base pay in the
event there is not further rehab going on or a longer term payment for
living expenses if the veteran continues in some form of rehab or
education program.
Second, following the completion of the rehab or education program,
the disabled veteran would receive an ``earnings-loss'' payment in
order to make up for any lower earning capacity that might remain after
training, should that occur. In many cases, there should not be an
earnings loss.
Third, a ``quality of life'' payment would be made to compensate
for ``non-work related'' effects in the event of permanent physical or
mental combat-related injuries.
The purpose of these steps is to support and encourage the injured
veteran to advance as completely as possible using education and rehab
and then to assess the effect on both earnings capacity and quality of
life. It is recognition that in an information and service economy such
as we have today, even significantly injured veterans may be able to be
helped to a position where they would not experience an earnings-loss
but would still be entitled to a quality of life payment.
Two of the commissioners on the Dole-Shalala Commission were
examples of how VA or GI Bill financed education could put someone in
such a position. Marc Giammatteo, an Army Captain had been severely
wounded in his leg while in Iraq. He was also attending Harvard
Business School, getting an MBA and spending his summer working at an
investment bank. Jose Ramos was a Navy Corpsman who had also been
serving in Iraq and had lost his right arm to the shoulder. He was
completing a double major in Arabic and national security at George
Mason. Both of these individuals should be in a position where they
would not experience an earnings loss but would experience a quality of
life decrement. On the other hand, Tammy Edwards, also on the
Commission, is the wife of an Army enlisted man who was severely burned
and experienced a brain injury while on active duty. His earnings loss
would be significant in addition to his quality of life decrement.
Other Areas Needing Strengthening
As important as integrating the disability evaluation and
restructuring the disability and compensations payment are to
facilitating the transition from active duty to veterans' status, there
are other areas that need to be strengthened. Among the most important
of these is making sure adequate care is available for any veteran who
is experiencing PTSD or TBI. The DoD and the VA have been working hard
to improve the prevention, diagnosis and treatment of both PTSD and TBI
but much remains to be done. In addition, reducing the stigma
associated with PTSD remains a problem for both active duty and veteran
populations.
A major problem for both the Defense Department and the VA is that
there is a national shortage of mental health professionals just as
there is a national shortage of primary care professionals.
Nonetheless, both departments will need to aggressively work on
resolving this problem as aggressively and creatively as they can. It
would also be helpful to provide programs to family members and
caregivers to help them understand and deal with PTSD and TBI. Any
efforts that can be undertaken to prevent PTSD and TBI from occurring,
would be well worth-while on many fronts.
Efforts also need to continue to strengthen support for families.
We had recommended expanding Defense Department respite care and
extending the Family and Medical Leave Act for up to six months for
spouses and parents of the seriously injured. The latter is especially
a challenge in our currently constrained fiscal environment.
One of the most heartening findings of the Dole/Shalala Commission
was that the quality of care provided to the wounded servicemembers was
of very high quality. Most of the problems that occurred, occurred
during the ``hand-offs''--that is, the transitioning from inpatient to
outpatient status, from one facility to a second facility or from
active duty to veteran status. Both the Defense Department and the VA
have worked hard to reduce these problems and to simplify the path to
recovery but more still needs to be done for our returning wounded
warriors.
Thank you Mr. Chairman. I would be happy to answer any questions
you or the Committee may have.
Executive Summary:
Before the introduction of the Integrated Disability Evaluation
System (IDES), servicemembers first needed to separate from his or her
service and then to enter the VA process, requiring two different
exams. The process and criteria for determining fitness differed across
services and the process for determining disability differed between
the services and the VA. The result was real and perceived differences
in equity of treatment across services and between the services as well
as a lengthy and frequently contentious process.
The IDES produces a single exam, done by a VA certified physician
that serves both as the basis for determining fitness to serve and to
establish a level of disability. The services continue to determine
fitness to serve; the VA determines the disability level.
The result has been to cut the time from about 540 days to less
than 295 days. It is a substantial reduction but far from the stated
goal of 100 days. In addition, occasional lengthy and inexplicable
delays are still reported. Several issues remain. First, why did it
take so long to have the IDES fully rolled-out--from its development in
2007 until the fall of 2011? Second, shortening the time is important
but clear agreement on the functions and goals of the disability
evaluation program is equally important. Some questions remain here as
well. The need also remains for ongoing, periodic medical evaluations
to determine whether initial levels of disability continue in the
future.
The Dole/Shalala Commission, where I was a commissioner, also
recommended the complete restructuring of the disability and
compensation system. Like the IDES, the goal was to simplify the
disability determination, reduce parallel activities and inequities and
most importantly, provide a basis for veterans to return to productive
lives as fully and quickly as possible. To do this, we recommended a
``transition payment'' that would provide living expenses to the
disabled veteran and their families during rehab, training and
education. This was to be followed by an estimate of earnings-loss
which may remain after training and/or education has been completed and
which would also be accompanied by a quality of life payment, if
appropriate. This division recognized that in an information and
service economy, disabilities that previously would have produced
earnings losses may no longer do so but quality of life decrements may
continue. Three of the commissioners provided examples of how these
differences might work.
Other areas also need strengthening to facilitate the transition
from active duty servicemember to veteran. These include assuring that
care is available to any veteran experiencing PTSD or TBI and working
to reduce the stigma attached to both of these. The ongoing shortage of
mental health professionals in the U.S. will make this a challenge.
Efforts are also needed to continue strengthening support for families.
We had recommended expanding respite care and extending FMLA for up to
six months for spouses and parents of the seriously injured. The latter
is a challenge in our fiscally-constrained environment.
On a positive note, most of the problems that were identified
during the work of the Dole/Shalala Commission concerned the ``hand-
off'' process and not the quality of care actually delivered. We need
to ensure that both are appropriate for our returning wounded warriors.
Prepared Statement of Kenneth Fisher
Chairman Runyon, Members of the Committee:
On behalf of co-chairs Dole and Shalala who could not be with us
today, the members of the commission, and my fellow commissioner Gail
Wilensky, I appreciate the opportunity to appear before you today. Both
as a commissioner and a Chairman of the Fisher House Foundation, I have
devoted the last 12 years of my life towards improving both the care
and the quality of life of our military, those wounded, veterans and
their families. Today's hearing on the DES and the seamless transition
are critical to this Nations security and I am proud to discuss my work
on the commission, its recommendations and action steps, and how this
system must be made simple, easily understandable and easier to
navigate. But I must admit to being a bit confused. We are the greatest
Nation on earth, with the best equipped and the best trained military
in the history of the world. What puzzles me is the fact that it has
been five years since the findings of Dole Shalala and we are still
having hearings on the same issues as 2007.
Before I begin, I feel compelled to preface my statement by
explaining our mission. We were charged by President Bush to examine,
evaluate, and analyze the care and process related to our returning
wounded global war on terror servicemen and women. We looked at the
system through the eyes of the wounded service people. We were solution
driven, and held numerous field hearings, interviewed wounded, base
commanders, doctors and family members as well as others who played a
role in the recovery process. We not only examined the problems and
inadequacies but also looked for best practices that might help improve
their care. Our goal was to simplify and help eliminate the log jam,
which was the result of the fighting lengthy two front wars with a VA
that was already challenged by the weight of an intolerable
beaurocratic system. By doing this, we sought to eliminate the back log
and claims that had reached approximately 800,000-900,000.
While the living conditions at Walter Reed were indeed horrendous,
this was only the tip of a massive iceberg. We found hundreds of troops
waiting months for follow up appointments or awaiting the rating
process. This gap in benefits caused massive problems known to but a
few.
The commission was given six months to evaluate the entire
disability evaluation system and our findings were thoughtful,
inclusive, and easily implementable. It was not our intention to put
forth hundreds of recommendations that would have been difficult to
implement or too expensive as a whole.
And as a side bar, I would like to compliment our Nation's world
class military healthcare professionals whose work and use of the
latest technologies resulted in a 95% battlefield survivor rate.
Today, five years after our report was made public, there has been
progress, to be sure, but, and with all due respect, not nearly fast
enough, and the appearance that there is no real sense of urgency.
Tracking the results of the commission has been difficult, as
admittedly I would not expect the process to be transparent. But again,
we were given the task of OEF/OIF, with the hope that its adoption
would have moved the system along faster.
Our recommendations were short and to the point.
Our first recommendation called for a recovery care coordination
program - a plan to smoothly guide and support servicemembers from
start to finish. This would apply to both the VA and the DoD. I believe
this has been implemented, although I cannot speak to its success. On
this I would have to differ to our VA and DoD representatives. In the
interest of time I thought we would focus on the four issues that I
think are crucial.
Our second recommendation called for an overhaul of disability. Our
plan called for one physical administered by DoD who then determines
fitness to serve. If separation is required, they are compensated on
rank and length of service, and then they are moved to the VA who
determines their rating and benefits along with a series of payments.
The joint DoD VA plan that is currently in use is the Integrated
Disability Evaluation System which is now out of the pilot program and
is in use system wide as they phase out the legacy program over the
next two years. It calls for one physical administered by the VA. The
DoD component is done simultaneously - they determine fitness to serve
through the MEB and PEB. The VA rating systems apply, and the entire
process is designed to eliminate the benefit gap. Pilot programs were
able to take the legacy process of 500 days down to 300, but as the
system was expanded - the waiting time climbed back to 500 days.
According to the GAO, there are some glaring weaknesses - chief
among them staffing issues. In addition, VA doctors are having
integration issues at DoD facilities, which come as no surprise to me.
There were disagreements in diagnosis, which is not uncommon - but it
does add more time to the process. And I must admit to being a bit
confused as to why VA doctors are performing the DoD physical. I
believe an Army doctor, for example, is better suited to determining
whether a soldier is fit to serve. This also frees up VA doctors not
only to treat the younger veterans as they enter the VA but also an
older set of veterans who are reentering the VA system. But I cannot
emphasize enough - in the private sector the best possible plans are
just words on paper if there isn't enough qualified people to implement
said plan. This is an over simplified written in the interest of time
constraints. This includes recovery care people as well PEBLO's and
other crucial personnel.
Another important recommendation highlighted is the incompatibility
of the DoD and VA IT systems and as our report put it, this alone is
not the silver bullet. However, if information could be transmitted
this way, the veterans would have less paper work, and find out what is
available to them much faster at the push of a button. We believed that
information sharing was critical to the help of the system.
We recommended life time treatment for PTSD. These men and women
have endured multiple deployments; have been in intense urban fighting,
often against civilian insurgents who too often hide behind innocent
women and children. They have seen horrific injuries caused by IED's.
And the stigma associated with coming forward and asking for help
leaves too many to suffer in silence and if they are home their
families do suffer as well. We believed this was a major problem when
our report was made public, and it has been for any servicemember who
fought in battle be it World War II, Korea, Vietnam or today.
Today it is evident why this was a major recommendation. Five years
after our report was made public, there have been well over 1000
suicides - out pacing the civilian population, domestic violence, and
divorce, drug and alcohol abuse, homelessness, joblessness, are all at
unacceptable levels. Just the other day in USA Today, an article
appeared discussing alcohol within the ranks of the Army, and the fact
that they have delayed for three years a confidential counsel program
for treatment. They had begun a pilot program in 2009, but it was ended
after high dropout rates. According to the article, 25% have a drinking
problem.
The issue's importance is self explanatory because of the
collateral damage it causes. Here again, staffing shortages are at the
heart of the issue, as with disability. We need to consider engaging
the private sector to help with has become the signature wound of this
war. The stigma has not completely vanished, and this wound is the
worst kind because it cannot be seen until after it manifests itself.
Perhaps we need to reexamine screening before and after deployment,
and I believe a spousal educational program is vital. They are the
first line of defense, and if they know what to do after seeing their
loved one's behavior change.
I believe that progress has been made in our family support
recommendation, as the family medical leave act has been extended to
six months, and the VA now offers a caregiver stipend to the caregiver.
Military families bear burdens that the average American has no
concept of. And for too long, military families bear their stress
either alone or with other military families. When one gets wounded,
that stress can be unbearable. The private sector has stepped up and
numerous foundations are in action and I would encourage Congress, the
DoD and the VA to find the ones that work and embellish them, not
impede them by making them part of the intolerable beaurcracy that
exists system wide. They have the infrastructure, boots on the ground,
and the overwhelming desire to help. There will always be unmet needs,
but public private partnerships can bridge that gap, and paint the way
to the future.
Mr. Chairman, This concludes my statement. In the interest of time,
I tried to keep the nuts and bolts of our report to a minimum, and the
fact that most people are already familiar with our report, judging by
the criticism it generated. It was always our intention to have
Congress and the Veterans Service Organizations weigh in and while they
objected to certain parts of our report, it must be emphasized that the
needs of today's young veterans are immediate and this new generation
of veterans are coming into the system by the thousands. Times are
different, their wounds are different, but I assure you had we had the
time we would have examined all veterans because anyone who has worn
this Nation's uniform deserves the best we have to offer. A thank you
for your service is not enough anymore. I am now ready to answer any
questions you may have.
Prepared Statement of James Terry Scott, LTG USA (RET)
Mr. Chairman and Members of the Subcommittee: It is my pleasure to
appear before you today representing the Advisory Committee on
Disability Compensation and the Veterans Disability Benefits Commission
that met from 2005 to 2007 and reported out to you in October of that
year.
The Advisory Committee is chartered by the Secretary of Veterans
Affairs under the provisions of 38 U.S.C. in compliance with P.L. 110-
389 to advise the Secretary with respect to the maintenance and
periodic readjustment of the VA Schedule for Rating Disabilities. Our
charter is to ``(A)ssemble and review relevant information relating to
the needs of veterans with disabilities; provide information relating
to the character of disabilities arising from service in the Armed
Forces; provide an on-going assessment of the effectiveness of the VA's
Schedule for Rating Disabilities; and provide on-going advice on the
most appropriate means of responding to the needs of veterans relating
to disability compensation in the future''.
Your letter asked me to testify on the Advisory Committee's views
on the transition from servicemember to Veteran, with a particular
focus on the implementation of the Integrated Disability Evaluation
System (IDES).
First, a bit of background. At the time the Veterans Disability
Benefits Commission was created by the National Defense Appropriations
Act of 2004 it was already apparent that the peacetime system for
transitioning sick and injured servicemembers to Veteran status was
overwhelmed. From the outset, and well before the reprehensible
situations at the Walter Reed Barracks and other locations were
recognized, the Commission recognized the need for a seamless and rapid
transition process that protected the servicemember while he or she
progressed to Veteran status. Transition became one of the major issues
studied by the Commission. Interim recommendations addressing
transition issues were offered as deliberations progressed.
The Veterans Disability Benefits Commission (VDBC)
examined the policies and processes within the Departments of
Defense, Veterans Affairs, Labor, Health and Human Services, and the
Social Security Administration that affected military separation or
retirement. Each of these entities plays a significant role in the
transition of Veterans and their families.
Of the 113 recommendations the Commission made, many of them
pertained to improving the transition process. I am providing for the
record a list of the key transition recommendations and the status of
their implementation as I understand it.
4.4 and 4.5: VA should develop a process for updating disability
examination work sheets and mandate the use of approved templates.
(This is currently being addressed by the adoption of Disability
Benefit Questionaires for the use of VA and non-VA medical examiners.)
4.10: VA and the DoD should conduct a comprehensive
multidisciplinary medical, psychological, and vocational evaluation of
each Veteran applying for disability compensation at the time of
service separation. (This is partially addressed by the IDES system for
sick or injured servicemembers and by the expanded TAP briefings.
Complete physical exams for all separating servicemembers are still not
required.)
4.23: VA should immediately begin to update the current rating
schedule beginning with those body systems addressing the evaluation
and rating of PTSD and other mental disorders and of traumatic brain
injury and then proceed through the other body systems until the Rating
Schedule has been comprehensively revised. (This is currently being
addressed by VA with a projected completion in 2016.)
5.7: DoD should require a mandatory benefits briefing to all
separating military personnel, including Reserve and National Guard
members prior to discharge from active service. (This is being
partially addressed by the services and VA through expanded TAP
briefings.)
5.28: VA should develop and implement new criteria specific to
posttraumatic stress disorder in the VA Schedule for Rating
Disabilities. (This has been done and is awaiting approval.)
6.9: Access to vocational rehabilitation should be expanded to
all medically separated servicemembers. (Programs have been expanded
but universal access has not been achieved.)
6.10: All service disabled veterans should have access to
vocational rehabilitation and employment services. (These programs have
been expanded, but are still not available to all service disabled
veterans.)
7.11: VA and DoD should adopt a consistent and uniform policy
for rating disabilities, using the VA Schedule for Rating Disabilities
(VASRD). (This has largely been accomplished by DoD accepting the
VASRD. It is an integral part of the IDES.)
7.13: VA and DoD should realign the disability evaluation
process so that the services determine fitness for duty and
servicemembers who are found unfit are referred to VA for disability
rating. All conditions that are identified as part of a single,
comprehensive medical examination should be rated and compensated. (The
IDES system has adopted this procedure.)
10.1: VA and DoD should enhance the Joint Executive Council's
strategic plan by including specific milestones and designating an
official to be responsible for ensuring that the milestones are
reached. (This has been fully implemented by VA and DoD.)
10.3: DOL and SSA should be included in the Joint Executive
Council to improve the transition process. (DOL participation in
transition and in follow up has greatly increased.)
10.4: To facilitate seamless transition, Congress should
adequately fund and mandate the Transition Assistance Program (TAP)
DoD-wide to ensure that all servicemembers are knowledgeable about
benefits before leaving the service. (Expansion of TAP is a major
ongoing effort in VA today).
10.5: Benefits Delivery and Discharge (BDD) should be available
to all disabled exiting servicemembers (to include National Guard,
Reserve, and medical hold patients). (Progress unknown).
10.6: DoD should mandate that separation examinations be
performed on all servicemembers. (While progress has been made, this is
still not a requirement in all services for all separating members.
While requiring resources, this policy will pay great dividends in
future years by providing a clear picture of physical and mental
condition at separation which can be used in determining service-
connection for disability.
10.8: DoD should expand existing programs that translate
military occupational skills, experience, and certification to civilian
employment. (Progress unknown.)
10.11: VA and DoD should expedite development and implementation
of compatible information systems including a detailed project
management plan that includes specific milestones and lead agency
assignment. (This complex issue is under development.)
Of the recommendations pertaining to transition that both the
Veterans Disability Benefits Commission and the Advisory Committee on
Disability Compensation have offered, the one with the most potential
to reduce the time to process claims and improve accuracy and
consistency is the ongoing plan to revise the VASRD. This complex,
multi-year revision will incorporate current medical knowledge and
technology as well as streamline the diagnosis, evaluation, and
adjudication processes.
Another key recommendation with potential long term positive effect
is the movement to an electronic claims record. This is another
extremely complex challenge that the VA has accepted and is working.
When fully implemented it will simplify and expedite the claims
process.
The Current IDES program incorporates many of the recommendations
from the Veterans Disability Benefits Commission and the Advisory
Committee on Disability Compensation. It represents a tremendous effort
on the part of VA and DoD to focus on the transition of servicemembers
who are sick or injured to Veteran status. All parties, including the
Congress are frustrated by the average time still required to complete
the transition. However, from the perspective of someone who has had
the opportunity to contribute to this effort over the last eight years,
I believe the progress is significant and, more importantly, that the
progress will continue.
On behalf of the Advisory Committee, thank you for the opportunity
to testify on this important matter.
Prepared Statement of John L. Wilson
Mr. Chairman and Members of the Subcommittee:
On behalf of the Disabled American Veterans (DAV) and our 1.2
million members, all of whom are wartime disabled veterans, I am
pleased to be here today to testify before the Subcommittee on
Disability Assistance and Memorial Affairs and address the
implementation of the Integrated Disability Evaluation System (IDES).
DAV is actively engaged in providing claims assistance to military
members before they leave active duty with our 30 Transition Service
Officers (TSOs) assisting over 55,900 servicemembers in 2011 and our
250 National Service Officers (NSOs) representing over 259,000
veterans, their families and survivors for that same period.
IDES is the result of a recommendation of several commissions,
including the Veterans' Disability Benefits Commission, \1\ and the
President's Commission on Care for America's Returning Wounded
Warriors, which stated that the ``DOD and VA should create a single,
comprehensive, standardized medical examination that the DOD
administers. It would serve DOD's purpose of determining fitness and
VA's of determining initial disability level.'' \2\
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\1\ Veterans' Disability Benefits Commission, October 2007, page
376
\2\ The President's Commission on Care for America's Returning
Wounded Warriors (July 2007), page 7.
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The Disability Evaluation System (DES) pilot project was launched
in 2007 by the Department of Defense (DOD) and the Department of
Veterans Affairs (VA). Using lessons learned from that pilot, the
legacy DES began the transition to IDES in October 2010 to include a
total of 140 locations, with the goal of expediting the delivery of VA
benefits to all out-processing military members.
A comparison between the DES pilot and legacy DES found Active
Component military members completed the pilot in an average of 289
days, and Reserve Component military members completed it in an average
of 270 days, compared to a legacy DES average of 540 days. Surveys
revealed significantly higher satisfaction among DES pilot
participants. On July 30, 2010, the DOD Senior Oversight Committee co-
chairs directed that IDES expand worldwide. \3\
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\3\ Department Of Defense Task Force On The Care, Management, And
Transition of Recovering Wounded, Ill, And Injured Members of the Armed
Forces, Disability Evaluation System, page D-34.
---------------------------------------------------------------------------
The legacy DES was replaced with the IDES in four stages \4\ and
was fully deployed by October 2012.
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\4\ Statement of John R. Campbell, Deputy Under Secretary of
Defense (Wounded Warrior Care and Transition Policy), Department of
Defense, before Senate Committee on Veterans' Affairs Hearing on Review
of the VA And DOD Integrated Disability Evaluation System (November 18,
2010).
\5\ IDES Trifold Brochure
Stage I-West Coast and Southeast (October-December
2010)--28 Sites
Stage II-Mountain Region (January-March 2011)--24 Sites
Stage III-Midwest and Northeast (April-June 2011)--33
Sites
Stage IV-Outside Continental United States (OCONUS)
(July-September 2011)--28 Sites
Total IDES locations when complete: 140
Under this system, military members are referred to IDES when their
continued service is curtailed as a result of a physical or mental
health condition and they are placed on a medical profile making them
ineligible for deployment or unable to carry out the duties of their
rank or military specialty. The following chart depicts the revised
time lines for each step of the IDES process:
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
As a result of treatment and being on medical profile, military
members are evaluated by a Medical Evaluation Board (MEB), which is
typically comprised of at least two physicians. If the MEB determines
that the member has a medical condition that is incompatible with
continued military service, an MEB Narrative Summary is prepared and
the case is referred to a Physical Evaluation Board Liaison Officer
(PEBLO).
PEBLOs guide servicemembers through the IDES process to ensure they
are aware of the options available to them and to help with the many
decisions they need to make while still in on active duty. The PEBLO
compiles administrative data, informs military members of the IDES
process and the MEB, and then refers them to the VA Military Services
Coordinator (MSC).
The VA MSC then meets with the military members to advise them
about the next phase of the IDES process, assist in completion of
documentation, establish a formal VA disability claim, and initiate
case development. The VA MSC requests the appropriate VA medical
examinations, monitors their progress, provides copies of the completed
examination reports to the PEBLO, and completes any additional
development actions as needed.
Once the medical examinations are completed, the VA MSC provides
them to the PEBLO and the VA Disability Evaluation System Rating
Activity Site (D-RAS) which prepares the proposed disability rating.
The PEBLO incorporates the medical examination results in the IDES case
file and provides it to the MEB convening authority. The MTF then
conducts an MEB and provides the results back to the PEBLO, including
the results of the MEB's response to any rebuttal of the member about
the MEB findings. The PEBLO then provides a copy of the MEB findings,
to include the completed VA medical examination results, to the
military member and forwards the case to the PEB administrator if the
MEB did not return the military member to duty. The PEB administrator
prepares and provides the member's case to the Informal PEB (IPEB).
The IPEB is typically comprised of a two- or three-member board.
The IPEB adjudicates the case and requests the D-RAS provide the
proposed ratings for the military members' conditions that the IPEB has
determined to be unfit. The D-RAS prepares the proposed disability
ratings, and reconsideration of the proposed ratings, if the military
member requested this. Once all information is received, the IPEB
decides whether the member can continue in the military. If so, they
are designated ``fit'' and returned to duty. If not, they are found
``unfit.'' There are three broad types of medical separations the
member can receive as a result of being found unfit: separated without
severance pay, separated with severance pay, or retirement.
Once the military member is informed of the IPEB's decision, they
can either accept those findings or appeal the decision to the Formal
Physical Evaluation Board (FPEB). The FPEB is comprised of a three-
member board, two personnel officers and a physician. They review all
the information that the IPEB had, with the added feature of the member
being able to personally appear before the FPEB and offer additional
evidence. The FPEB then holds a hearing, weighs the prior evidence, the
member's testimony as well as any new evidence presented, and renders
its recommendation. The member can accept the decision of the FPEB, or
request reconsideration of the proposed ratings. Just as with the IPEB,
there are three broad types of medical separations the member can
receive: separated without severance pay, separated with severance pay,
or retirement.
Military members have a final appeal option of the FPEB findings
regarding fitness for duty through all subsequent levels allowed by
their branch of service, such as the Department of the Navy Council of
Review Boards and the Department of the Air Force Personnel Council.
The three types of medical separations, separated without severance
pay, separated with severance pay, or retirement, can result in several
types of medical discharges. Specifically, those who receive a
disability rating of 20 percent or less receive a Discharge With
Severance Pay or DWSP. Those whose medical conditions were found to
exist prior to military service and found unfit can be ``discharged
under other than Chapter 61, title 10 or (DUOT) without disability
compensation if their conditions existed prior to service and were not
permanently aggravated through military service. Those who receive a
disability rating of 30 percent or more may receive Permanent
Retirement, or be placed on the Temporary Disability Retired List and
reevaluated at least every 18 months until their conditions become
stable with a final disability rating decision rendered at the five
year point. An exception would be mental disorders due to traumatic
stress on active duty which require re-evaluation within six months
after discharge, if assigned a disability rating of not less than 50
percent.
While DAV is generally pleased with the IDES, we are concerned
about certain aspects of the program. One area is servicemembers
participating in IDES not having ready access to representation from a
veterans service organization (VSO) in the same manner as they did
under the legacy DES.
The issue of access to counsel to advise military members on the VA
disability claims process was cited as a concern by the Recovering
Warrior Task Force (RWTF). The RWTF is charged with conducting an
assessment of the effectiveness of DOD programs and policies for
Recovering Warriors (RWs). In recommendation 19, the RWTF found during
RWTF onsite visits that legal personnel indicated that they were
greatly understaffed. The Army, Navy, and Marine Corps provide legal
counsel for both MEB and PEB. The Air Force provides specific legal
counsel only for the PEB. Air Force base level legal counsel can
address IDES issues prior to PEB. However, the Air Force is the service
with the lowest satisfaction with legal counsel and the only service
who's IDES participants were not more satisfied than their legacy DES
participants. These survey results reinforce the importance of
providing legal counsel for the MEB as well as the PEB. \6\ The
relationship between access to legal counsel and satisfaction with the
IDES process is clear. Despite survey results demonstrating the value
of having legal counsel available throughout the disability evaluation
process, the majority of RWTF focus group participants said they lacked
personal experience with or knowledge of these specialized legal
resources. \7\
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\6\ DOD Recovering Warrior Task Force Report, September 2, 20111,
page 22.
\7\ Ibid.
---------------------------------------------------------------------------
Most military members undergoing the discharge evaluation process
may not be aware of the complexities of the disability adjudication and
retirement systems. As a result, they may be accepting PEB decisions
that are not in their best interest and/or the benefits they receive
may be less than what they would have been had they understood the
long-term consequences of their decision to accept a particular PEB
decision. As stated in the latest RWTF report, ``Service members going
through the IDES process often do not have a clear idea about where
they are going and what their futures hold.'' \8\
---------------------------------------------------------------------------
\8\ Ibid, RWTF Service member focus group results. March/April
2011, page 43.
---------------------------------------------------------------------------
Most servicemembers may not know how complex the IDES disability
adjudication is and we believe their best interests would be served if
they had access to the free assistance from certified representatives
from VSOs who can not only provide them with a full understanding about
the process and their rights but also act as their advocates. DAV, in
accordance with DAV Resolution 177, and also with the other co-authors
of The Independent Budget has urged the DOD and VA to address this
observed gap in IDES and expand VSO access.
DAV was actively engaged in the legacy DES but VSOs were excluded
when the program was redesigned and replaced with IDES. Under the
legacy DES, our TSOs represented 282 military members before DOD's
Physical Evaluation Boards from July 2008 to June 2009 but those
numbers have declined to 92 from July 2009 to June 2010 and to 22 from
July 2010 to June 2011. This change was based on the DOD and VA's focus
on speeding the delivery of benefits so they could be placed in the
hands of separating military personnel closer to the time of their
discharge. Just as with the larger disability claims process and its
current focus of ``breaking the back of the backlog,'' IDES is
similarly focused. It is our view that while speed is an important
factor, any claim, whether while on active duty or as a veteran should
be done right the first time with an emphasis on timeliness and rating
decision accuracy.
DAV brings vast experience and expertise about claims processing
with our service officers holding powers of attorney for hundreds of
thousands of veterans and their families. Our NSOs and TSOs continue to
be actively engaged in informing military members of their eligibility
for VA and DOD benefits though briefings at Transition Assistance
Program classes. We also provide assistance to those who request
accelerated receipt of their VA disability benefits under VA's Benefits
Delivery at Discharge (BDD) and Quick Start. To participate in BDD the
military member must apply within 180 days of discharge but no less
than 60 days. If they are closer than 60 days from separation then they
can use Quick Start. We assisted over 55,900 military members in 2011
under these three programs. As a result, DAV and other VSOs play an
integral part in the claims process and undeniably make the VA's job
easier by helping veterans prepare and submit better claims, requiring
less time and resources for them to be developed and adjudicated. If
provided broader access, we can make the DOD's job easier as well by
ensuring military members going through IDES do have a clear idea about
where they are going and what their futures hold.
There has been some positive movement that partially addresses VSO
access. The VA Integrated Disability Evaluation System Implementation
Guide states that VA Military Services Coordinators (VA MSCs) will
``explain the availability of Veterans Service Organizations and
provide a VA Form 21-22, Appointment of Veterans Service Organization
Claimant's Representative, if the Service member expresses interest in
this resource.'' \9\ While this is an improvement, we recommend this
guidance be modified so the VA MSCs explain the option of
representation by a VSO during IDES, whether or not the military member
expresses an interest. Given the many issues that the member has to
handle at this important juncture, changing this interchange to a more
positive exchange may be more productive.
---------------------------------------------------------------------------
\9\ VA Integrated Disability Evaluation System Guide, December,
2011, page 16.
---------------------------------------------------------------------------
While the guidance to VA MSCs is in the right direction, there has
been no such change from the DOD directing PEBLOs to raise VSO
representation as an option at any point in the process. Therefore, we
recommend that PEBLOs be required to inform military members about the
option of VSO representation as well. Having PEBLOs provide this option
earlier in the IDES process, and on the DOD side of the rating process,
would help ensure that military members know that VSOs are available to
represent them not just with the VA but also with the DOD as their
disability claim is processed.
The last area to address is the effectiveness of the PEBLOs. The
RWTF found in its work with focus groups that many participants had
limited knowledge as to the role of the PEBLO. Although several spoke
favorably, more often than not comments about PEBLOs were negative.
Military members seemed to expect them to be more of an advocate that
they were. \10\ Twenty-eight percent of RWs responding to the RWTF
mini-survey indicated that the PEBLO was very or extremely helpful,
while 32 percent indicated the PEBLO was moderately helpful. These
statistics would indicate that, while 60 percent of respondents had a
favorable impression of PEBLOs, a significant minority of 40 percent
did not have a favorable impression.
---------------------------------------------------------------------------
\10\ DOD Recovering Warrior Task Force Report, September 2, 20111,
page 21.
---------------------------------------------------------------------------
The RWTF mini-survey results are in contrast with the more positive
survey findings of the DOD Office of Wounded Warrior Care and
Transition Policy (WWCTP). They found PEBLO customer service earned 79
percent to 88 percent satisfaction ratings across the services. DOD
WWCTP also found that 65 percent of survey respondents indicated that
the PEBLO managing their case was helpful or very helpful to them.
While DAV has received information from the field that indicates
the performance of PEBLOs has continued to improve generally, there are
occasions in which PEBLOs have incorrectly advised members on what
their actual disability ratings are. Recently, a PEBLO advised a member
that he could not personally appear before the Formal Physical
Evaluation Board to appeal the IPEBs decision. This was clearly in
error, but one of DAV's NSOs was able to provide the correct
information to the member. In order to prevent these types of errors
and improve satisfaction, we believe it is imperative that the training
and quality control be reviewed and more closely monitored.
Mr. Chairman, this concludes my testimony. I would be glad to
answer any questions you may have.
Prepared Statement of Phil Riley
Chairman Runyon, Ranking Member McNerney, and Members of the
Subcommittee:
Wounded Warrior Project (WWP) appreciates your holding this hearing
and welcomes the opportunity to share our perspective on the Integrated
Disability Evaluation System (IDES) - a critical, but still troubled
pathway in the transition from servicemember to veteran.
I am Phil Riley, a Senior Benefits Liaison with WWP. In that
capacity, it is my privilege to assist wounded, ill, and injured
servicemembers in navigating the confusing road from medical
evaluations to the critical benefits' determinations associated with
their military retirement or separation. As a retired Army Colonel who
has worked with the disability evaluation process for some six years,
including time as a veteran's service officer, it's my assessment - and
that of WWP - that much more work is needed to close the wide gap
between the goals underlying IDES and realization of those goals. We
believe VA is doing its part in the IDES process. In our view, the
Department of Defense (DoD) needs to do more remedial work.
IDES, of course, has its roots in the problems wounded warriors
experienced under the so-called ``legacy Disability Evaluation
System,'' the DES. Under that system servicemembers whose injuries or
medical conditions rendered them no longer fit for continued military
service went through a very lengthy multi-stage processes, with both
DoD and VA conducting their own separate medical evaluations and
subsequent disability rating processes. Under DES, servicemembers
routinely experienced many-months' waits between discharge from service
and receiving their first VA benefits payment as well as
inconsistencies in how servicemembers' injuries were evaluated in the
two systems. \1\ In 2007, it took an average of 540 days under the
legacy DES for a servicemember to clear both DoD and VA disability-
evaluation processes. \2\
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\1\ U.S. Medicine, Wait Times Heading in Wrong Direction in New
Integrated Disability System; VA Blames `Transition Difficulties'''
July 2011; Kimberly Hefling, The Associated Press, ``Claim Processing
Keeps Injured Troops Waiting,'' May 18, 2011.
\2\ Tom Philpott, ``Disability Evaluation Reforms Seen Falling
Short,'' Army Times, March 31, 2011.
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The bipartisan Commission on Care for America's Returning Wounded
Warriors (``the Dole-Shalala Commission''), formed in that year, urged
that DES be overhauled. Among its findings, the Commission reported
that fewer than 50% of servicemembers understood the DoD disability
evaluation system, and that only 38% of active duty and 34% of the
reserve component were ``somewhat'' satisfied with it. \3\ The
Commission recommended that the two departments ``create a single,
comprehensive, standardized medical evaluation that DoD administers,''
\4\ with DoD maintaining its authority to determine fitness-to-serve
and VA becoming solely responsible for setting disability ratings and
awarding compensation. \5\ Its recommendation aimed to update and
simplify the disability determination and compensation process by
eliminating parallel activities and to reduce inequities. \6\
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\3\ The President's Commission on Care for America's Returning
Wounded Warriors, July 2007, p. 6.
\4\ Id. at 7. Service members found unfit due to their combat-
related injuries would then receive payment for years served and
comprehensive health care coverage for themselves and their families
through DoD's TRICARE program. Id.
\5\ Id.
\6\ Id. at 6.
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Creation of IDES and the Goals of an Integrated System
The Commission's work was carried forward by the congressionally-
established Wounded, Ill and Injured Senior Oversight Committee (SOC)
which ultimately instituted a more modest reform to integrate the two
systems which resulted in establishing a pilot integrated disability
evaluation system. The vision was ``to create a servicemember-centric,
seamless and transparent DES'' \7\ by developing a jointly-conducted
military medical evaluation process under which servicemembers receive
a single set of physical disability evaluations and disability ratings,
conducted and prepared by VA, with simultaneous processing by both
departments--using VA protocols for disability examinations and VA
disability ratings to make their respective determinations--to ensure
the earliest possible delivery of disability benefits. \8\ The goals of
the new IDES process were to create: (1) a less complex and non-
adversarial system; (2) faster, more consistent evaluations and
compensation; (3) a single medical exam and a single-source disability
rating; and (4) a smooth transition to veteran status. \9\ The IDES
pilot began in the National Capital Region in November 2007 with a goal
of reducing the time (from referral of a case to the DoD medical
evaluation board to delivery of VA benefits) to 295 days for active
duty and 305 days for reserve component servicemembers. \10\ Following
a phased expansion of the IDES pilot over about a year and a half
period, IDES became fully operational as of October 2011. \11\ Under
the new IDES process, a servicemember is to receive a full medical
examination conducted by the VA, which is used as the basis for
determining both fitness for continued duty in military service and
entitlement to DoD benefits and VA compensation.
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\7\ Is This Any Way to Treat our Troops? Part III: Transition
Delays: Hearing Before the H. Committee on Oversight and Government
Reform, 112th Cong. (2011) (prepared statement of Lynn Simpson, Acting
Principal Deputy Undersecretary of Defense for Personnel and Readiness,
U.S. Department of Defense).
\8\ Id.
\9\ Integrated Disability Evaluation System Pilot Overview,
presentation at VA/DOD Joint Venture Conference, October 2010,
available at: http://www.tricare.mil/dvpco/downloads/lvjvc/Day2-1045--
JVConfVADODSpecialtyPanelIDES.ppt
\10\ U.S. GAO, Military and Veterans Disability System: Worldwide
Deployment of Integrated System Warrants Careful Monitoring, GAO-11-
633T (Washington, D.C., May 2011), 4.
\11\ U.S Department of Veterans Affairs Budget Request for Fiscal
Year 2013: Hearing Before the H. Committee on Veterans' Affairs, 112th
Cong. (2012) (prepared statement of Hon. Eric K. Shinseki, Secretary,
U.S. Department of Veterans Affairs).
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The IDES Process
The IDES process, while differing in detail from service to
service, begins with a servicemember's treating physician \12\ or unit
commander making a referral to a Medical Evaluation Board (MEB). That
board, generally composed of medical care professionals, \13\ evaluates
the servicemember's injuries and ongoing treatment to determine if the
Member is able to meet medical retention standards and return to full
duty - and, if not, to make a recommendation (to a Physical Evaluation
Board (PEB)) as to whether he or she is fit for continued service
following medical treatment. From the start of the MEB referral, the
servicemember is to be assigned a Physical Evaluation Board Liaison
Officer (PEBLO) to help assist him/her throughout the IDES process. The
PEBLO is responsible for assembling all the information included in the
servicemember's DES case file: all medical records, test results, and
exams performed for the MEB; letters from a servicemember's chain of
command related to how the condition impacts duty; and other personnel
records the MEB may require. \14\
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\12\ A doctor is to refer a case to the MEB only upon satisfaction
that all has been done medically to improve the condition(s).
Department of Defense, Wounded, Ill and Injured Compensation and
Benefits Handbook, October 2011, 17.
\13\ Id. If a servicemember's condition includes a mental health
condition, a mental health care provider should be on the panel, as
well. Id.
\14\ Id.
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The MEB does not conduct formal hearings, and the servicemember is
not afforded the opportunity to appear before the board. If the MEB
determines that a servicemember does not meet medical retention
standards, it will forward that recommendation to a PEB. \15\ The MEB
results and recommendation are documented in a narrative summary
(NARSUM) which becomes the single most important piece of evidence the
PEB uses. After the servicemember receives the MEB's NARSUM, the PEBLO
will review it with the servicemember. A servicemember may ask for an
Independent Medical Review (IMR) and/or a Judge Advocate General (JAG)
counselor to review the NARSUM to ensure it is fully developed and
accurate. \16\ The servicemember does have the opportunity to submit a
rebuttal to be considered by the MEB. Far too often, in our view, the
response to the rebuttal is ``no changes accepted.''
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\15\ If the MEB determines a servicemember does meet medical
retention standards (or will be able to perform full duties within one
year) the servicemember may return to duty.
\16\ Walter Reed Army Medical Center PEBLO Office, Integrated
Disability Evaluation System Quick Series Review Guide.
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In the second phase of the process, the informal PEB (IPEB) will
evaluate the servicemember's fitness for duty. Generally, the IPEB is
comprised of three people, with a mix of military and civilian members,
including at least one physician and one nonmedical officer. \17\
Again, the servicemember does not attend this meeting. \18\ Using the
packet compiled by the PEBLO, the IPEB will review the medical records,
the NARSUM, personnel evaluations, and letters from the commander and
vote as to whether the servicemember is fit to continue service. \19\
The PEBLO will then notify the servicemember of the findings of the
IPEB. If the IPEB makes a determination of fitness, the servicemember
has 10 calendar days to accept the decision and return to duty or offer
a rebuttal and request a formal PEB. If the IPEB determines a
servicemember is unfit, he/she has 10 calendar days to decide on a
course of action; the options are (1) to accept the decision, (2)
accept the decision but request a reconsideration of the VA disability
rating, (3) offer a rebuttal and request a formal PEB, or (4) request
both a formal PEB and reconsideration of the VA disability rating. \20\
If a servicemember requests a formal PEB, he/she is allowed to appear
before the board with legal representation. The formal PEB hearing must
conduct a de novo review- all factual questions must be addressed as if
for the first time. The formal PEB's decision may change from the IPEB.
The formal PEB will then notify the appropriate service headquarters of
its determination. Once service headquarters receives the final PEB
determination, the servicemember may be separated, medically retired,
or returned to duty. \21\
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\17\ DoD regulations list minimum requirements for PEB membership
and leaves the exact determination of who sits on the board for each
military department to decide. Department of Defense, Wounded, Ill and
Injured Compensation and Benefits Handbook, October 2011, 18.
\18\ Id.
\19\ The PEB will determine a servicemember's disposition--return
to duty, separation, or permanent or temporary retirement. Department
of Defense, Wounded, Ill and Injured Compensation and Benefits
Handbook, October 2011, 18.
\20\ Walter Reed Army Medical Center PEBLO Office, Integrated
Disability Evaluation System Quick Series Review Guide.
\21\ Id. If the Service member appeals the formal PEB findings, the
appropriate military department considers the appeal and returns to
duty, separates, retires, or assists the servicemember to complete an
inter-Service transfer, if appropriate and approved. Under Secretary of
Defense, Integrated Disability Evaluation System Directive-Type
Memorandum 11-015, Dec. 2011.
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A servicemember found to be unfit by the PEB will still receive two
separate disability ratings under the new IDES process: (1) a rating by
the PEB that evaluates only those conditions deemed to make the
servicemember unfit for duty (which determines whether or not the
servicemember will qualify for medical retirement and what benefits the
servicemember is eligible to receive from DoD), and (2) a VA rating of
all service-connected conditions (whether the conditions make the
servicemember unfit for duty or not). Both the DoD and VA ratings are
to be based on the VA Schedule for Rating Disabilities (VASRD).
IDES Goals versus IDES in Practice
In our view, IDES should be judged by reference to the goals it was
to achieve - a less complex, non-adversarial system that operates more
quickly and with greater transparency and consistency to provide a
smooth transition to veteran status. Even today, however, our Wounded
Warriors still encounter great difficulty in navigating a system they
find to be highly complicated, difficult to understand, unnecessarily
contentious, and often ponderously slow. We at WWP who have been
representing these servicemembers see a serious lack of quality-control
in a system often marked by inconsistent practices, decisions based on
incomplete or inaccurate medical records, and wide variability in the
reliability of information and advice furnished to servicemembers
confronting difficult, life-changing circumstances.
Case Examples
The experiences of two warriors, with whom we at WWP have worked,
illustrate the kinds of problems we're describing. In both instances,
these warriors are at a sensitive stage of the process and requested
that we omit reference to their names.
The Officer: The first, an Army officer sustained a penetrating
head injury in Iraq. He has had a long remarkable rehabilitative
journey, and his wife was by his side through the course of his
painfully slow recovery. As he gradually regained lost function, the
couple could begin to think and worry about the future. As she
explained it, given her role as a full-time caregiver, his injury
deprived two college-educated people of the ability to work. ``Don't
worry,'' he was told, ``you'll be 100%; you'll be fine.'' That
misplaced expression of confidence reflected a widespread misconception
that inured soldiers would collect both retirement pay and VA
disability compensation. But, as they ultimately learned--with VA
compensation offsetting military retired pay - a 100% disability rating
represented only 60% of his monthly military income. The couple faced a
very confusing choice as to whether to elect to receive military
retirement pay or Combat Related Special Compensation. Making a prudent
decision required understanding the relationship between, and the
calculations regarding, (1) DoD military retirement, (2) VA
compensation, (3) VA special monthly compensation, and (4) DoD Combat
Related Special Compensation. The couple came to realize that Army
personnel who help the wounded navigate the system are not necessarily
knowledgeable on the interrelationship between those financial pieces,
and at times those advising them were not helpful. In fact, their JAG,
finance office, and PEBLO gave the couple conflicting information on
the critical point: would a wounded soldier receive both military
retired pay and VA compensation concurrently? Each was unaware of how
the above four compensation programs offset each other. Confusion on
such a basic point of information highlights the dilemma facing
servicemembers with often severe multiple injuries.
Not only are key decisions facing a warrior in the course of the
IDES process confusing, but the information from which critical
determinations are made is often incomplete or even inaccurate. In the
officer's case, for example, the NARSUM failed to include any
description of his day-to-day functional impairment, but simply set out
a list of his medical conditions. Even at that, one of those conditions
- loss of use of an arm - was omitted from this critical document. An
Independent Medical Review was, in fact, critical of the NARSUM and
included the reviewing physician's observation regarding a section
listing residuals from TBI--
``[It] is hard to read and almost incomprehensible to the
military physician: it is crucial to remember that these reports are
intended for the audience of the PEB and servicemember. The writing
should be unequivocal and precise, which is not the case here.''
While the MEB accepted some of the officer's points of rebuttal,
the Board did not rewrite the NARSUM, which was ultimately the basis of
the PEB's determination.
While IDES was intended to foster a smooth transition, it is
subject to troublingly disruptive pressures. For example, the Warrior
Transition Unit to which the officer was assigned worked intrusively
and applied pressure - to include harassing the PEBLO--to hurry the
process along. Similarly, while the IDES process provides appeal
rights, their experience was that the WTU actively discouraged him from
appealing the PEB decision, as that would slow the process down. These
weren't isolated experiences. Earlier in the course of his
rehabilitation, the couple was subjected to pressure to sign papers
that resulted in cutting short still-needed rehab care (against medical
advice) and rushing him into the MEB process.
While IDES was designed to achieve greater timeliness, the
officer's experience was but the officer's experience in that regard
was of a heavy-handed military attempting to push him through
prematurely where that early haste led to errors, culminating in a
lengthy appeal process that was compounded by long delays in getting
needed VA examinations.
This mature, college-educated couple's rough journey through the
IDES process certainly calls into question how well a much less
sophisticated young warrior with similar injuries and without expert
representation might have fared.
The Master Sergeant: An Army Reserve Master Sergeant with a 24-year
military career sustained multiple severe physical injuries, a
traumatic brain injury, and developed chronic post-traumatic stress
disorder after the Humvee under his command was hit by a roadside bomb
in Iraq in 2005. This servicemember endured a long, rough road to
recovery that included 26 surgeries and over a hundred medical
procedures, and that (among other disabling conditions) resulted in
loss of function in the dominant hand due to severed nerves.
Given the voluminous body of medical records that had been compiled
by the time the MEB process was initiated in 2010, the Sergeant made
sure to bring those records - which filled a large suitcase - to the
meeting with the PEBLO and asked for the opportunity to review the MEB
packet before it was forwarded to the Board. This packet was not made
available for the Sergeant to review. Moreover, the VA physician who
carried out the MEB physical exam had been provided only with a single
medical record file, and even expressed frustration about the inability
to conduct the physical exam properly without further records. Upon
contacting the PEBLO about the missing medical records, the Sergeant
was told, ``if additional records are needed, the VA doctors will
request them from the MTF.''
In February 2011, the Sergeant received a 137-page NARSUM; despite
its length, it omitted several service-connected conditions. The
Sergeant was overwhelmed by having to review this very lengthy
technical document in seven days. This was compounded by not being able
to get a face-to-face meeting with the PEBLO. A JAG officer whom the
Sergeant asked for help provided only a limited review of the case that
didn't allay the concerns; an effort to secure additional JAG
assistance at another installation was rebuffed. The Sergeant was later
referred to another JAG officer, who seemed stretched thin with a large
backlog of cases, but who did eventually assist in drafting a request
for an independent medical review (IMR), but the IMR wasn't done
because the PEBLO failed to accurately explain the IMR process to the
local primary care Air Force doctor who was to conduct the IMR. An IMR
was finally done in April 2011, but involved only a review of the
NARSUM without any review of the Sergeant's medical treatment records,
and resulted simply in upholding the flawed NARSUM. Although the
extended process appeared to be nearing an end, the Sergeant was
informed by the PEB doctor in July 2011 that disability ratings could
not be completed without additional pictures of the injuries. It was
only in January 2012 that the Sergeant got notice that VA had
``recommended'' a 100% rating but with a final decision deferred
pending review of medical records regarding service-connection for
other medical conditions. The adjudicative process was completed with
assignment of a 100% rating 24 months after the Sergeant's unit
commander requested MEB initiation.
Timeliness and Lack of Quality-Control
IDES was intended to improve the timeliness of the disability-
evaluation process, but rather than realizing the 300-day goal for
moving a servicemember through the system, the process is apparently
taking an average of nearly 400 days. \22\ To assess IDES solely by
reference to timeliness, however, is to overlook the dangers inherent
in moving too quickly - and in doing so, foreclosing the servicemember
from getting needed medical care and increasing the risk of prejudicial
error. In fact, the IDES process is particularly vulnerable to what
amounts to quality-control issues--incomplete examinations, examination
reports that fail to include new diagnoses, incomplete or insufficient
NARSUMs, and missing critical documentation. Such problems - sometimes
attributable to pressures to move cases along - ultimately contribute
to delay and adversely affect the ultimate disability rating
determination. WWP often hears from warriors, especially those in
Reserve and National Guard units, who cite long delays in the system,
and of having to fight to get needed medical treatment.
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\22\ Seamless Transition: Improving VA/DOD Collaboration: Hearing
Before the S. Veterans' Affairs Committee, 112th Cong. (2011)
(statement of Hon. William J. Lynn, III, Deputy Secretary, U.S.
Department of Defense).
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Delays encountered during the MEB process can have a compound
effect, resulting in medical exams ``expiring'' or no longer being
accurate, requiring nurse case-managers and PEBLOs to order new exams.
Too often warriors' medical and mental health conditions are
incompletely diagnosed or not even assessed during medical exams,
resulting in incomplete exam summaries and delays in needed care. As a
result, examiners must take extra time to clarify the summaries, and in
some cases, redo the exam. \23\
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\23\ U.S. GAO, Military and Veterans Disability System: Worldwide
Deployment of Integrated System Warrants Careful Monitoring, GAO-11-
633T (Washington, D.C., May 2011), 7.
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While substituting a VA evaluative medical examination for what had
been duplicative separate DoD and VA exams under the legacy system was
to have saved time, IDES has not eliminated sharp differences of view
between the two departments. \24\ On that point, my experience and that
of others representing servicemembers is aptly captured by the
following observations:
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\24\ Id.
``The MEB places no value in the results of the VA examination.
There are many cases in which VA has diagnosed PTSD and other
conditions as moderate to severe, and the MEB disregards the findings
and bases it on their own evaluation. MEB review of the Service
Member's medical treatment records is also not thorough in many cases.
The system is full of cases where the treating Psychiatrist and the
Examining Psychiatrist at the VA are overruled by the Doctors on the
MEB. Often the same thing is done in Orthopedic departments. VA
documents the severity of the Service Member's disability by reference
to its effect on a variety of normal daily activities including ability
for exercise, sports and effect on a job. The MEB consistently
disregards these findings and minimizes them in the so-called
`Consolidation of Inconsistencies.' What is obvious is that the MEB has
reached a decision often prior to the VA examination and refuses to
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take the VA examination into proper consideration.'' \25\
\25\ Interview with Jerry Johnson.
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Given the MEB's mode of operation, the Board findings - documented
in the NARSUM--are often flawed. While the NARSUM is the single most
important document describing a warrior's physical and mental
limitations, it is rarely fully developed, comprehensive, or accurate.
Too often the MEB process either fails to identify and fully document
in the NARSUM all of the warrior's medical conditions, or it minimizes
them. It is particularly troubling, in this regard, that MEBs routinely
fail to take the time to review a servicemember's complete medical
records or to research those records in depth. In addition, the
military seldom affords servicemembers the complete physical
examination required by regulation. \26\ By law, the armed forces are
required to document all service-connected medical conditions,
medically acceptable for a VA disability rating. \27\ However, MEBs, in
preparing the NARSUM, routinely fail to include the servicemember's
medically acceptable conditions, and focus only on those conditions
affecting the servicemember's ability to serve. The upshot of that
narrow focus and resultant omissions is to make it more difficult for
the servicemember to establish service-connection for disabilities that
are incurred in service but simply not noted in the NARSUM. These
failures also have an impact ``downstream'' - increasing the number of
appeals in the already- backlogged VA adjudication system.
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\26\ ``A complete physical examination must be recorded in the
MEB.'' AR 40-400 (27 January 2010);
``The overall effect of all disabilities present in a soldier whose
physical fitness is under evaluation must be considered.'' AR 635-40,
sec. 3-1b.
\27\ Under Secretary of Defense, Integrated Disability Evaluation
System Directive-Type Memorandum 11-015, Appendix 8, Attachment 4, Dec.
2011; Department of Defense Instruction 1332.38, July 2006.
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In contrast to the many instances in which warriors experience long
delays in moving through the MEB/PEB process, we see instances such as
discussed above, where warriors are seemingly rushed through the
process, many of them National Guard and Reserve members. These
circumstances inevitably create problems ranging from incomplete
treatment to erroneous disability ratings. WWP is working with several
warriors who were referred to the MEB while still undergoing treatment
or had developed new medical problems, and as a result received an
incomplete NARSUM. In such instances, the MEB process should be delayed
or stopped. All medical conditions should be diagnosed and treated
before the MEB process even begins.
Dual-Adjudication Undercuts the Goal of a Timely, Streamlined System
One of the most critical barriers to a timely, streamlined system
is that IDES retains the redundancy of a dual-adjudication process.
Army Surgeon General, LTG Eric Schoomaker, in testifying before the
Senate Appropriations Subcommittee on Defense, acknowledged that the
system ``remains complex and adversarial,'' and warriors ``still
undergo dual adjudication where the military rates only unfitting
conditions and the VA rates all service-connected conditions.'' \28\ At
the same hearing, the then-Undersecretary of Defense for Personnel and
Readiness described the ideal system as one that would produce ``a
single evaluation based upon one medical record.'' \29\ Eliminating
this redundancy would represent an important reform, but would not
alone eradicate the range of problems warriors encounter in moving
through the disability evaluation system. Substantive errors in
decision-making go unaddressed in those many cases when the PEBLO
assisting the warrior is not adequately trained and the warrior is
either lacks representation or is not effectively represented.
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\28\ Tom Philpott, ``Disability Evaluation Reforms Seen Falling
Short,'' Army Times, March 31, 2011.
\29\ Id.
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IDES Leaves Too Many Ill-informed and Unrepresented
Generally, warriors and their family members are uninformed or do
not understand the IDES process. The system's complexity leads some to
become cynical, as in the case of one Wounded Warrior who commented,
``they make it convoluted and you get so frustrated that you want to
give up. I've never been as stressed out as I am in this process.''
\30\ Servicemembers' lack of understanding of the process also
contributes to flawed case-adjudication. With the failure to inform
servicemembers at the outset of the MEB referral of the importance of
their medical records and the need for supporting documentation, many
are wholly unprepared for the challenge associated with establishing
service-connection.
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\30\ Beldock
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In theory, the military's assignment of a PEBLO to each
servicemember undergoing the IDES process should close the information-
gap. Beginning with an initial briefing before the servicemember's
first physical examination for the MEB, the PEBLO's role is to inform
the service-member of what to expect at various phases of the process,
assist the servicemember in gathering medical information and
documentation, and review the MEB and PEB determinations with the
servicemember. The reality, however, is that some of these officers do
not fully understand the system or have such large caseloads they can't
provide each servicemember adequate instruction and assistance. While
the nature of the process requires the PEBLO to maintain an ongoing
flow of information to the servicemember, warriors often report that
they rarely hear from their PEBLO. But even under the best of
circumstances, the PEBLO acts as the servicemember's counselor and
liaison, but that officer is not the servicemember's advocate before
the MEB or PEB.
Servicemembers do have access to JAG representation \31\, and some
efforts have been made to provide training for the JAGs. In our view,
however, there is wide variability in the level of expertise on IDES
issues among JAGs, and certainly not enough JAGs have the necessary
expertise. Servicemembers themselves often express reluctance to avail
themselves of the assistance of a JAG officer, often based on the
perception that a military/government lawyer may not represent their
best interests.
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\31\ In our experience, at least one JAG officer and a paralegal
are stationed in the military treatment facilities to assist when MEBs
take place.
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Not only is the servicemember generally unrepresented but that
individual is not afforded the opportunity to appear before the MEB to
discuss his health status. Accordingly, the MEB's development of a
narrative summary is based, and dependent, on the medical records
available to the MEB, and its interpretation of those records. Lack of
representation is especially problematic at the point that the
servicemember receives the MEB determination, because the individual is
given just seven working days to review and appeal the NARSUM before it
is forwarded to the PEB for a determination of fitness, separation, or
military retirement. This is an unreasonably limited period of time for
an individual to obtain reliable advice or counsel, particularly in the
often complex cases that involve multiple severe injuries, let alone
enough time for many warriors to review and comprehend NARSUM findings
and the significance of omissions or inaccuracies in that document. The
servicemember has only an additional five days within which to seek an
IMR to challenge the NARSUM before the case moves to the PEB, and is
not afforded the option of providing evidence from a specialist of his/
her own. In contrast, the IMR - generally performed by a physician
under contract to DoD--is less than ``independent,'' and is seldom a
specialist able to address specific issues. In our experience, very few
such reviews come back with any change in determination; yet our own
reviews often show strong bases for an IMR to challenge the findings.
WWP's representation of growing numbers of Wounded Warriors through
this process has highlighted problems under IDES, but has also led us
to develop solutions. We offer the following recommendations in the
belief that the IDES system can and must be materially improved, and
urge this Committee to work with the Armed Services Committee to spur
the Executive Branch to make needed changes.
WWP Recommendations
(1) Direct DoD and VA to provide (i) better instruction and
outreach on IDES for warriors and their caregivers, and (ii) better
instruction on IDES for warrior transition unit and other pertinent
staff who work with warriors and their families and caregivers.
(2) Direct DoD to re-engineer, and institute quality-controls on,
the ``front-end'' of the IDES process to--
(a) Provide procedures and safeguards to protect servicemembers,
and particularly National Guard and Reserve members, from being pushed
into and rushed through the MEB process.
(b) Ensure that the MEB process is not begun until optimum
medical care has been provided and the servicemember's conditions have
been diagnosed, and that such process will be deferred under
circumstances where a significant new medical condition develops.
(c) Ensure that NARSUMs are fully developed and accurately
document all service-connected medically acceptable conditions of a
warrior, to include (i) requiring MEBs to review thoroughly all medical
records, and (ii) providing opportunities for the servicemember to meet
with the MEB.
(d) Allow ample time for a warrior to review his/her NARSUM with
the assistance of an advocate and/or a medical provider (to include
additional time for servicemembers with multiple, severe injuries).
(e) Provide substantially improved avenues for effective
assistance to and representation of servicemembers undergoing physical
and mental health disability evaluations, including expanding the
number - and improved training--of PEBLOs and JAGs, and encouraging the
use of certified veterans' service officers throughout the IDES
process.
(f) Provide servicemembers the opportunity and sufficient time to
obtain a review of the NARSUM and all pertinent medical records by a
specialist(s) of the servicember's choosing, and the opportunity to
present such specialist findings in rebuttal.
(3) Adopt the key recommendation of the Dole-Shalala Commission by
establishing a single adjudication system with a single agency
responsible for disability evaluation that would not only provide
needed consistency, but help realize a more streamlined, timely
process.
(4) Ensure leadership and oversight at the highest level to
achieve the required system re-engineering and quality-control measures
to realize the goals of IDES.
Conclusion
WWP believes that, whatever the injury, every warrior going through
the IDES process should receive comprehensive medical treatment, full
and fair adjudication of their medical conditions and disability
evaluation, and accurate compensation for service-related health
conditions. Today, almost five years after a bipartisan commission
called for streamlining the complicated disability evaluation system
that so poorly served Wounded Warriors, the goals envisioned for that
system have yet to be realized. WWP recognizes that VA and DoD staffs
have devoted much time and effort to improving the disability
evaluation process, but more must be done to produce a system worthy of
our Wounded Warriors and the sacrifices they have made. We call for a
re-engineering of IDES processes, and institutionalization of quality-
controls along with continuing Congressional oversight, as the pathway
to meeting this obligation to our warriors.
Reevaluating the transition from servicemember to Veteran: Honoring a
shared commitment to care for those who defend our freedom
Overview of Wounded Warrior Project Testimony
The Integrated Disability Evaluation System (IDES) was intended to
create: (1) a less complex, non-adversarial system; (2) faster, more
consistent evaluations and compensation; (3) a single medical exam and
a single-source disability rating; and (3) a smooth transition to
veteran status. In large part, those critically important goals have
yet to be achieved. While VA has done its part, DoD still has much work
to be done.
DoD must address both structural and operational problems in the
IDES. These include: (1) artificial timelines that create pressures to
prematurely push servicemembers into the medical-evaluation process and
result in their being rushed through the Medical Evaluation Board (MEB)
process; (2) an MEB process that relies on reviewing only partial and
often-incomplete medical records (and does not even meet with the
servicemember) to produce an often-incomplete and inaccurate narrative-
summary, which is the most critical evidence considered by the final
decisional authority; (3) resultant errors in the narrative summary
that make it more difficult ultimately to establish service-connection
and that have the effect of increasing the number of appeals in an
already clogged VA adjudication system; (4) lack of sufficient time for
the servicemember to understand and challenge the content or accuracy
of that decision document; (5) lack of a meaningful mechanism for the
Member to secure a truly independent medical review of key decision
documents; and (6) wide disparity in the extent of effective assistance
and representation of members in the IDES process.
We urge the Committee to work with the Armed Services Committee to
spur the Executive Branch to make needed changes. Among those
recommendations, we urge that DoD be directed to re-engineer and
institute quality-controls on the ``front-end'' of the IDES process.
Among those needed steps, DoD must provide safeguards to protect
servicemembers from being pushed into and rushed through the MEB
process. That process should not begin until optimum medical care has
been provided and the servicemember's conditions have been diagnosed.
System changes are badly needed to ensure that narrative summaries are
fully and accurately developed, to include requiring MEBs to review
thoroughly all medical records, and provide opportunities for the
servicemember to meet with the MEB. Servicemembers also need more time
to review the MEB summary, and need greater access to effective
representation and assistance, as well as the opportunity to have the
summary reviewed by a specialist of the servicemember's choosing.
WWP recognizes that VA and DoD staffs have devoted much time and
effort to improving the disability-evaluation process, but more must be
done to produce a system worthy of our Wounded Warriors and the
sacrifices they have made. We call for a re-engineering of IDES'
processes, and institutionalizing quality-controls along with
continuing Congressional oversight as the pathway to meeting the
obligation owed our warriors.
Prepared Statement of Eric Greitens, Phd
Mr. Chairman and Members of the Subcommittee, thank you for the
opportunity to testify this morning as the Founder and CEO of The
Mission Continues. The Mission Continues challenges veterans to serve
and lead in communities across America.
We believe that any system that is designed to create successful
transitions for veterans, will only work if veterans are first
recognized for the immense abilities that they bring back to their
communities. We have learned that by focusing on these strengths,
despite some of the most severe disabilities, we can facilitate
successful transitions from warrior to citizen.
As a Navy SEAL, I served four tours in the Global War on Terrorism.
On my last deployment in Iraq, my unit was hit by a suicide truck bomb.
I was treated at the Fallujah surgical hospital and returned to full
duty 72 hours later, but some of my friends - some of whom were
standing an arms length from me - were hurt far worse than I was.
When I returned home, I visited them and went to Bethesda Naval
Hospital to visit other wounded Marines. As all of you know, when you
meet with our wounded servicemembers, you are often talking with young
men and women, the balance of their lives still before them. I asked
each of them about their units, their hometowns, their deployments, and
when I asked, ``What do you want to do when you recover?'' Each one of
them said, ``I want to return to my unit.'' Their bodies had been
injured, but their spirit of service had endured.
My experience at Bethesda that day was not unique. In a recent
survey of post-9/11 veterans, 92% strongly agreed or agreed that
serving their community is important to them.
At The Mission Continues we create successful transitions by
engaging returning veterans to continue their service by engaging them
in six-month fellowships at nonprofit and public service organizations
in their communities: an Army specialist from the 82nd Airborne now
trains service dogs for the disabled; a Marine Corps sergeant now
builds home with Habitat for Humanity; an enlisted airman who now
serves her fellowship as a support attendant at a women's shelter.
During their Fellowships, our veterans are provided with stipends,
mentors, and broad curriculum to achieve one of three post-Fellowship
goals. They go on to full-time employment, full-time education, or
participate in an ongoing role of service in their communities. To
date, we have awarded Fellowships to 255 post-9/11 veterans, who have
served with 168 organizations across the country.
For example, in Mississippi County, Anthony Smith served his
Fellowship working with under-privileged youth. In 2004, Anthony was
serving as a major in the Army when he was hit by a rocket-propelled
grenade. After spending 64 days in a medically induced coma, he awoke
to find that he was blind in one eye, had lost his right arm underneath
the elbow, and that parts of his leg, hip and spinal cord were damaged.
Like many of the veterans that we work with, his transition was
difficult, and he started to doubt whether or not he was needed here at
home.
After Anthony became a Mission Continues Fellow, he found a renewed
sense of purpose. Through his Fellowship, Anthony is using martial arts
to mentor at-risk youth. Daily, dozens students from his community
enter Anthony's dojo. Using pushups, modeling patience, and teaching
self-control, Anthony teaches lessons in his community everyday.
In two independent research reports, the George Warren Brown School
of Social Work at Washington University has found that nearly 80% of
the participants in our program felt that serving in the community had
a positive effect on their future employability, performance, and
promotion, or that it instigated them to make a career change. In fact,
86% of participants reported transferring their military skills to
civilian employment and 100% of Fellows reported that they will
probably or definitely stay involved in volunteer activities and public
service in the future.
Mr. Chairmen and Members present, the story of this generation of
veterans is still being written. We have a tendency to rely on PTSD
figures, unemployment statistics, and suicide rates to tell us how our
veterans are transitioning from the military to civilian life. But
these statistics do not tell the whole story. These statistics do not
capture a veteran's desire to continue to serve and the willingness to
lead in communities upon their return.
They do not tell the story of Jake, a former Marine who now
coordinates rescue missions to international disasters; or April, the
Army veteran from Chicago, who serves as a mentor to refugee children
in the classroom. Across America, veterans are serving again. In fact,
the majority of the members in this Committee have Mission Continues
Fellows serving in their district or neighboring districts. And last
year, with our Fellows as examples, The Mission Continues engaged over
15,000 Americans to spend a day of service with veterans in their
communities. Our Mission Continues Fellows are enduring leaders who
have overcome pain and turned it to wisdom. They are veterans whose
commitment to our country did not end on the battlefield.
In order for veterans to transition successfully, communities
across America must begin to recognize the service they still have to
give. We believe that when the story of this generation of veterans is
written, it will not only be a story of the wars they have fought
overseas; it will also be a story of the homes built, the parks
restored, the young minds engaged by veterans whose mission continues
here at home.
Mr. Chairman, we are grateful for your support and the support of
this Subcommittee. I would welcome any questions that you or other
Members may have. Thank you.