    [Senate Hearing 112-556]
    [From the U.S. Government Publishing Office]

                                                            S. Hrg. 112-556

      SEAMLESS TRANSITION: REVIEW OF THE INTEGRATED DISABILITY EVALUATION
                                     SYSTEM

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

                                    HEARING

                                   BEFORE THE

                         COMMITTEE ON VETERANS' AFFAIRS
                              UNITED STATES SENATE

                          ONE HUNDRED TWELFTH CONGRESS

                                 SECOND SESSION

                                   __________

                                  MAY 23, 2012

                                   __________

           Printed for the use of the Committee on Veterans' Affairs

             Available via the World Wide Web: http://www.fdsys.gov

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                         COMMITTEE ON VETERANS' AFFAIRS

                       Patty Murray, Washington, Chairman
    John D. Rockefeller IV, West         Richard Burr, North Carolina,
        Virginia                             Ranking Member
    Daniel K. Akaka, Hawaii              Johnny Isakson, Georgia
    Bernard Sanders, (I) Vermont         Roger F. Wicker, Mississippi
    Sherrod Brown, Ohio                  Mike Johanns, Nebraska
    Jim Webb, Virginia                   Scott P. Brown, Massachusetts
    Jon Tester, Montana                  Jerry Moran, Kansas
    Mark Begich, Alaska                  John Boozman, Arkansas
                           Kim Lipsky, Staff Director
                     Lupe Wissel, Republican Staff Director

                                C O N T E N T S

                                  ----------

                                  May 23, 2012
                                    SENATORS

                                                                       Page
    Murray, Hon. Patty, Chairman, U.S. Senator from Washington.......     1
    Boozman, Hon. John, U.S. Senator from Arkansas...................     4
    Burr, Hon. Richard, Ranking Member, U.S. Senator from North
      Carolina.......................................................     5
        Prepared statement...........................................     5
    Tester, Hon. Jon, U.S. Senator from Montana......................     6
    Johanns, Hon. Mike, U.S. Senator from Nebraska...................    94

                                   WITNESSES

    Rooney, Jo Ann, Acting Under Secretary of Defense for Personnel
      and Readiness, U.S. Department of Defense......................     6
        Prepared statement...........................................     9
        Response to prehearing questions submitted by Hon. Richard
          Burr.......................................................    12
        Response to posthearing questions submitted by:
          Hon. Patty Murray..........................................    33
          Hon. Richard Burr..........................................    47
          Hon. Bernard Sanders.......................................    51
        Response to request arising during the hearing by:
          Hon. Jon Tester and Hon. John Boozman......................    89
          Hon. Patty Murray..........................................   100
    Gingrich, John R., Chief of Staff, U.S. Department of Veterans
      Affairs........................................................    52
        Prepared statement...........................................    53
        Response to prehearing questions submitted by Hon. Richard
          Burr are merged in with same to DOD........................    13
        Response to posthearing questions submitted by:
          Hon. Patty Murray..........................................    33
          Hon. Richard Burr..........................................    47
          Hon. Bernard Sanders.......................................    56
        Response to request arising during the hearing by:
          Hon. Richard Burr..........................................    89
          Hon. Jon Tester............................................    92
          Hon. Patty Murray..........................................    98
    Bertoni, Daniel, Director, Education, Workforce, and Income
      Security, U.S. Government Accountability Office................    57
        Prepared statement...........................................    60
        Response to posthearing questions submitted by Hon. Bernard
          Sanders....................................................    78
        Response to request arising during the hearing by Hon. Mike
          Johanns....................................................    96
    Interim Committee Staff Report: Investigation of Joint Disability
      Evaluation System..............................................    79

                                    APPENDIX

    Paralyzed Veterans of America; prepared statement................   103

      SEAMLESS TRANSITION: REVIEW OF THE INTEGRATED DISABILITY EVALUATION
                                     SYSTEM

                                  ----------

                            WEDNESDAY, MAY 23, 2012

                                           U.S. Senate,
                                Committee on Veterans' Affairs,
                                                        Washington, DC.
        The Committee met, pursuant to notice, at 10:05 a.m., in
    room SD-562, Dirksen Senate Office Building, Hon. Patty Murray,
    Chairman of the Committee, presiding.
        Present: Senators Murray, Tester, Burr, Johanns, and
    Boozman.

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

        Chairman Murray. Good morning and welcome to today's
    hearing to examine the ongoing efforts of the Department of
    Defense and the Department of Veterans Affairs to provide a
    truly seamless transition for our servicemembers and our
    veterans.
        Almost a year ago today, this Committee held a hearing on
    VA and DOD efforts to improve transition. We explored a number
    of issues, including the Integrated Disability Evaluation
    System. At the hearing, we had an opportunity to hear from both
    Departments about the state of the joint program. The
    Departments' testimony that day spoke to how the Departments
    had created a more transparent, consistent, and expeditious
    disability evaluation process. Their testimony also states IDES
    is a fairer, faster process.
        Well, now that the joint system has been implemented
    nationwide, I have to say that I am far from convinced that the
    Departments have implemented a disability evaluation process
    that is truly transparent, consistent, or expeditious.
        There are now over 27,000 servicemembers involved in the
    disability evaluation system. As more and more men and women
    return from Afghanistan and as the military downsizes, we are
    going to see an even larger group of servicemembers transition
    from the military through the disability evaluation process.
        This process impacts every aspect of a servicemember's life
    while they transition out of the military, but it does not stop
    there. If the system does not work right, it can also
    negatively affect the servicemember and their family well after
    they have left active duty. Getting this right is a big
    challenge, but it is one that we have no choice but to step up
    to meet.
        I have seen the impacts of a broken system, whether it is
    from a wrong diagnosis, an improper decision, or never-ending
    wait times, and when the system does not work and
    servicemembers cannot get a proper mental health evaluation or
    diagnosis, it means they are not getting the care that they
    need. Without the proper care, these men and women may find
    themselves struggling to readjust to family or civilian life,
    and they often struggle to find work.
        Worse yet, we have heard stories of soldiers overdosing on
    drugs, and in far too many cases, taking their own lives. These
    are real tragedies affecting real servicemembers, and they are
    happening despite a system intended to provide greater support
    to our wounded, ill, and injured. I have seen first hand the
    impact an improper decision can have on a soldier and his
    family.
        Earlier this year, I met Sergeant First Class Stephen Davis
    and his wife, Kim, at Joint Base Lewis-McChord in my homestate
    of Washington. Sergeant Davis led his men in combat in both
    Iraq and Afghanistan. He was exposed to multiple IED explosions
    during his service, and after being treated by the Army for
    years for PTSD and other mental health disorders, he was told,
    during the disability evaluation process, that he was making up
    his ailments.
        From speaking with him, I can tell you that Sergeant Davis
    and the hundreds of other men and women at Joint Base Lewis-
    McChord are far from satisfied with the transparency and
    consistency of the disability evaluation process. All of these
    men and women had been diagnosed with, and in many cases, were
    receiving treatment for PTSD during service.
        But then during the disability evaluation process, they
    were told they were exaggerating their symptoms, they were
    labeled as malingerers, and their behavioral health diagnoses
    were changed. Since then, the Army has launched investigations
    and hundreds of soldiers are now being reevaluated in an effort
    to make this right. In fact, the most recent update from the
    Army shows that out of the 196 cases that have been
    reevaluated, 108 have resulted in a diagnosis of PTSD. That is
    more than half of these men and women.
        Still more have received other significant behavioral
    health diagnoses. Other referrals and reevaluations are still
    occurring. I am still hearing from those who have completed
    their reevaluations only to find themselves stuck back in the
    same Disability Evaluation System that failed them.
        Despite all these men and women have been through, they
    continue to have their behavioral health injuries minimized and
    feel like their chain of command does not understand what they
    are going through. Clearly more needs to be done to build
    uniformity and accountability into the process of identifying
    those who are struggling with PTSD and other behavioral health
    problems.
        In recent weeks, the Army has taken a number of steps in
    the right direction. Their recent policy on the diagnosis and
    treatment of PTSD addresses a number of the concerns that I
    have raised. It standardizes the Army mental health care
    through the use of proven treatments and assessments, it
    recognizes how extraordinarily rare it is for servicemembers to
    fake symptoms of PTSD, and this acknowledgment is critical, as
    we saw all too often that accusation at Madigan Army Medical
    Center.
        Additionally, just last week, the Army took another
    critically important step forward in addressing the concerns I
    have been raising by announcing a comprehensive Army-wide
    review of behavioral health evaluations and diagnosis in
    support of the Disability Evaluation System. I want to applaud
    the Army leadership for taking some significant steps toward
    addressing these issues. This is going to take continued
    engagement from the Army leadership.
        Now, I know some may argue that this is just a Joint Base
    Lewis-McChord problem or an Army problem, but it is not. This
    is a systemwide problem. We will continue to see issues similar
    to those at Madigan until the DOD and VA ensure policies and
    actions, like those we have seen from the Army in recent weeks,
    are adopted across the services and throughout the joint
    system.
        Ensuring servicemembers receive a proper diagnosis in the
    care and benefits they earned is an obligation we have as a
    Nation. We owe it to these men and women to get this right.
        These are not the only challenges confronting the
    Integrated Disability Evaluation System. We are going to hear
    today from GAO about other challenges facing the Departments,
    challenges which I must say sound all too familiar. Everyone on
    this Committee knows of VA's struggles to address the claims'
    backlog.
        I am troubled because numbers from the Integrated
    Disability Evaluation System paint a similar picture.
    Enrollment continues to climb, the number of servicemembers'
    cases meeting the Departments' timeliness goals is unacceptably
    low, and the amount of time it takes to separate and provide
    benefits to a servicemember through this system has risen each
    year since its inception.
        This continued rise in the amount of time it takes to
    provide a servicemember with a decision has to be addressed.
    The goal the Departments have set for completing IDES is 295
    days for active duty and 305 days for reservists. Last year, on
    average, it took active duty servicemembers 394 days and
    reservists 420 days. That is around 100 days longer than your
    goal, and it is simply unacceptable.
        Dr. Rooney, Mr. Gingrich, right now the Departments are
    failing these servicemembers. The only thing this Committee is
    interested in are the solutions to this problem and the
    dedication of your leadership in making things better. We
    cannot allow the same problems that plague the larger
    disability claim system to negatively impact the transition of
    thousands of servicemembers in the next few years. The
    consequences are too severe.
        Clearly, a lot of work remains to be done. But we have seen
    the Army moving in the right direction. Now DOD and VA need to
    take these lessons learned and apply them across the entire
    system. Not only will this require quick action, but most
    importantly, this effort is going to require the total
    engagement, cooperation, and support of all senior leaders at
    both Departments to get this done right.
        While DOD and VA are at a critical juncture, I am confident
    that by working harder and smarter and faster, the Departments
    can improve the system for thousands of men and women who will
    be transitioning in the next couple of years. With that, I will
    turn to Senator Boozman.
        Ranking Member Burr was in another meeting and just joined
    us, so we will first turn to Senator Boozman for his statement.

                    STATEMENT OF HON. JOHN BOOZMAN,
                       U.S. SENATOR FROM ARKANSAS

        Senator Boozman. Thank you, Chairman Murray, and thank you
    and Senator Burr for holding this hearing to discuss the
    Integrated Disability Evaluation System, including how well it
    is working and what is being done to improve it. Also thank you
    to our witnesses for joining us today.
        As we will hear today, it is clear that the Integrated
    Disability Evaluation System, or IDES, is still facing real and
    significant challenges. Overall, it is taking more than 1 year
    for servicemembers to go through this process, about one third
    longer than the VA and the Department of Defense intended. At
    some military bases, it is still taking much longer than that.
    In fact, only 18 percent of active duty servicemembers are
    transitioning to civilian life within the agency's 295-day
    goal.
        During this time, wounded, ill, and injured servicemembers
    are waiting to find out whether they can continue serving in
    the military or have to build new lives as civilians. For those
    who are ready and able to move on with their lives, this must
    seem like an eternity.
        I think the number of servicemembers in this process who
    are administratively discharged or court martialed or died from
    unnatural causes, including suicides and overdoses, raises
    serious questions about what the impact these delays may be
    having on the personal well-being of our Nation's wounded
    warriors. Also, I think we need to consider whether the IDES is
    truly setting them up to succeed after leaving the military.
        As the Committee has been told by many servicemembers going
    through this process, the uncertainty about when and where they
    might leave the military can actually prevent them from getting
    their civilian lives in order, such as buying a house, finding
    a school, or taking a job.
        On top of that, it appears that this system is not as
    straightforward or user-friendly as it was intended. Listen to
    what the Wounded Warrior Project said about the IDES process
    earlier this year: ``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.'' Other words that
    have been used to describe IDES include adversarial, long, and
    disjointed.
        There is another hidden liability here that I think is
    important to note and that is the potential impact that the
    backlog may have on our military readiness, particularly in a
    time when some in Washington are talking about drawing down our
    force strength. Right now there are about 19,000 soldiers, as
    in just in the Army, who are in this process. I am under the
    impression that these servicemembers are still considered as
    being in the military, so that comes out of the bottom line for
    Army's in-strength and cannot be replaced until they have
    completed the IDES process.
        Based on these and other issues we will hear about today,
    it is clear that we are still a long way from actually having
    created a seamless transition for many wounded, ill, and
    injured military personnel. So I hope the Committee will have a
    good discussion about what can be done to simplify this
    disability system, speed up the process for those who are ready
    to move on with their civilian lives. And with that, I yield
    back my time.
        Chairman Murray. Thank you very much. Senator Burr?

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

        Senator Burr. Madam Chairman, I just ask unanimous consent
    to put my statement in the record. Thank you.
        [The prepared statement of Senator Burr follows:]
            Prepared Statement of Hon. Richard Burr, Ranking Member
        Good morning, Chairman Murray. Welcome to you and to our witnesses.
    Thank you for calling this hearing to discuss the Integrated Disability
    Evaluation System--or IDES.
        This joint VA and Department of Defense process was meant to help
    ease the transition to civilian life for injured or ill servicemembers,
    by allowing them to find out before they leave the military what
    benefits they will receive from both agencies. But, as we'll hear
    today, there have been consistent performance challenges with this new
    system.
        In fact, at Committee hearings last May, we heard about inadequate
    IT solutions, staffing shortages, and other problems that were leading
    to delays and frustrations for many servicemembers. At that time, it
    was taking about 400 days to go through the process--100 days longer
    than the target set by the agencies. Also, serious concerns were raised
    about the personal toll those delays may be having on many
    servicemembers and about the quality of their lives during this
    process.
        We heard then about a number of efforts that were underway to
    improve IDES. But--one year later--we'll hear about some of those same
    problems, and it's still taking nearly 400 days for injured and ill
    servicemembers to transition to civilian life. For members of the Guard
    and Reserves, it can take even longer--as much as 650 days. That's a
    long time for servicemembers to be held in limbo--not knowing whether
    their military careers are over and, if so, what benefits and services
    they would receive.
        Also, we continue to hear from servicemembers who are frustrated
    that they cannot plan for civilian life--like accepting a job or
    enrolling in school--because they don't know when they will leave the
    military. What's worse is the number of servicemembers going through
    this process who have taken their own lives, succumb to drugs, or
    suffered other unfortunate outcomes.
        Given all of this, it's understandable that stakeholders have
    called this process convoluted, contentious, and slow. Even the Army's
    Deputy Chief of Staff recently said this about it (quote):

            The biggest area that we need help is the Disability Evaluation
            System. It's fundamentally flawed. It causes an adversarial
            relationship with our medical professionals * * *. It's long.
            It's disjointed * * *.

        The bottom line is that many servicemembers and their families are
    not being well served by this process. So, we need to look at what
    should be done in the short term to bring relief to the 27,000 military
    personnel going through IDES now. But, we also need to seriously look
    at whether this system--as currently structured--will ever provide
    servicemembers with the high level of service they deserve.
        Madam Chairman, we should not be content with a cumbersome process
    that leaves injured and ill servicemembers in a state of uncertainty
    for more than a year, when they want and need to move on with their
    lives. The men and women who have been harmed while serving our Nation
    deserve better. So, I hope we can work collectively to find solutions
    that will cut through the bureaucracy and, more importantly, will truly
    help ease their transition to civilian life.

        I again thank the witnesses for being here, and I thank the Chair.

        Chairman Murray. Thank you very much. At this time, I want
    to--oh, Senator Tester, I did not see you come in.
        Senator Tester. Thanks.
        Chairman Murray. You are welcome.

                     STATEMENT OF HON. JON TESTER,
                       U.S. SENATOR FROM MONTANA

        Senator Tester. I would just like to say thank you, Dr.
    Rooney, for being here, and Mr. Gingrich, and Mr. Bertoni. I
    would just say that since I have been on this Committee, which
    has been five-and-a-half years now, we have been talking about
    this issue. Obviously it is not an easy issue or it would be
    done already.
        By the same token, maybe we ought to get the Committee on
    Military Affairs in here, but you are here, Dr. Rooney, but to
    put pressure on the DOD to make sure they are doing their job
    as we put pressure on the VA to make sure they are doing their
    job. Let me just give you a real quick statistic.
        Secretary Shinseki mentioned that his goal for the
    disability compensation and pension claims is 125 days, 98
    percent accuracy. Right now, according to the report Mr.
    Bertoni put out, it is 394 days and it is 79 percent accurate.
    We have got an issue here, and the reason I know we have got an
    issue here is because I have got veterans calling me all the
    time. It is too complicated, they do not know how to get
    through it, and quite frankly, the folks who serve this country
    deserve better.
        We have got to figure out how to get this right, and I do
    not think IDES is doing it right now, but I could be corrected
    on that and I look forward to that if you do correct me,
    because the bottom line is, what this Committee does is
    important, but what is even more important is the services we
    give to our vets and the folks that need help and have earned
    that help need to get it and need to get it now. Thank you,
    Madam Chair.
        Chairman Murray. OK. Thank you very much. Now, at this
    time, I would like to introduce and welcome today's witnesses.
    Representing the Department of Defense is the Acting Under
    Secretary of Defense for Personnel and Readiness, Dr. Jo Ann
    Rooney. Dr. Rooney, we had the chance to talk about several of
    these issues at the field hearing I held in Tacoma a few months
    ago, and I really appreciate your willingness to testify before
    this Committee again, and I am pleased you are continuing to
    focus on this issue.
        Joining us from the Department of Veterans Affairs is VA's
    Chief of Staff, Mr. John Gingrich. From the Government
    Accountability Office, we have Mr. Daniel Bertoni, the Director
    of Education, Workforce, and Income Security Issues. I want to
    thank each one of you for joining us this morning and we look
    forward to hearing your testimony. Your prepared remarks will,
    of course, appear in the record. Dr. Rooney, we will begin with
    you.

     STATEMENT OF JO ANN ROONEY, ACTING UNDER SECRETARY OF DEFENSE
           FOR PERSONNEL AND READINESS, DEPARTMENT OF DEFENSE

        Ms. Rooney. Thank you. Good morning, Chairman Murray,
    Ranking Member Burr, and Members of the Committee. It is my
    pleasure to be here today to testify on current efforts focused
    on reviewing and improving the Integrated Disability Evaluation
    System, or IDES. I am pleased to be appearing with one of my
    partners from the Department of Veterans Affairs.
        As Departments, we are working closely together to provide
    an integrated, seamless process for wounded, ill, or injured
    servicemembers as they transition to veteran status. Taking
    care of our servicemembers is the absolute highest priority of
    the Department of Defense. Part of taking care of our
    servicemembers includes ensuring their honorable service is
    recognized and they are compensated in both DOD and VA systems
    for injuries and illnesses incurred during that service.
        The Department has undertaken many initiatives to
    accomplish this, but we acknowledge there is much more work to
    be done. Over the past 5 years, the Departments of Defense and
    Veterans Affairs 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 wounded, ill, and injured 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. The Joint Executive
    Council, or JEC, co-chaired by the VA Deputy Secretary Gould
    and me, devotes part of each bimonthly meeting to reviewing the
    progress and understanding the ongoing actions toward achieving
    our goal of seamless transition from servicemembers to
    veterans.
        Similarly, the quarterly meeting conducted jointly by the
    Secretary of Defense and the Secretary of Veterans Affairs,
    with their senior leaders, to oversee and drive progress toward
    the stated goals. One of these efforts is IDES. IDES delivers a
    more servicemember-centric design, a simpler process, more
    consistent evaluations, and compensation, easier transition to
    veteran status, case management advocacy, and an established
    relationship between the servicemember and VA prior to
    separation.
        It also provides increased transparency through better
    information flow to servicemembers and their families as well
    as a reduced gap between separation, or retirement from
    service, and receipt of VA benefits.
        The IDEA streamlines the Disability Evaluation System with
    servicemembers receiving a single set of physical disability
    examinations conducted according to VA examination protocols,
    proposed disability ratings prepared by VA that both
    Departments can use, and dual processing to ensure the earliest
    possible delivery of disability benefits.
        Currently the IDES is in use at 139 locations across all
    services. Since November 2007, 19,518 servicemembers have
    completed the IDES process. The IDES has also reduced that
    post-separation benefits gap between DOD and VA from an average
    of 240 days in 2007 to 50 days currently, which means disabled
    veterans receive their VA benefits 79 percent faster under the
    current IDES than before.
        Even with the marked improvements in performance the IDES
    has brought to the disability evaluation process, we have much
    work remaining. Both Departments are committed to constant
    evaluation of each step throughout the process and will
    continue to seek long-term innovative solutions focused on
    improving the experience of our wounded warriors. We must do
    that.
        We also much carefully review the critical steps in IDES to
    reach the 295-day completion goal for at least 60 percent of
    those entering the process by the end of this calendar year.
    The military services are each in the process of implementing
    actions to improve efficiency and effectiveness. Since October
    2011, this fall, the Army has added 513 medical evaluation
    board and physical evaluation board personnel and enhanced
    accountability by establishing performance metrics to measure
    the productivity of board staff.
        The Army has also completed a senior leader assessment of
    the execution of the IDES at installations across the Army.
    This assessment identified specific actions required to enhance
    and standardize performance across the Army. The Navy and
    Marine Corps have added ten doctors and 37 case managers to
    their medical evaluation board staff last year and anticipate
    the addition of 23 more doctors next year.
        Physical evaluation board staffs have increased in both
    Navy and Marine Corps by 47 percent, allowing them to process
    75 percent of the Navy and 69 percent of the Marine cases
    through this particular phase in less than the 120-day phase
    goal. The Air Force has also leaned forward and started to
    utilize Air Force National Guard personnel to support the
    evaluation process and established a pre-IDES eligibility
    screening process, again to increase efficiency.
        The Office of the Secretary of Defense has also removed
    policy impediments, implemented procedural improvements, and
    enhanced oversight and assistance to the services. Examples of
    these include reducing minimum informal physical evaluation
    board staffing requirements from three members to two members,
    authorizing doctoral level psychologists to sign medical
    evaluation boards. Prior they were not able to.
        Allowing military departments to process initial trainees
    through the Legacy system. Additionally, DOD is working with
    our VA partners to improve IDES execution by improving training
    and case management software, implementing a common paperless
    standard for electronic transfer of files by this summer, and
    developing other integrated electronic record file sharing
    methods which will enhance the efficiency of the IDES.
        The Departments anticipate these improvements when
    implemented this summer of 2012 will reduce IDES time, on
    average, by 20 to 30 days. The Departments are committed to
    ensuring that disability evaluation and compensation of
    injured, ill, and wounded servicemembers is thorough, fair, and
    accurate.
        We are continually reviewing the process and the
    requirements to adequately staff, and when necessary, surge the
    IDES so it remains responsive to the needs of recovering
    servicemembers in the services as they draw down and reset
    their forces. Yet we understand there is room for improvement
    in all parts of our processes and are committed to working
    toward that end.
        After two decades of war with an all-volunteer force that
    has seen marked improvements in survival of previously
    unsurvivable combat injuries, the expectations of what happens
    after a servicemember becomes ill or injured are fundamentally
    different. The Department is now focused on taking advantage of
    all the advances in medical care, restorative therapies, and
    rehabilitation to allow a servicemember to achieve his or her
    greatest potential.
        This includes retention in military service whenever
    possible. This concept of being made whole reflects a
    commitment to the servicemembers to restore the highest level
    of function possible physically, mentally, spiritually, and
    financially and providing all the benefits that are justified.
        The target of 295 days to complete the IDES process was
    originally identified to address the concerns and frustrations
    of servicemembers who did not believe they were being properly
    cared for and felt they were languishing in an uncoordinated,
    insensitive system. Since these issues surfaced, many resources
    have been brought to bear to improve the coordination and care
    and the adjudication of benefits.
        The complexity of injuries, sophisticated treatment
    strategies, coordination of care, and change in the
    philosophical approach to the goals of patient-centric versus
    military department-centric has redefined the timeliness for
    completion of the system. In fact, it has become more of a
    system centered on improving and defining ability rather than
    singularly focused on transition of a servicemember to veteran
    status and is often individualized in its application to
    achieve this goal.
        The Department reaffirms its commitment to care for and
    honor those who have protected our Nation by serving in
    uniform. In order to meet our sacred responsibilities to this
    next greatest generation, we must fully leverage the
    capabilities and strategies and strengths of both the
    Department of Defense and Veterans Affairs. We must break down
    the barriers that prevent us from delivering the highest
    quality care to those who need it and deserve it.
        Thank you again for the opportunity to be with you today,
    Madam Chairman, and I look forward to the Committee's
    questions.
        [The prepared statement of Ms. Rooney follows:]

      Prepared Statement of Dr. Jo Ann Rooney, Acting Under Secretary of
          Defense, Personnel and Readiness, U.S. Department of Defense

        Chairman Murray, Ranking Member Burr, and Members of the Committee:
    Thank you for inviting me to testify before you on the current status
    of the Integrated Disability Evaluation System (IDES) and current
    efforts to improve it.
        The 2007 revelations regarding suboptimum conditions for wounded
    warriors at Walter Reed Army Medical Center made for a stark wakeup
    call. In the nearly five years since, the Department of Defense (DOD)
    has worked in tandem with our Department of Veterans Affairs (VA)
    colleagues to improve policies, procedures, and conditions that impact
    care of our wounded warriors. Today, we meet at a time of historic
    cooperation between the Departments of Defense and Veterans Affairs.
    Thanks to President Obama's commitment to Veterans and delivering the
    care they have earned, we have established a program of support between
    our Departments that is more responsive and comprehensive in scope than
    ever before. More so than at any time in our Nation's history, those
    who separate from military service are greeted by more comprehensive
    mental and physical care; by greater opportunity for education and
    jobs, and by a deeper societal commitment to ensuring their welfare.
    When you compare the experience of our troops today to the generation
    of heroes who returned from Vietnam, the progress made toward a single
    system of lifetime care is significant, yet we must continue to make
    improvements.

                                   BACKGROUND

        After the Career Compensation Act of 1949 created the basic
    structure of the Department's Disability Evaluation System (DES), it
    remained relatively unchanged until November 2007. In response to
    public and Congressional concern after reports of inadequate conditions
    for wounded warriors at Walter Reed, the joint DOD and VA Senior
    Oversight Committee (SOC) chartered a pilot designed to create a more
    Servicemember-centric, seamless, and transparent disability program.
    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 law.
        The pilot was launched at three major military medical treatment
    facilities in the National Capital Region on November 21, 2007--Walter
    Reed Army Medical Center, National Naval Medical Center, Bethesda, and
    Malcolm Grow Air Force Medical Center. It successfully created an
    integrated process that delivers Departments of Defense and Veterans
    Affairs benefits as soon as possible following release from active duty
    and significantly reduced the gap in benefits that existed in the
    previous system. DOD found the DES Pilot to be faster, more equitable,
    and more efficient than previous approaches. In a representative survey
    of over 1,000 Servicemembers, those in the DES Pilot were more
    satisfied with their experience than those in the legacy process. As a
    result, in July 2010, the Deputy Secretaries of Defense and Veterans
    Affairs directed worldwide implementation to begin in October 2010, and
    to be completed by September 2011. On December 31, 2010, the DES Pilot
    officially ended and the first Integrated Disability Evaluation System
    (IDES) site became fully operational.
        The IDES, similar to the DES Pilot, streamlines the disability
    process so Servicemembers receive a single set of physical disability
    examinations conducted according to VA examination protocols and
    disability ratings prepared by VA. The Departments of Defense and
    Veterans Affairs share the examination results and ratings to relieve
    Servicemembers of the burden of redundant examination requirements and
    divergent ratings for the same disability. Under Title 10 authority,
    the Department 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 10 percent or
    higher is awarded. It also determines eligibility for other VA benefits
    and services. The IDES permits both Departments to provide disability
    benefits at the earliest point allowed under their respective U.S.C.
    Titles. In March 2012, the post-separation wait for VA disability
    benefits was 79% shorter than in 2007 under the separate DOD/VA
    processes.
        The National Defense Authorization Act (NDAA) for FY 2008, Public
    Law 110-181, required DOD to utilize the VA Schedule for Rating
    Disabilities (VASRD). The Departments of Defense and Veterans Affairs
    are currently developing a memorandum of understanding that will allow
    DOD to become a member of the working groups updating the VASRD and
    give DOD the opportunity to make recommendations prior to the
    publication of proposed changes in the Federal Register. The
    Department's ability to provide this input is critical given the direct
    connection between VASRD ratings and the decision to place
    Servicemembers on the medical retirement list with annuities, benefits,
    and healthcare. This issue is being evaluated by the Benefits Executive
    Council, which is a joint DOD/VA forum, and anticipates completion over
    the next several months.
        In summary, IDES delivers a more Servicemember-centric design, a
    simpler process, more consistent evaluations and compensation, easier
    transition to Veteran status, case management advocacy, and an
    established relationship between the Servicemember and VA prior to
    separation. It also provides increased transparency through better
    information flow to Servicemembers and their families and a reduced gap
    between separation or retirement from service to receipt of VA
    benefits.

                                    CASELOAD

        The Department evaluated 18,393 Servicemembers for disability
    during 2011, 22% more than in 2001. More than 50% of the Servicemembers
    evaluated for disability in 2011 completed the legacy DES process.
    Today, fewer than 2,000 Servicemembers remain in that legacy process.
    The Department is rapidly completing the evaluation of these legacy
    cases and will be complete with a small number of exceptions by
    September 2012.
        As the number of Servicemembers in the independent legacy process
    has declined, the number of Servicemembers in IDES has grown. Since
    November 2007, 49,478 Servicemembers have entered and 19,518 have
    completed the IDES, 2,589 members did not complete the IDES process due
    to a host of reasons including death, disenrollment, or return to
    active duty. As of early this month, 27,371 Servicemembers were in the
    IDES (67 percent Army, 12 percent Marines, 9 percent Navy, and 12
    percent Air Force). Two decades of war has contributed to the
    Department's disability case load and many of these ill and injured
    suffer from complex conditions which take time to properly diagnose and
    evaluate. We anticipate the number of Servicemembers in the IDES will
    continue to grow as members return from Afghanistan and the Services
    reduce their end strength.
        We are concerned about the IDES performance, both in terms of the
    quality of service provided and time it takes to complete the process,
    the Department is mindful that disability evaluation has a dual
    purpose. The first purpose is to ensure our Nation maintains a fit
    fighting force. The second is to compensate disabled Servicemembers and
    recognize their honorable service. The Department also understands that
    before we evaluate a Servicemember for possible separation from
    service, we must also ensure we provide them the best medical treatment
    and consider them for other duties that allow continued service to
    their country. Both of these factors affect the time required to
    complete the IDES process to ensure we provide due diligence and
    process to every Servicemember. It is the Department's strong
    conviction that we must not simply expedite the process at the expense
    of eroding these basic tenets. However, we must ensure the process is
    as efficient as possible. The Department is committed to ensuring the
    disability evaluation and compensation of injured, ill, and wounded
    Servicemembers is thorough, fair, and accurate. We are continually
    reviewing the process and the requirements to adequately staff, and
    when necessary, surge the IDES so it remains responsive to the needs of
    recovering Servicemembers and the Services as they draw-down and reset
    their forces.

                              CURRENT PERFORMANCE

        Prior to the IDES, the Departments of Defense and Veterans Affairs
    used separate disability evaluation processes which resulted in long
    wait times within each department. In addition, in 2007, the
    Departments of Defense and Veterans Affairs estimated disabled Veterans
    faced a 240-day gap between exiting military service and receiving full
    VA benefits. By March 2012, the IDES enabled the Departments of Defense
    and Veterans Affairs reduce the post-separation benefits gap from an
    average of 240 days in 2007 to 50 days, which means disabled Veterans
    received their VA benefits 79% faster under the IDES than before.
        Active component Servicemembers averaged 395 days in the IDES in
    March 2012. Approximately 80 days of this time consisted of
    Servicemembers in transition--clearing their installation and taking
    voluntary earned leave prior to separating from military service.
    Voluntary leave and clearing the barracks are distinct efforts from
    disability processing and vary significantly by individual. Therefore,
    the Department is evaluating whether this transition time should be
    excluded as part of the IDES time measurement metric. The Department is
    committed to constant evaluation of all our processes and will continue
    to seek long-term innovative solutions focused on improving the
    experience of our wounded warriors. Although the Department is not
    currently meeting the IDES processing time goal, we are focusing on the
    following action areas to close the 100-day gap.
        Staffing. The Services are applying surge manpower where needed.
    The Army has hired 1,218 out of 1,400 additional civilians (87%
    complete) to staff the IDES in anticipation of current caseload and
    future spikes in the IDES utilization. The Department of the Navy added
    staff at Camp Lejeune and reduced cases experiencing time delays by 21%
    in one month. The Department of the Navy also increased its Informal
    Physical Evaluation Board (IPEB) staffing by 47%, which reduced IPEB
    processing time from 50 days in January to 11 days in March 2012, well
    within the goal of 15 days. The Department of the Air Force is
    currently reviewing staffing requirements for their physical evaluation
    board.
        Leadership. The Services and VA leaders meet regularly (both inter-
    agency and intra-agency) to ensure they oversee and drive progress
    within their organizations. There are several examples of this
    coordination. The first is the bi-monthly Joint Executive Council (JEC)
    chaired by the Deputy Secretary of Veterans Affairs and Under Secretary
    of Defense for Personnel & Readiness. The second includes monthly
    reports of the IDES performance provided to the Secretaries of Defense
    and Veterans Affairs and reviewed at each JEC. The third is the ability
    of the Services to provide examinations of each installation including
    the performance of individual cohorts and identify under-performing
    situations. The fourth is the focus Deputy of Defense Management Action
    Group (DMAG) meeting, attended by senior military and civilian leaders
    from across DOD. The DMAG agenda for the summer of 2012 includes a
    detailed review of the IDES program. The Department is in the beginning
    stages of exploring strategic reforms to the process. The Department
    appreciates the Committee's support, and looks forward to working with
    the Congress as we continue to improve IDES.

                           A LOOK TOWARDS THE FUTURE

        In past wars, particularly with a conscripted force, it was
    expected that seriously injured or ill Servicemembers would transition
    to veteran status and receive long-term care through VA. This concept
    was generally accepted by all stake holders including lawmakers,
    military leadership, Servicemembers, and society.
        After two decades of war with an all-volunteer force that has seen
    marked improvements in survival of previously un-survivable combat
    injuries, the expectations of what happens after a Servicemember
    becomes ill or injured are fundamentally different. The Department is
    now focused on taking advantage of all the advances in medical care,
    restorative therapies, and rehabilitation to allow a Servicemember to
    achieve his or her greatest potential. This includes retention in
    military service when possible. This concept of being made ``whole''
    reflects a commitment to the Servicemember to restore the highest level
    of function possible--physically, mentally, spiritually, and
    financially--and providing all benefits that are justified. We now have
    many Servicemembers, some of whom are blind, have spinal cord injuries,
    or have lost limbs serving proudly on active duty.
        This strong commitment to rehabilitation and continued productive
    service in the military by ill and injured Servicemembers, many with
    more complex visible and invisible wounds then previously seen, has
    lengthened treatment and rehabilitation strategies and the time
    retained on active duty while recovering. It has also created a new
    mind-set for the injured Servicemember. Today there is a focus on
    attaining maximum functional ability before a decision is made to
    remain in or separate from active duty. Lawmakers and senior military
    leaders have endorsed this philosophy and Servicemembers embrace this
    change, driven by the desire to remain in active service because it is
    their chosen career.
        The target of 295 days to complete the IDES process was originally
    identified to address the concerns and frustrations of Servicemembers
    who did not believe they were being cared for properly and felt they
    were languishing in an uncoordinated, insensitive system. Since these
    issues surfaced, many resources have been brought to bear to improve
    the coordination of care and the adjudication of benefits.
    Specifically, Wounded Warrior Regiments and Wounded Warrior Battalions
    have been established along with other efforts to group, coordinate and
    focus optimized care and recovery for the Servicemembers and provide
    for families. In addition, much attention and unprecedented resources
    have focused on addressing the invisible wounds of war--PTSD, TBI and
    Behavioral Health issues--largely ignored in previous conflicts;
    illnesses which often complicate recovery from other injuries. The
    complexity of injuries, sophisticated treatment strategies,
    coordination of care and change in the philosophical approach to the
    goals of patient centric vs. military department centric care has
    redefined the timelines for completion of the disability evaluation
    system. In fact, it has become more of a ``system'' centered on
    improving and defining ``ability'' rather than singularly focused on
    transition of the Servicemember to veteran status and is often
    individualized in its application to achieve this goal. The current
    philosophical commitment to make the Servicemember ``whole'' and give
    them opportunities to remain in service is now coming in conflict with
    rigid timelines and legacy policies and procedures. As we look to long-
    term strategic reform being satisfied that we have achieved maximum
    efficiencies in the current IDES, it may be appropriate to focus on
    developing metrics which consider the number of days along with desired
    outcomes that measure how the system serves the overall needs of
    wounded warriors and the contemporary military.

                                   CONCLUSION

        While the Department supports the level of effort and progress
    made, we fully acknowledge there is much more to do. The Department has
    positioned itself to implement improvements and continue progress in
    providing support to our Servicemembers, veterans, and their families
    while supporting recovery, rehabilitation, and re-integration. Our
    dedicated Servicemembers, veterans, and their families deserve the very
    best. We pledge to give our best efforts to supporting their recovery,
    rehabilitation, and return to their communities.
                                     ______

    Response to Prehearing Questions Submitted by Hon. Richard Burr to DOD,
    Office of Wounded Warrior Care and Transition Policy and VA, Office of
          Policy and Planning, Integrated Disability Evaluation System

        (a) The number of servicemembers expected to enter the IDES process
    per year at each site.
        DOD Response. See attached spreadsheet, WWCTP SVAC Response Data,
    column header, ``Expected Referrals per year (a).''

    Notes:
        (1) Expected referrals per year based on medical evaluation boards
    the Military Departments reported in fiscal year 2011.
        (2) Department of the Navy data represents combined referrals for
    Navy and Marine Corps servicemembers.
        (3) Referral data for Walter Reed National Military Medical Center
    includes referrals from Ft. Belvoir and Ft. Meade.
        (b) For each site, the total current staffing level for Physical
    Evaluation Board Liaison Officers (PEBLOs) and the ratio of PEBLOs to
    servicemembers.
        DOD Response. See attached PEBLO ratio spreadsheet for ratio of
    PEBLOs to servicemembers.

        The Services reported staffing for each location based upon the
    following:

              PEBLO Case ratio is defined as the number of trained PEBLO
            full-time-equivalent (FTE) staff divided by 100/365 (.27)
            multiplied by the total number of new cases (to be defined by
            the Military Department) at the location per year.

              (# of PEBLOs)  [(.27)  (# of MEBs per year)] = Current
            PEBLO Ratio
        (c) For each site, the total current staffing level for Military
    Service Coordinators (MSCs) and the ratio of MSCs to servicemembers.
        DOD/VA Response. The attached spreadsheet, ``IDES Sites VA MSC-VSR
    Staff Levels,'' is the list of IDES Sites and respective military
    services coordinator caseloads. Monthly volumes at IDES sites range
    from less than 1 per month to a high of nearly 150 cases. VBA supports
    low-volume sites with part-time staffing.

        (d) The length of time, on average, servicemembers have been
    pending in the IDES process at each site.
        DOD Response. See WWCTP SVAC Response Data (response to question
    (a)), column header, ``Average Time Pending (d).''

        (e) The number of individuals who have been pending in the IDES
    process for longer than 295 days at each site.
        DOD Response. See WWCTP SVAC Response Data (response to question
    (a)), column header, ``# Cases Pending > 295 Days (e).''

        (f) The number of individuals who have been pending in the IDES
    process for longer than 540 days at each site.
        DOD Response. See WWCTP SVAC Response Data (response to question
    (a)), column header, ``# Cases Pending > 540 days (f).''

        (g) The total number of individuals who have completed the IDES
    process at each site.
        DOD Response. See WWCTP SVAC Response Data (response to question
    (a)), column header, ``# Cases Completed VA Benefits (g).''

        (h) The number of individuals from each site who completed the IDES
    process and were placed on the permanent disability retirement list.
        DOD Response. See WWCTP SVAC Response Data (response to question
    (a)), column header, ``# PDRL Cases (h).''

        (i) The number of individuals from each site who completed the
    process and were placed on the temporary disability retirement list.
        DOD Response. See WWCTP SVAC Response Data (response to question
    (a)), column header, ``# TDRL Cases (i).''

        (j) The number of individuals from each site who completed the
    process and were separated with severance pay.
        DOD Response. See WWCTP SVAC Response Data (response to question
    (a)), column header, ``# Separated with Severance (j).''

        (k) The total number of individuals from each site who have been
    removed from the IDES process.
        DOD Response. See WWCTP SVAC Response Data (response to question
    (a)), column header, ``# Cases Removed from IDES (k).''

        (l) The number of individuals from each site who were removed from
    the IDES process and received an Administrative Discharge after court
    martial.
        DOD Response. See WWCTP SVAC Response Data (response to question
    (a)), column header, ``# Court Martial (l).''

        (m) The number of individuals from each site who were removed from
    the IDES process and received an Administrative Discharge (excluding
    court martial).
        DOD Response. See WWCTP SVAC Response Data (response to question
    (a)), ``# Admin Removed excluding Court Martial (m).''
        (n) The number of individuals from each site who have died during
    the IDES process and the causes of their deaths.
        DOD Response. See WWCTP SVAC Response Data (response to question
    (a)), column header, ``# Deceased (n).'' For detailed information about
    causes of death, see the following chart from Office of Wounded Warrior
    Care Transition Policy.

        (o) The number of individuals in the IDES process at each site who
    were returned to duty.
        DOD Response. See WWCTP SVAC Response Data (response to question
    (a)), column header, ``# Cases RTD (o).''

        (p) Of the individuals who were returned to duty at each site, the
    number who underwent medical examinations provided by the Department of
    Veterans Affairs (or its contractors) prior to being returned to duty
    and the total number of examinations that were provided for those
    individuals.
        DOD Response. See WWCTP SVAC Response Data (response to question
    (a)), column header, ``# Cases RTD after Exam (p1).''
        Note: This column contains the number of cases that were returned
    to duty after receiving IDES exams. DOD was not able to subtract the
    number of cases in which DOD performed the exam and also notes that DOD
    used these exams in their process to determine fitness for duty.
        WWCTP SVAC Response Data, column header, ``# Cases with Exams Used
    by DOD But Not for VA Benefits (p2)'' contains the number of cases with
    exams that were used by DOD but not usable to determine eligibility for
    VA benefits.
        DOD suggests the SVAC staff query VA to determine the total number
    of compensation and pension exams provided by the Department of
    Veterans Affairs (or its contractors) prior to Servicemembers being
    returned to duty.

        VA Response. The cumulative enrollment of Servicemembers in IDES
    since November 2007 is 50,021. The total number returned to duty (RTD)
    who also had examinations is 3,270. *The average number of examinations
    provided by VA for Servicemember returned to duty is four (3,270 x 4 =
    13,080) (*sentence added by WWCTP).
        The overall percentage of Servicemembers returned to duty who also
    had examinations is 6.5 percent. The attached spreadsheet, ``VA
    Analysis of Servicemembers Returned-to-Duty After VA Medical Exams
    since IOC,'' provides the RTD requested information by site.

        (q) The funding level for the IDES process for each site, including
    funds that will be provided from any source.
        DOD Response. DOD will provide the requested budget execution
    information as soon as possible. DOD is not able to provide the
    information at this time because the Department does not fund
    disability costs from a single program and collecting the information
    requires an extensive data call to the Military Departments. In the
    interim, the attached funding data was submitted as part of the FY 2013
    President's Budget request. In addition, the attached spreadsheet
    includes the Services estimated FY 2013 funding requirements that were
    requested within the Overseas Contingency Operations budget request.
    The Department is developing a future budget exhibit to provide this
    information annually.
        Note: The DOD answer is pending final review by OSD Comptroller
    office.
        VA Response. In FY 2012, VA will spend approximately $70.8 million
    in support of the IDES process. This figure is comprised of $18.2
    million for IDES exams through the Veterans Health Administration,
    $38.6 million for General Operating Expenditures which includes payroll
    (salary and benefits), travel, equipment and supplies, etc., and $14
    million on contract exams through VBA.

                           IDES Funding for Services

                                     ______

    Response to Posthearing Questions Submitted by Hon. Patty Murray to Jo
        Ann Rooney, Acting Under Secretary of Defense for Personnel and
     Readiness, U.S. Department of Defense and John R. Gingrich, Chief of
                   Staff, U.S. Department of Veterans Affairs
        Question 1. In 2010, GAO identified the issue of diagnostic
    disagreement within the Integrated Disability Evaluation System (IDES)
    in their report GA0-11-69, Military and Veterans Disability System.
    Recommendation 2 of GA0-11-69 recommended that the Secretaries of the
    Departments of Defense (DOD) and Veterans Affairs (VA) ``establish a
    mechanism to continuously monitor disagreements about diagnoses between
    military physicians and VA examiners and between PEBs and VA rating
    offices.'' In response to this finding:

        a. Has DOD and VA modified the VA's Veterans Tracking Application
    (VTA) to continuously monitor diagnostic disagreements?
        VA Response. VTA has now been modified to include a Quality Review
    Tab. The Physical Evaluation Board (PEB) can use this tab to identify a
    diagnostic variance.
        DOD Response. Yes, VA provides IDES IT support and recently
    modified VT A to incorporate a diagnostic difference monitoring
    capability.

        b. When will this modification be available to all VTA users?
        VA Response. This modification was made available to all VTA users
    on June 11, 2012.
        DOD Response. VA made this VTA modification available to all IDES
    users on June 9, 2012.

        c. How will VTA users be instructed to utilize this capability to
    capture data on diagnostic disagreements?
        VA Response. VTA users have been instructed via monthly VTA live
    meeting training to utilize this capability to identify data in cases
    that have diagnostic disagreements. VTA reporting capability to track
    and monitor diagnostic disagreements has not been developed at this
    time.
        DOD Response. The Military Departments received familiarization
    with the VTA 2.0 enhanced capabilities during pre-release user
    acceptance testing. We and our VA partners continue to conduct monthly
    training for PEBLO's to address basic and advanced/detailed
    capabilities, such as Quality Review, which includes Diagnostic
    Disagreement. We continue to improve our training materials through the
    VT A web site and recurrent training teleconferences.

        Question 2. Provide DOD, VA and any individual Service policy
    guidance that addresses the handling of diagnostic disagreements
    between DOD and VA.
        VA Response. The process of addressing the issue of diagnostic
    differences needs to include a definitive determination that there is
    in fact an issue with significant impact to the disability process. The
    Government Accountability Office (GAO) in 2010 noted that the
    occurrence and prevalence of diagnostic disagreements and their impact
    on IDES case processing time are unknown because DOD and VA have no way
    to track such disagreements. Following a period of discussion, DOD
    engaged the contractor LMI to study claims of diagnostic disagreements
    (aka diagnostic difference); LMI issued a report in October 2011.

        a. LMI confirmed that diagnostic disagreements are not tracked by
    any DOD or VA system or reporting process. Because they are not
    tracked, they were unable to quantify the prevalence of diagnostic
    disagreements and their effect on timeliness within IDES.
        b. LMI concluded that generally (1) the issue of diagnostic
    disagreements is almost completely confined to behavioral and mental
    health conditions and (2) improved coordination between the VA and DOD
    has significantly reduced the number of disagreements.

        While VA has no written policy guidance regarding diagnostic
    discrepancies for disability evaluations, VA has no objection to such a
    policy once it is established what barriers may exist in executing
    acceptable disability examinations. Meanwhile, opportunities to enhance
    DOD/VA communications are available. For example, if the examiner is
    aware that there is treatment history in the service medical record,
    he/she should request the Military Services Coordination to have it
    provided to him/her. If the Medical Evaluation Board (MEB) clinician
    determines that a diagnostic discrepancy exists, then the most
    efficient way to manage this is for the MEB clinician to phone the VA
    mental health disability examiner and provide the additional
    information. This is the same methodology utilized to address a
    diagnostic discrepancy in the therapeutic arena, clinician-to-clinician
    follow-up.

        DOD Response. DOD issued policy guidance on handling diagnostic
    disagreements in December 20 II (http://www.dtic.rniVwhs/directives/
    corres/pdf/DTM-11-0l5.pdf). An excerpt of DOD's guidance, which
    instructs Military Department Physical Evaluation Boards to apply the
    diagnostic codes VA provides if the diagnoses differ between the
    Departments, follows:

            ``b. Within 15 days of receiving proposed disability ratings
            from the D-RAS, apply the ratings using the diagnostic code(s)
            provided by the D-RAS to the Servicemember's unfitting
            conditions and publish the disposition recommendation. For
            example, if the PEB identifies a condition to the D-RAS as
            schizophreniform disorder but the D-RAS rates the condition as
            psychotic disorder not otherwise specified (VASRD 9210), the
            PEB will apply the rating as ``schizophreniform disorder rated
            as psychotic disorder not otherwise specified (VASRD 9210).''

        Question 3. Please provide an organizational chart for the
    management of IDES within DOD, VA and within each Service.
        VA Response. Note attached Operational Model Diagram.

        Question 4. In their March, 2012, briefing to the Committee, the
    Departments reported, in part: Deputy Chief Management Office (DCMO)--
    is the single DOD POC for IDES Information Technology (IT); leading
    efforts to define IT strategy, discover and map IT portfolio and lead
    collaboration with VA.
        VA Executive Director Virtual Lifetime Electronic Record (VLER)
    EPMO identified as VA POC for IDES Information Technology. Please
    detail the collaboration between DOD and VA POCs, including:

        a. A delineation of the Departments' shared strategic goals,
    assumptions and planning for IDES IT collaboration;
        VA Response. VA's VLER Enterprise Program Management Office (EPMO)
    works closely with DOD Deputy Chief Management Office (DCMO) and the
    Under Secretary of Defense for Personnel and Readiness (USD (P&R)) to
    delineate shared strategic goals, assumptions and planning for IDES IT
    collaboration as part of ongoing governance activities and
    documentation created under the Joint Executive Council (JEC), Benefits
    Executive Council (BEC), VLER Overarching Integrated Project Team
    (OIPT) and other VA/DOD interagency governance boards. VA VLER EPMO
    regularly meets with DCMO, USD P&R, and the three Military Departments
    during the VLER OIPT to review IDES requirements and perform IT
    planning, design, and execution.
        DOD Response. The DOD Deputy Chief Management Office (DCMO) and the
    Under Secretary of Defense for Personnel and Readiness (USD (P&R)) work
    closely with the Department of Veteran Affairs (VA) Executive Director
    (ED) Virtual Lifetime Electronic Record (VLER) to delineate shared
    strategic goals, assumptions and planning for IDES IT collaboration.
    DCMO, USD P&R, and three Military Departments regularly meet with VA
    VLER during the VLER Overarching Integrated Project Team (OIPT) to
    review IDES requirements and perform IT planning, design, and
    execution. The Departments share IT goals via the Joint Executive
    Council (JEC), the Benefits Executive Council, Information Sharing/
    Information Technology (BEC IS/IT) working group, HEC/IM/IT Information
    Management Technology Working Group, Interagency Program Office (IPO)
    and the Virtual Lifetime Electronic Record (VLER) office.

        b. A prioritized list of current and planned IDES IT projects,
    including timeline, critical milestones, and planning documents for the
    development and implementation of each such project;
        VA Response. The VLER EPMO works closely with DCMO and USD (P&R) on
    several IT projects that will provide benefits to our transitioning
    Servicemembers and Veterans:

         Automating Disability Benefits Questionnaire (DBQ)
    Information Collection: A capability to provide a TurboTax-like, Web-
    based forms to facilitate the collection of specific disability VA
    Rating Schedule information from VA and private clinicians who perform
    disability examinations. The initial capability will be available by
    the end of Summer 2012, with all Disability Benefits Questionnaire
    (DBQ) forms available in the automated solution by Fall 2012.
         eBenefits: Secure Web portal that provides a central
    location for Servicemembers, Veterans, and their families to research,
    find, access, and manage their benefits and personal information. VA
    and DOD are committed to improving the online experience for Veterans
    and Servicemembers. More than 1.4 million Veterans and Servicemembers
    use eBenefits to access more than 40 capabilities made available via
    eBenefits.va.gov.
         Electronic Case File Transfer (eCFT): Provides VA case
    managers, Veterans Health Administration (VHA) Clinicians, and Veterans
    Benefits Administration (VBA) Rating Adjudicators the ability to
    receive Service Treatment Records and additional claims information in
    an electronic format from the DOD, ultimately resulting in more timely
    and efficient adjudication of disability claims. VA and the DOD will
    deploy the capability at several pilot sites during August 2012.
         VLER Data Access Services (DAS): The initial capability to
    implement core data access services for use by producers and consumers
    of information through the VLER DAS will be available by July 2012.
         Veteran Tracking Application (VTA): Electronic system
    designed to monitor Servicemembers and Veterans performance of the IDES
    process. VTA 2.0 was released on June 9, 2012 providing enhanced
    information sharing between VA and DOD case managers and additional DD-
    214 data required for claims processing.

        DOD Response. DCMO and USD (P&R) ED VLER work closely on several IT
    projects that will benefit transitioning Servicemembers. Some of these
    are ``bridge'' solutions until fielding of Integrated Electronic Health
    Record (iEHR) and VLER. Projects include:

        Automating Disability Benefits Questionnaire (DBQ) Information
    Collection: VA is developing a capability to provide a TurboTax-like,
    Web-based forms to facilitate the collection of specific disability VA
    Rating Schedule information from VA and private clinicians who perform
    disability examinations. The initial capability will be available in
    summer 2012, with all Disability Benefits Questionnaire (DBQ) forms
    available in the automated solution by fall 2012.
        eBenefits: Secure Web portal that provides a central location for
    Servicemembers, Veterans, and their families to research, find, access,
    and manage their benefits and personal information. VA and DOD are
    committed to improving the online experience for Veterans and
    Servicemembers. More than 1.4 million Veterans and Servicemembers use
    eBenefits to access more than 40 capabilities made available via
    eBenefits.va.gov.
        Electronic Case File Transfer (eCFT): Will provide DOD and VA the
    ability to exchange Service Treatment Records and additional claims
    information in an electronic format, resulting in more timely and
    efficient adjudication of disability claims. VA and the DOD plan to
    deploy the capability at several pilot sites in August, 2012.
        VLER Data Access Services (DAS): VA and DOD plan to provide an
    initial capability to implement core data access services for use by
    producers and consumers of information through the VLER DAS.
        Veteran Tracking Application (VTA): Electronic system designed to
    monitor Servicemembers and Veterans performance of the IDES process. VA
    released VTA 2.0 on June 9, 2012, providing enhanced information
    sharing between VA and DOD case managers and provides additional DD-214
    data required for claims processing.

        c. An end-to-end enterprise-wide IDES IT solution;
        VA Response. VA receives over a million claims for benefits each
    year. IDES is a critical program in support of Servicemember transition
    to Veteran status. As such, VLER EPMO has worked closely with subject
    matter experts and senior leaders within the VA--Veterans Benefits
    Administration (VBA) and VHA--and the Department of Defense USD (P&R),
    DCMO, Military Departments--in developing and documenting strategies to
    provide full IT support to the IDES program. Capabilities such as
    tracking, work flow management, reporting, and case file transfer are
    developed and delivered on incremental basis.
        Under the VLER Initiative, VA delivers enhancements every 6 months
    to better support the field and increase transparency, accountability,
    and timeliness within IDES. In an effort to modernize the tools
    available to IDES care managers and to better serve our Veterans, VLER
    is transitioning VTA to a new technology platform. This platform, which
    is shared with the Veterans Relationship Management (VRM) initiative,
    will provide VTA users with enhanced functionality and streamline
    future information sharing efforts between VA and DOD case/care
    management/coordination and benefits assistance lines of business. The
    Federal Recovery Coordination Program (FRCP) was the first VTA module
    to transition to this new platform on June 4, 2012. VA is facilitating
    the transition of the remaining VTA modules such as IDES. In addition,
    VA and DOD are piloting strategies to exchange case files
    electronically between care coordinators in an effort to diminish the
    time it takes to physically transfer files.
        VLER Data Access Services (DAS), referenced above, in conjunction
    the Veterans Benefit Management Systems (VBMS), represent the latest in
    technology and business transformation efforts focused on reducing
    claims backlog for Veterans. Once fully implemented, claims information
    from DOD will be orchestrated by the VLER DAS to VBMS for streamlined,
    paperless claims adjudication.
        DOD Response. DCMO and the Office of Warrior Care Policy (WCP) have
    worked closely with VA and the Military Departments to develop and
    document strategies to provide full IT support to the IDES program.
    Capabilities such as tracking, work flow management, reporting, and
    case file transfer are developed and delivered on incremental basis.
    The DCMO, supporting the Office of Warrior Care Policy (WCP), is
    providing business process mapping, and business process analysis
    expertise to identify best practices and system architecture best
    practices. The Department will use this effort to inform and integrate
    IDES IT requirements into larger enterprise solutions, including iEHR,
    VLER, and the VLER Data Access Services (DAS). VLER DAS, in conjunction
    the Veterans Benefit Management Systems (VBMS), represent the latest in
    technology and business transformation efforts focused on reducing VA's
    claims backlog. Once fully implemented, VLER DAS will enable
    streamlined, paperless claims adjudication from the DOD to VBMS.

        d. Any formal policy, directive(s) or other guidance issued by the
    Department(s) establishing an organizational, leadership and or
    governance structure for joint IDES IT collaboration; and
        VA Response. Business process and requirements validation for VLER
    Capability Area (VCA) 1 is governed by the Health Executive Council
    (HEC). Business process and requirements validation for VCAs 2, 3, and
    4 is governed by the Benefits Executive Council (BEC). VCA 1 IT
    execution is overseen by the DOD/VA IPO Advisory Board, which is
    officially chartered and reports directly to the Secretary of Veterans
    Affairs and Secretary of Defense. VCA 2, 3, and 4 IT execution is
    overseen by the VLER Overarching Integrated Project Team (OIPT), which
    reports to several Executive Steering Committees and Task Forces. The
    VLER OIPT charter is currently in coordination.

        DOD Response. The DOD/VA Joint Executive Council (JEC) provides
    overall organization IT governance oversight for functional
    requirements and IDES/VLER Benefits. The Inter-Agency Program Office
    Advisory Board, which is officially chartered and reports directly to
    the Secretary of Veterans Affairs and Secretary of Defense, provides
    organization IT governance oversight for iEHR and VLER Health
    acquisition, and IT execution. The Health Executive Council governs
    business process and requirements validation for VLER Capability Area
    (VCA) 1. The Benefits Executive Council governs business process and
    requirements validation for VCAs 2, 3, and 4. The VLER Overarching
    Integrated Project Team (OIPT), which reports to several Executive
    Steering Committees and Task Forces, oversees IT execution of VCA 2, 3,
    and 4. The VLER OIPT charter is currently in coordination between DOD
    and VA.

        e. Metrics or criteria utilized by the Departments (e.g., VA's
    project management accountability system (PMAS)) to evaluate the status
    of project-specific and enterprise level IDES IT collaboration between
    the Departments.
        VA Response. The VA Office of Information and Technology (OIT)
    Program Management Accountability System (PMAS) sets strict guidance on
    metrics and criteria to evaluate project specific and enterprise level
    IDES IT. PMAS is a performance-based project management discipline that
    is mandated by the Assistant Secretary for Information & Technology
    (AS/IT) for all planning, development, and delivery all IT development
    projects. The intent of PMAS is to improve the rate of success of VA's
    IT projects. PMAS uses incremental product build techniques for IT
    projects, with delivery of new functionality (tested and accepted by
    the customers) in cycles of six months or less. Projects managed under
    PMAS are tightly monitored and are subject to being halted when
    significant deviations to plan occur and insufficient remediate plans
    are presented. PMAS is a rigorous management approach intended to
    deliver smaller, more frequent releases of new functionality to
    customers.
        All IT projects in support of IDES tracking/reporting are governed
    by PMAS. Throughout the lifecycle of the project, status against
    project milestones (e.g. requirements complete, development complete,
    Production Release) is recorded within the Primavera scheduling tool,
    and used to track the progress of the project.
        A monthly Warrior Support IPT meeting is held on the 3rd Wednesday
    of every month, and includes representatives from the business and
    technical communities. VA leadership reviews the status of PMAS
    projects through regular and consistent reporting against established
    baselines, such red-flag and milestone reviews.

        DOD Response. The VA Office of Information and Technology (OIT)
    Program Management Accountability System (PMAS) sets strict guidance on
    metrics and criteria to evaluate project specific and enterprise level
    IDES IT. PMAS is a performance-based project management discipline that
    is mandated by the Assistant Secretary for Information & Technology
    (AS/IT) for all planning, development, and delivery all IT development
    projects. The intent of PMAS is to improve the rate of success of VA's
    IT projects. PMAS uses incremental product build techniques for IT
    projects, with delivery of new functionality (tested and accepted by
    the customers) in cycles of six months or less. Projects managed under
    PMAS are tightly monitored and are subject to being halted when
    significant deviations to plan occur and insufficient remediate plans
    are presented. PMAS is a rigorous management approach intended to
    deliver smaller, more frequent releases of new functionality to
    customers.
        All VA IT projects in support of IDES tracking/reporting are
    governed by PMAS. Throughout the lifecycle of the project, status
    against project milestones (e.g. requirements complete, development
    complete, Production Release) is recorded within the Primavera
    scheduling tool, and used to track the progress of the project. VA
    hosts a monthly Warrior Support IPT meeting the 3rd Wednesday of every
    month, which includes representatives from the business and technical
    communities. VA leadership reviews the status of PMAS projects through
    regular and consistent reporting against established baselines, such
    red-flag and milestone reviews.

        Question 5. Please describe the steps taken by the Departments to
    ensure that any IT solution for IDES is capable of being integrated
    into VLER. As part of this description, please detail how VLER factors
    into the Departments' development of a shared IDES IT strategy and
    ongoing collaboration.
        VA Response. The Departments have taken deliberate steps to ensure
    any IT solution for IDES is capable of being integrated into VLER. VLER
    EPMO oversees IDES IT systems as an integrated component of the broader
    VLER EPMO portfolio.
        To ensure the synchronization of current and future IT solutions
    with the long-term VLER effort, VLER leverages existing projects,
    carefully defined architecture, and web services strategies to ensure
    that interfaces with the VLER Data Access Services can be created. For
    example, through the Information Sharing Initiative (ISI), VA and DOD
    share case coordinator information across Federal Case Management Tool
    (FCMT), VTA, and DOD systems.

        DOD Response. The Departments have taken deliberate steps to ensure
    any IT solution for IDES is capable of being integrated into VLER. VLER
    oversees IDES IT systems as an integrated component of the broader VLER
    portfolio. The DOD/VA Benefits Executive Council Information Sharing/
    Information Technology (BEC IS/IT) group is specifically tasked to
    coordinate, validate and promote IDES strategic and interagency
    information sharing to ensure an IDES end-to-end information technology
    solution within iEHR and VLER. Additionally, the effort to map current
    DOD, VA and Military Department IT systems (and their funding streams)
    supporting IDES will help inform the BEC IS/IT of near, mid and long
    term IT requirements.
        To ensure the synchronization of current and future IT solutions
    with the long-term VLER effort, VLER leverages existing projects,
    carefully defined architecture, and web services strategies to ensure
    that interfaces with the VLER Data Access Services can be created. For
    example, through the Information Sharing Initiative (ISI), VA and DOD
    share case coordinator information across Federal Case Management Tool
    (FCMT), VTA, and DOD systems.

        Question 6. Committee oversight has discovered that the current
    medical evaluation process for soldiers with TBI and PTSD is
    inconsistent. The medical records of reviewed cases reflect these
    inconsistencies, as some medical records combine and document symptoms
    of both PTSD and TBI and others do not, leaving each as a separate
    diagnosis.

        a. What is the DOD and VA standard of practice for diagnosing TBI
    and PTSD?
        VA Response. VA clinicians adhere to the standards of practice
    established by the VA/DOD Clinical Practice Guideline for the
    Management of Concussion/Mild Traumatic Brain Injury (TBI). VA
    clinicians also adhere to the standards of practice established by the
    VA/DOD Clinical Practice Guideline for the Management of Post-Traumatic
    Stress.

        DOD Response. The DOD and VA standards of practice for diagnosing
    TBI and PTSD are based on published definitions and clinical practice
    guidelines. Both the Veterans Health Administration (VHA) Directive
    2009-028 and the DOD (Health Affairs Memorandum, October 2007) define
    TBI as a traumatically induced structural injury or physiological
    disruption of brain function as a result of an external force. The VHA
    Directive and DOD Memorandum define severity level of TBI using the
    Glasgow Coma Scale score, length of loss of consciousness, and length
    of post-traumatic amnesia. In both agencies, the diagnosis of mild TBI
    (mTBI) is based on the injury event as well as changes in mental status
    occurring during the injury. The VA/DOD Clinical Practice Guidelines
    for the Management of Concussion/Mild Traumatic Brain Injury was
    developed in 2009 and outlines the standard criteria for the diagnosis
    of mTBI.
        Policy Guidance for the Management of Concussion/Mild TBI in the
    Deployed Setting (DTM 09-033) requires mandatory assessment of a
    Servicemember (SM) involved in potentially concussive events including
    vehicle associated with a blast event, collision or rollover; any SM
    within 50 meters of a blast, a direct blow to the head or loss of
    consciousness. The identified potentially concussive events provide a
    standardized method for the implementation of screening and diagnosis
    of acute mTBI in a deployed setting.
        In 2010, the DOD and VA jointly published, ``The Clinical Practice
    Guidelines for the Management of Post-traumatic Stress.'' This
    guideline supports the Diagnostic and Statistics Manual of Mental
    Disorders, 4th Edition, Text Revision (DSM-IV TR) as the standard for
    all behavioral health providers who work within Military Treatment
    Facilities (MTFs) to use for the diagnosis of PTSD, as required by
    licensing laws and credentialing agencies.

        b. How is each standard of practice applied?
        VA Response. VA issued VHA Directive 2010-012, ``Screening and
    Evaluation of Possible Traumatic Brain Injury in Operation Enduring
    Freedom/Operation Iraqi Freedom Veterans,'' in March 2010. This
    Directive establishes the policy for the administration of the TBI
    screening, comprehensive evaluation, and treatment of Operation
    Enduring Freedom/Operation Iraqi Freedom Veterans receiving medical
    care within VHA.
        VA also developed a computerized Comprehensive TBI Evaluation
    Template that is used to document the results of every comprehensive
    evaluation conducted following positive TBI screening findings.
        The VA Uniform Mental Health Services Handbook (VHA Handbook
    1160.01) addresses a multitude of clinical practice issues, and
    indicates that treatment and assessment for mental health disorders
    must be consistent with the appropriate clinical practice guidelines.

        DOD Response. VA and DOD application of practice policies and
    procedures address the deployed and non-deployed DOD settings, as well
    as the post-separation environment of the VA. MTF credentialed
    providers make a diagnosis of TBI and PTSD based on appropriate
    provider education, clinical references, and compliance with licensing
    laws. These providers combine clinical practice guidelines and clinical
    judgment to arrive at a diagnosis. They may use various methods of
    assessment, including interviews, instruments and psychological
    screening, to evaluate whether or not a given SM meets the criteria for
    TBI and or PTSD.
        DTM 09-033 is an example of a DOD deployed setting policy for mTBI
    that is a standard applied to practice. DTM 09-033 requires all
    military personnel involved in potentially concussive events be
    promptly evaluated through use of a standard tool, the Military Acute
    Concussion Evaluation (MACE). There are also comprehensive screening
    programs for TBI that have been implemented to facilitate the detection
    of mTBI. The Post Deployment Health Assessment has PTSD and TBI
    screening questions to identify redeployed SMs who may have a history
    of concussion or have PTSD symptoms. In the non-deployed setting, the
    standard of practice for both PTSD and TBI care is applied through
    dissemination and implementation of evidence based guidelines. In
    addition, numerous clinical support tools have been developed and
    disseminated to assist the provider in navigating the assessment and
    treatment of both PTSD and mild TBI when SMs continue to have symptoms.
        Additionally, programs such as PTSD Treatment in Primary Care
    Settings, Re-Engineering Systems of Primary Care Treatment in the
    Military (RESPECT-Mil), and Behavioral Health Integration enables DOD
    primary care providers to screen and treat health-seeking patients in
    primary care clinics for PTSD, suicidal ideation, and depression while
    integrating behavioral health care providers into routine care.
        VA issued the VHA Directive 2010-012, ``Screening and evaluation of
    possible TBI in OEF/OIF Veterans,'' in March 2010. This Directive
    establishes the policy for the administration of the TBI screening,
    comprehensive evaluation, and treatment of OEF/OIF/OND Veterans
    receiving medical care within VHA. As part of this evaluation protocol,
    VHA developed a mandatory computerized Comprehensive TBI Evaluation
    Template that requires a diagnostic conclusion regarding the occurrence
    of TBI to be documented.

        c. What is the DOD and VA standard of practice for documenting
    differences between TBI and PTSD in the medical record?
        VA Response. VA's Comprehensive TBI Evaluation Template directs the
    medical provider to make a determination as to whether the Veteran's
    current symptoms are related to TBI, or to a mental health condition,
    including Post-Traumatic Stress Disorder (PTSD), or to a combination of
    TBI and mental health problems. It is not always possible to
    differentiate between the causes of some symptoms. In those cases, the
    symptoms are related to both conditions. VA's PTSD and Mental Health
    Disorders Disability Benefits Questionnaires (DBQs) specifically
    require the examiner to document whether or not the Veteran has a
    diagnosed TBI, and if so, to document if it is possible to
    differentiate what symptom(s) is/are attributable to each diagnosis.
    The topic of differentiating PTSD symptoms from TBI symptoms is
    addressed during the Office of Disability and Medical Assessment's
    online TBI and PTSD Certification trainings.

        DOD Response. Although many symptoms of TBI and PTSD overlap, they
    are two separate clinical conditions with two separate diagnostic
    criteria. The diagnostic criteria for TBI are established through a
    history and physical exam at time of injury and are documented through
    the use of ICD-9 codes as further defined by published definitions and
    guidelines. Point of injury assessment remains the most accurate
    approach to early identification of the presence of a TBI through
    mandatory concussion screening that occurs at various levels to ensure
    detection and maximize treatment opportunities. If a SM is diagnosed
    with PTSD and TBI, two separate ICD-9 codes are entered into the
    electronic health record. VA directs the medical provider to determine
    if the Veteran's current symptoms are related to TBI, or to a mental
    health condition (to include PTSD), or to a combination of TBI and
    mental health problems. It is not always possible to differentiate
    between the causes of some symptoms. If symptoms are related to both
    conditions, both diagnoses are made. VA's PTSD and Mental Health
    Disorders Disability Benefits Questionnaires (DBQs) specifically
    require the examiner to document whether or not the Veteran has a
    diagnosed TBI and if so, to document if it is possible to differentiate
    what symptom(s) is/are attributable to each diagnosis. The topic of
    differentiating PTSD symptoms from TBI symptoms is addressed during
    Disability and Medical Assessment online TBI and PTSD Certification
    trainings.

        d. Do all DOD and VA medical facilities adhere to the same
    standards of practice in diagnosing TBI and PTSD?
        VA Response. The policy established by VHA Directive 2010-012 and
    the Comprehensive TBI Evaluation Template apply across all VA
    facilities. VHA-wide performance measures allow monitoring of adherence
    to standards utilizing an External Peer Review Process. This External
    Peer Review Process would address the standards of practice of
    diagnosing both TBI and PTSD.

        DOD Response. DOD and VA have policies and procedures in place to
    ensure adherence to standards of practice in TBI and PTSD care by all
    providers. Some of these VA guidelines have already been discussed. The
    Services generate policies to which DOD providers are expected to
    adhere. Examples of Service policies related to these issues include
    the following:

         OTSG/ MEDCOM Policy Memo 12-035 Policy Guidance on the
    Assessment and Treatment of Post-Traumatic Stress Disorder
         OTSG/ MEDCOM Policy Memo 10-040 Screening Requirements for
    Post-Traumatic Stress Disorder and Mild Traumatic Brain Injury (mTBI)
    for Administrative Separations of Soldiers
         NAVMED Policy 11-001 Implementing Required Medical Exam
    before Administration Separation For Post-Traumatic Stress Disorder
    (PTSD) or Traumatic Brain Injury (TBI).

        e. If not, what are the reasons for not adhering to the standard of
    practice?
        VA Response. VA monitors consistent adherence to the TBI and PTSD
    standards of practice across all medical facilities.

        DOD Response. Providers are expected to meet the standard of care
    for each individual patient. Policies and guidelines cannot anticipate
    all of the possible reasons a provider may deviate from a standard of
    practice. Patients may require deviations from standard practice due to
    individual clinical care needs as determined by their health care
    provider. Providers are expected to clearly document rationale and
    clinical decisionmaking whenever they deviate from these standards of
    practice. In addition, an individual may refuse care.

        f. Are there instances in which a provider may deviate from the
    standard of practice in evaluating TBI or PTSD? If so, please explain
    these instances.
        VA Response. VA has policy and procedures in place to ensure
    adherence to standards of practice in TBI and PTSD care by all
    providers. VHA Rehabilitation Services and Mental Health Services are
    not aware of TBI/PTSD assessments or diagnoses being made outside of
    the standard of practice and do not sanction providers diagnosing
    outside of standard clinical guidance. DMA has in place Quality
    Assurance programs that can identify compliance with standards of
    practice.

        DOD Response. TBI and PTSD patients may require deviations from
    standard practice due to individual clinical care needs as determined
    by their health care provider. At times, standards of practice have
    difficulty keeping pace with the ever-evolving science of diagnostics,
    treatment and care. As a result, providers must use reasonable clinical
    judgment and support their diagnostic and care decisions with sound
    scientific literature and patient care documentation. With respect to
    TBI care, the clinical algorithms and guidelines are applied to each
    patient. Provider guidance addresses individual variations in treatment
    based upon each SM's symptoms and recovery time. Each Veteran who
    enters the Polytrauma System of Care, at any level of service, requires
    an Individualized Rehabilitation and Community Reintegration Care Plan
    (VHA Handbook 1172.04). Differences in treatment approach or the need
    for consultative service with the other specialty care center would be
    documented in these treatment plans.

        Question 7. During testimony, VA referenced the potential impact
    that passage and implementation of the ``VOW to Hire Heroes Act'' may
    have on IDES.
        a. Describe how VA anticipates this law will impact IDES.
        VA Response. Section 1631(b) of Pub. L. 110-181, the National
    Defense Authorization Act of 2008, authorized automatic eligibility to
    VA's Vocational Rehabilitation and Employment services for severely
    injured or ill Servicemembers. Section 231 of the VOW to Hire Heroes
    Act (PL 112-56) extended the sunset date of that authorization from
    December 31, 2012, to December 31, 2014.
        VA implemented Pub. L. 110-181 through a memorandum of
    understanding (MOU) with DOD. In this MOU, it was agreed that a
    Servicemember participating in IDES and/or referred to a Physical
    Evaluation Board (PEB) is automatically eligible. This process allows
    VA to assist Servicemembers early in their transition to civilian life
    without waiting for a VA memorandum rating to determine entitlement to
    vocational rehabilitation and employment services.
        We are currently finalizing the details of a plan to implement the
    portion of the VOW Act related to Transition Assistance Program (TAP).

        b. What is the expected increase in the number of disability claims
    that VA anticipates as a result of implementation of this law?
        VA Response. As noted above, we are currently working out the
    details of a plan to implement the portion of the VOW Act related to
    TAP, which may impact the number of disability claims that VA
    anticipates. Until we have the final plan, we are unable to make any
    estimates. We expect the final plan to be completed in October 2012.

        c. If VA anticipates an increase in disability claims receipts,
    what actions has VA taken to prepare for this anticipated increase?
        VA Response. As noted above, we are currently working out the
    details of a plan to implement the portion of the VOW Act related to
    TAP, which may impact the number of disability claims that VA
    anticipates.

        Question 8. DOD testimony stated that the Departments ``* * * are
    currently developing a memorandum of understanding that will allow DOD
    to become a member of the working groups updating the VASRD and give
    DOD the opportunity to make recommendations prior to the publication of
    proposed changes in the Federal Register.''
        a. Has DOD participated in the VASRD update project to date and if
    so in what capacity?
        VA Response. DOD has appeared at the public forums on the VASRD
    update project and offered expertise and assistance at several of its
    working groups.
        DOD Response. DOD's participation in the update project has so far
    been limited to the public forums.
        The Deputy Assistant Secretary of Defense (Health Affairs, Clinical
    and Program Policy) attended portions of the VASRD Public Forum in New
    York City from January 17-26, 2012. DOD will continue to participate by
    sending representatives to these VASRD forums that review updates on
    ratings for specific body systems whenever possible. DOD
    representatives at these forums may provide input, but will not be
    voting members on the potential adjustments. The Secretary of the VA
    retains ultimate authority for managing changes to the VASRD.

        b. What impact, if any, will the memorandum of understanding and
    DOD participation have on VA's timeline for issuance of proposed rules?
        VA Response. The memorandum of understanding states that DOD may
    participate in the working groups and that VA will provide DOD 30 days
    to comment before publishing its proposed rules. VA does not anticipate
    any significant impact to the existing project timeline.
        DOD Response. The memorandum of understanding (MOU) mentioned above
    will provide for DOD to have clear methods for requesting any changes
    to the VASRD. It includes a provision for the DOD to apply to have a
    representative on the VA Advisory Committee, subject to approval by the
    Secretary of the VA. It provides DOD with a 30 day period to make
    comments on any updates to the VASRD prior to publication. Given these
    opportunities for DOD to participate early in the update process, it is
    anticipated that there will be minimal impact on the overall timeline
    for VA issuance of proposed rules and adjustments. This MOU has been
    coordinated at the deputy assistant secretary level at VA and DOD; it
    requires a legal review and then approval through the Secretaries.

        c. VA has announced that a VASRD Status Summit will be held on
    June 4-8 and 11-13, 2012 to allow the public to comment on working
    drafts of proposed regulations for nine body systems. Has or will DOD
    make recommendations prior to publication of proposed rules on the body
    systems for which draft proposed regulations have already been
    developed?
        VA Response. As stated above, the MOU gives DOD 30 days to comment
    before VA publishes the proposed rules.
        DOD Response. DOD was invited to send representatives to the
    conferences referenced, and the invitations and agendas were passed on
    to the Services, but they were not able to send subject matter experts
    for the particular body systems discussed. DOD was provided opportunity
    to comment on the proposed rules prior to the conferences, but did not
    have any recommended changes or objections. Based on the MOU, in the
    future DOD will have an opportunity to comment prior to publication of
    notice for these conferences, and will have longer lead time to ensure
    that DOD subject matter experts can take advantage of that opportunity
    for review and comment as needed.

        Question 9. The minutes of the VA and DOD Secretaries' February 27
    meeting state that the ``results of decisions on how redundancy and
    overlap issues in the VA and DOD care coordination programs will be
    resolved (to be made at May 2012 JEC)'' was set as a deliverable for
    the next Secretaries' meeting. Please describe that decision, the
    results, and the plan of action to address those issues.
        VA Response. The Joint Executive Council (JEC) formed a VA DOD
    Warrior Care and Coordination Task Force (VA DOD WC2TF). Task force
    recommendations will be briefed to the JEC (via the HEC and BEC) in
    August 2012. Current work of the VA DOD WC2TF includes:

         Establish overarching care coordination policy for
    severely injured, ill, and wounded warriors in transition
         Crosswalk the DOD Instructions and VA Handbooks addressing
    care coordination and case management into a single directive (``common
    doctrine'')
         Create a single, Comprehensive Plan for care, services and
    benefits for better synchronization and integration
         Establish a formal governance structure, informed by a
    Community of Practice that will serve as an ongoing forum for policy,
    programming and oversight.

        DOD Response. The Secretaries have directed that the two
    Departments complete the review and resolve the redundancies between
    the Federal Recovery Coordination and Recovery Coordination Programs by
    their next meeting in the September timeframe. DOD and VA, along with
    the military services and the Wounded Care Policy Department, have
    formed a Task Force which will forward recommendations to the August 10
    JEC.

        Question 10. The minutes of the VA and DOD Secretaries' February 27
    meeting state that for the next Secretaries' meeting the Departments
    will ``i. Determine resource implications of implementing the revised
    transition program for FY 2012 and FY 2013,'' as well as ``ii. Deliver
    implementation plan for revised Transition Assistance Program (TAP) and
    implementation of VOW Act to White House including the 'virtual
    delivery' of TAP so that interagency partners can plan the requisite
    support.'' Please provide the determination of resource implications
    described in (i), as well as the implementation plan for revised TAP
    (including virtual TAP) described in (ii).
        VA Response. As noted above, we are currently working out the
    details of a plan to implement the portion of the VOW Act related to
    TAP, which may impact the number of disability claims that VA
    anticipates.

        DOD Response.
        ``i. Determine resource implications of implementing the revised
    transition program for FY 2012 and FY 2013,''
        Members of the DOD/VA Veterans Employment Initiative Joint Task
    Force are in close dialog with the Office of Budget Management and the
    agencies and Military Departments have developed the implementation
    plan with costing. The IP is currently at the White House awaiting
    approval.
        In the meantime, the Department of Defense and our Department of
    Labor and Veterans Affairs are working hard to implement the mandate of
    the VOW to Hire Heroes Act. This requires all Servicemembers to attend
    the DOL Employment Workshop, which essentially nearly doubles the
    throughput for the DOL workshop. While some members will receive
    waivers to participate in the workshop, no member will be exempt from
    receiving Pre-separation Counseling and the VA Benefits briefing.

        ``ii. Deliver implementation plan for revised Transition Assistance
    Program (TAP) and implementation of VOW Act to White House including
    the `virtual delivery' of TAP so that interagency partners can plan the
    requisite support.''
        The response is at the end of the first paragraph:

            The DOD/VA Veterans Employment Initiative Task Force
            Implementation Plan is under review by the White House staff.
            This includes the proposal and costing for delivering new
            curriculums virtually. The Task Force proposes to leverage the
            Army's extensive work on virtual curriculums to develop and
            deploy the revised standardized curriculum in a virtual format.
            It is planned for the pilot to set the stage for expanded
            virtual delivery of instruction to meet the needs of dispersed
            military members. This will help Servicemembers access
            instruction more readily and prepare for transition earlier in
            the military life cycle.

        Additionally, President Obama announced, at the VFW Convention on
    July 23, the launch of the redesigned Transition Assistance Program
    (TAP) developed by an interagency task force which includes DOD, the
    Departments of Veterans Affairs (VA), Labor (DOL), Homeland Security
    (DHS), Education (ED), Office of Personnel Management (OPM), and the
    Small Business Administration (SBA). The re-design includes modified
    curriculum that assists in making transitioning Servicemembers ``career
    ready'' upon separation.
        The re-designed DOL Employment Workshop and the core modules for
    transition preparation began being piloted in July and will continue
    through August 2012. The locations include: Fort Hood, Texas; Ft. Sill,
    Okla.; Utica Army National Guard Base, N.Y.; Jacksonville Naval Air
    Station, N.C.; Norfolk NAS, VA; Randolph Air Force Base, Texas and
    Miramar Marine Corps Air Station, California. Based on results of the
    pilot, the curriculum will be modified, as appropriate. Using the
    modified curriculum and standardized learning objectives, the Military
    Services will expand Department-wide, to deliver service at
    approximately 250 military installations worldwide preparing
    Servicemembers to transition confidently from military service to the
    civilian workforce.

        Question 11. Please provide an update on progress made in the
    merger of the SOC and JEC, including any functions of the SOC which
    have not yet been fully incorporated into JEC operations. Has the
    Secretary of Defense appointed the DOD Deputy Secretary to co-chair the
    SOC, does the Department feel it is necessary or appropriate for the
    Deputy Secretary to continue overseeing the issues following the merger
    of these entities?
        VA Response. As of January 19, 2012, the JEC assumed all of the
    Senior Oversight Committee (SOC) functions for oversight of IDES. VA's
    Deputy Secretary Co-Chairs the JEC. DOD must decide the appropriate
    level of participation on the JEC.
        DOD Response. The merger of the SOC and JEC has been completed as
    of 20 March 2012 with all the former functions of the SOC incorporated
    into the JEC process. Due to the inclusion of senior leadership and the
    initiation of the Secretary of Defense/Secretary of Veterans Affairs
    meetings, which discuss specific JEC topics, it is not necessary for
    the Deputy Secretary to oversee JEC issues. Title 38 Section 320 has
    identified the Under Secretary of Defense for Personnel and Readiness
    as the DOD chair for the interagency committee. The Under Secretary of
    Defense for Personnel and Readiness has oversight for all policy issues
    and has direct access to the Secretary of Defense. The portfolios of
    both DOD and VA now line up for oversight of former SOC and current JEC
    topics.

        Question 12. Please describe any recent or planned realignment of
    components or functions of the Office of Wounded Warrior Care and
    Transition Policy, including what improvements the Department expects
    from such realignment, as well as how DOD will oversee and evaluate the
    efficacy of the realignment.
        VA Response. [VA defers to DOD.]
        DOD Response. The Office of Wounded Warrior Care and Transition
    Policy (WWCTP) was moved, effective June 1, 2012, to the Office of the
    Assistant Secretary of Defense for Health Affairs (ASD HA).
    Simultaneously, the Transition Assistance Program (TAP) component of
    WWCTP was moved under the office of the Assistant Secretary of Defense
    for Readiness and Force Management (ASD R&FM). WWCTP's name has been
    changed to Warrior Care Policy (WCP).
        The realignment of WCP, and its TAP component, within the broader
    Personnel and Readiness (P&R) portfolio will strengthen WCP's
    effectiveness in carrying out the Department's commitment to wounded
    warriors and its ability to effect change. WCP's current activities and
    support for wounded warriors directly relates to the health and
    healthcare of these individuals. WCP's programs and initiatives in
    support of wounded, ill and injured Servicemembers will not change;
    alignment within HA will provide enhanced support and coordination for
    these activities. WCP's strategic initiatives are being folded into the
    HA strategic plan and will be monitored and tracked during quarterly
    review and analysis meetings with the Service surgeon generals. The
    Deputy Assistant Secretary for WCP (DASD WCP) reports directly to the
    ASD HA and provides regular program updates at weekly ASD HA leadership
    meetings. The DASD WCP also retains responsibility as the principal
    advisor to the Office of the Under Secretary of Defense for Personnel
    and Readiness for Wounded Warrior matters.
        Likewise, the Transition Assistance Program (TAP), because of its
    wider applicability to all transitioning Servicemembers, is best
    aligned with activities and programs of the ASD R&FM. The ASD R&FM has
    oversight of military personnel policy, education policy and civilian
    policy, and is in the best position to lead, integrate and enhance the
    Department's necessary and critical focus on the transition issues for
    our military personnel. Direct oversight for TAP strategic initiatives
    and policy is provided by the deputy director of the newly established
    Transition to Veterans Program Office. The deputy director reports
    directly the ASD R&FM.

        Question 13. Please describe the activities and findings to date of
    the VA Wounded, Ill, and Injured Task Force, including a timeline for
    completion of the Task Force's review and implementation of any
    recommendations it will make.
        VA Response. The Wounded, Ill, and Injured Task Force conducted a
    VA-wide survey of programs providing care coordination, case management
    and/or benefits advisors. This identified a need to synchronize and
    integrate services amongst programs within VA and DOD. Current work of
    the VA DOD WC2TF includes:

         Establish overarching care coordination policy with common
    mission, language for severely injured, ill, and wounded warriors in
    transition
         Crosswalk the DOD Instructions and VA Handbooks addressing
    care coordination and case management into a single directive (``common
    doctrine'')
         Create a single, Comprehensive Plan for care, services and
    benefits for better synchronization and integration
         Establish a formal governance structure, informed by a
    Community of Practice that will serve as an ongoing forum for policy,
    programming and oversight.

        Recommendations will be briefed to the JEC (via the HEC and BEC) in
    August 2012.

        DOD Response. DOD defers to VA to provide the activities and
    findings to date of the VA Wounded, III, and Injured Task Force.
    However, Secretary Panetta directed that an internal DOD task force
    review the IDES process, with VA's support, and report to him by the
    end of September 2012 on improvement recommendations.

        Question 14. The Departments have set a goal of having 60 percent
    of new IDES claims processed within 295 (Active) and 305 (Reserve/
    Guard) days. Why was the goal set at only 60 percent of new claims?
    What is the Departments' plan for reaching 100 percent of new claims
    processed within the Departments established timelines?
        VA Response. The Departments strive to process all IDES cases
    within 295 days for Active Duty and 305 days for RC members. However,
    because each case has its unique challenges and there are many
    variables involved 60 percent was established as an initial achievable
    goal for calendar year 2012. In an ongoing effort to achieve 100
    percent of new claims processed within the established timelines, the
    departments will continue to streamline and automate as much of the
    process as possible, and explore and implement other process
    improvement measures.
        DOD Response. The DOD/VA Joint Executive Council established
    activities and milestones for improving the IDES in Joint Strategic
    Plan for Fiscal Years 2011-2013, Goal 3, Efficiency of Operations. The
    improvement metric is the percentage of Servicemembers who complete the
    IDES process within goal. In the plan, the Departments set a long-term
    goal that 80% of Servicemembers complete the IDES within goal (295 days
    for active component or 305 days for reserve component). The
    Departments set the interim that 60% of Servicemembers complete the
    IDES within goal in calendar year 2012. The Departments' goals
    recognize that each Servicemember's case is unique and that some
    Servicemembers will finish IDES in less than 295 days while others with
    more complex cases will take longer than 295 days. Although the
    Departments are striving to accelerate the IDES process for all, the
    current JSP goals incorporate the reality of variations in case
    complexity and the current caseload of Servicemembers awaiting
    disability evaluation.

        Question 15. Please detail the current operational status,
    activities, and resource, space and personnel allocations for each of
    the Vision, Traumatic Extremity Injuries and Amputation, and Hearing
    Centers of Excellence.
        VA Response. [VA defers to DOD.]
        DOD Response.

                       Hearing Center of Excellence (HCE)
    ------------------------------------------------------------------------

    ------------------------------------------------------------------------
    Operational Status            Achieved Initial Operating
                                   Capability (IOC): key staff appointed,
                                   plus contracted staff for daily
                                   operations, strategic communications,
                                   registry planning, research
                                   administration, and fitness for duty
                                   support.
                                  Full Operating Capability (FOC),
                                   defined as an operating hearing data
                                   registry, with launch of hearing
                                   protection campaign-expected
                                   December2013.
    ------------------------------------------------------------------------
    Activities                    Published Concept of Operations to
                                   guide IOC/FOC progression.
                                  Selected HCE Leadership-staff is
                                   joint DOD/VA (pending formal appointment
                                   process); extremely cohesive team and
                                   unified alignment of objectives.
                                  Determined overall staffing
                                   requirements-pending validation review
                                   and approval.
                                  Launched Web site
                                   (hearing.health.mil).
                                  Chartered DOD Fitness for Duty
                                   working group to determine auditory
                                   standards required for specific military
                                   occupations.
                                  Cataloged portfolio of DOD/VA
                                   hearing-related research activities to
                                   orchestrate best use of limited Federal
                                   research funding.
    ------------------------------------------------------------------------
    Resources                     Sufficient resources to date and
                                   into next FYs (FY 2012 = $10.9M).
    ------------------------------------------------------------------------
    Space                         Sufficient space allocated within
                                   Wilford Hall Ambulatory Surgical Center
                                   (8200 sq. ft. (SF) temporary space).
                                   Anticipate 3000 SF in permanent space.
    ------------------------------------------------------------------------
    Personnel Allocations         Executive Director appointed; 4
                                   Directorate Chiefs assigned; civil
                                   service hiring progressing with expected
                                   staff late CY 2013.
    ------------------------------------------------------------------------

           Extremity Trauma and Amputation Center of Excellence (EACE)
    ------------------------------------------------------------------------

    ------------------------------------------------------------------------
    Operational Status            Current manning is eight DOD
                                   staff, one VA staff, and zero
                                   contractors. Key staff hired include the
                                   Executive Director, Deputy Director, and
                                   Chief of Staff; contract manpower
                                   equivalents equal to 2.4 are inbound in
                                   July2012; the VA is hiring four full-time
                                   staff and each of the DOD Advanced
                                   Rehabilitation Center (ARC) sites are
                                   initiating actions for hiring personnel
                                   approved in the Concept of Operations
                                   (CONOPS).
                                  Planned Initial Operating
                                   Capability (IOC) date is 1October2012 and
                                   is defined as 50% manning at each ARC
                                   site, staff Directorate, and Executive
                                   Office, with the Manpower Concept Plan
                                   submitted. We forecast 17 DOD, three
                                   contractors, and one VA FTE on-board by
                                   our projected IOC. Research, global
                                   outreach, informatics, clinical care, and
                                   leadership sections are currently
                                   sustained. With future hires we will gain
                                   momentum toward greater capability.
    ------------------------------------------------------------------------
    Activities                    Published CONOPS and Balanced
                                   Scorecard to guide EACE progression.
                                  Army Manpower Concept Plan
                                   currently being written to conform to the
                                   Center of Excellence Oversight Board
                                   approved CONOPS staffing requirements.
                                   Selected EACE leadership team including
                                   Executive Director, Interim VA Deputy
                                   Director, Chief of Staff, and Deputy
                                   Director for Research. The four VA staff
                                   were approved for hire by VA leadership.
                                  Established Capability Integrated
                                   Product Team (DOD/VA) to develop the EACE-
                                   specific registry requirements for the
                                   planned Federated Registry, led by the
                                   Vision Center of Excellence.
                                  Building EACE Web site on
                                   health.mil. Expect completion within 30
                                   days.
                                  EACE executive leadership, VA
                                   Amputation System of Care (ASoC)
                                   leadership, and DOD ARC representatives
                                   met in January2012 to establish strong
                                   working relationships and gain better
                                   understanding of each other's missions.
                                   Currently conducting biweekly conference
                                   calls with ARC and ASoC leadership to
                                   better collaborate and address joint
                                   issues. Next EACE, DOD, and VA leadership
                                   meeting will be held in San Antonio
                                   31July to 2August2012 during the VA
                                   Amputation Skills Conference.
                                  Building portfolio development for
                                   DOD/VA EACE-related research activities.
                                   Seeking seats on programming boards, i.e.
                                   the Medical Research and Materiel Command
                                   (MRMC) Joint Program Committee for
                                   Clinical Rehabilitative Medicine (JPC-8),
                                   identifying research gaps and helping to
                                   establish research priorities.
                                  At the request of the European
                                   Command (EUCOM), EACE global outreach
                                   consultative activity to enhance amputee
                                   care capability in the Republic of
                                   Georgia Ministry of Defense is ongoing.
    ------------------------------------------------------------------------
    Resources                     Sufficient operations and
                                   maintenance (O&M) resourcing to date and
                                   in the Future Years Defense Program
                                   (FYDP). FY 2012 budget: $5.9 million.
    ------------------------------------------------------------------------
    Space                         Sufficient space allocated within
                                   all ARCs (San Antonio Military Medical
                                   Center (180 SF); Walter Reed National
                                   Military Medical Center, Bethesda (300
                                   SF); and Naval Medical Center, San Diego)
                                   and Executive Office in San Antonio,
                                   Texas (330 SF).
    ------------------------------------------------------------------------
    Personnel Allocations         Each ARC is actively hiring civil
                                   service employees. The Executive Office
                                   and VA are also placing maximum priority
                                   on hiring. The process is lengthy but is
                                   progressing well.Extremity Trauma and
                                   Amputation Center of Excellence (EACE)
    ------------------------------------------------------------------------

                        Vision Center of Excellence (VCE)
    ------------------------------------------------------------------------

    ------------------------------------------------------------------------
    Operational Status            DOD and VA executive leadership in
                                   place; leadership for 4 of 6 Directorates
                                   hired.
                                  Currently, 15.6 government staff
                                   hired with 8 contractors providing
                                   administrative support to two regional
                                   locations: National Capital Region and
                                   Joint Base Lewis-McChord.
    ------------------------------------------------------------------------
    Activities                    Transitioned from TRICARE
                                   Management Activity (TMA) to Navy Bureau
                                   of Medicine and Surgery (BUMED)--
                                   October2011.
                                  Published and received approval of
                                   VCE Strategic Plan and Concept of
                                   Operations by the MHS CoE Oversight
                                   Board--January2012.
                                  Developing VCE Program Management
                                   Plan.
                                  Developed FY11-12 vision research
                                   priorities--April2011.
                                  Research grantee site visits--in
                                   process.
                                  Deployed Defense and Veterans Eye
                                   Injury and Vision Registry (Vision
                                   Registry) Pilot--March2012.
                                  Developing VA Eye Injury Data
                                   Store to provide VA clinical data to the
                                   Vision Registry.
                                  Leading effort to develop
                                   functional requirements of a joint VA/DOD
                                   electronic eye note for the integrated
                                   Electronic Health Record (iEHR).
                                  Partnered with Harvard Medical
                                   School/Massachusetts Eye and Ear
                                   Infirmary/Schepens Eye Institute and
                                   Smith-Kettlewell Research Institute to
                                   conduct biannual symposia.
                                  Coordinating monthly Worldwide
                                   Ocular Trauma Video Teleconferences--
                                   March2011 (ongoing).
                                  Leading the process to include Fox
                                   eye shields in military individual first
                                   aid kits.
                                  Developing training initiatives
                                   and clinical recommendations for VA and
                                   DOD vision care providers.
                                  Coordinating with the Committee
                                   for Tactical Combat Casualty Care to
                                   include Fox eye shield use in first-
                                   responder training programs.
                                  Leading the effort with MHS Office
                                   of Strategic Communications for the
                                   health.mil Web site re-design.
                                  Presented/participated in national
                                   and international vision care educational
                                   programs.
                                  Directing gap analysis for
                                   assistive technology for the visually
                                   impaired.
                                  Published Federal Practitioner
                                   (circ.35,000) update ``Focus on
                                   Capabilities Not Disabilities--Sports and
                                   Recreation for the Visually Impaired
                                   Servicemember and Veteran''--June2012.
                                  Implementing a pilot vision
                                   impairment education center for
                                   Servicemembers, Veterans and their
                                   families at Walter Reed National Military
                                   Medical Center, Bethesda, MD.
    ------------------------------------------------------------------------
    Resource Allocation           Budget FY 2012: DOD $17.911M; VA
                                   $2.272M.
    ------------------------------------------------------------------------
    Space Allocation              Headquarters: Bethesda, MD (Walter
                                   Reed National Military Medical Center),
                                   approx. 1,700 sq. ft.--opened March2012;
                                   Arlington (Crystal City), VA; approx.
                                   14,500 sq. ft.--opened July2011
                                  VCE West: Tacoma, WA (Madigan Army
                                   Medical Center), approx. 120 sq. ft.
                                   under tenancy negotiation--opened
                                   October2010.
                                  VCE South: San Antonio, TX (San
                                   Antonio Military Medical Center)--in
                                   planning stages.
    ------------------------------------------------------------------------
    Personnel Allocation          Human capital assets as of 6/11/
                                   2012: Mil--1, DOD--11, VA--3.6; Total
                                   government staff--15.6; Total contract
                                   staff--8.
                                  Executive Director (DOD)
                                   appointment 2008.
                                  Deputy Director (VA) initial
                                   appointee 2008, successor appointment
                                   2010.
                                  Four of six Mission Area Directors
                                   hired (Information & Information
                                   Management, Technology, Rehabilitation &
                                   Reintegration, and Education and
                                   Training). Two Directors remaining to be
                                   hired: (Clinical Care Integration, and
                                   Research & Development
                                  Human capital, facilities, and
                                   resource management administrative
                                   support hired.
                                  Vision Services Care Coordinator
                                   hired to support DOD and VA clinical care
                                   coordination.
    ------------------------------------------------------------------------

                                     ______

    Response to Posthearing Questions Submitted by Hon. Richard Burr to Jo
        Ann Rooney, Acting Under Secretary of Defense for Personnel and
     Readiness, U.S. Department of Defense and John R. Gingrich, Chief of
                   Staff, U.S. Department of Veterans Affairs
        Question 1. In written testimony for the record, Paralyzed Veterans
    of America said this about the Integrated Disability Evaluation System
    (IDES):

            ``Servicemembers who are participating in the new approach to
            discharge evaluation are not systematically being encouraged to
            seek representation from a [veterans' service organization]
            Service Representative. Most are relying instead on the
            advisory services of military counsel, yet each service
            provides access to military legal counsel in different manners
            and circumstances.''

        a. What is being done to provide Servicemembers in IDES with access
    to representatives from veterans' service organizations (VSOs)?
        VA Response. [VA defers to DOD.]
        DOD Response. DOD policy requires the Military Departments to
    inform Servicemembers they may seek assistance during the IDES process
    from Government legal counsel provided by the Military Departments,
    private counsel retained at their own expense, or from a VA-accredited
    representative of a service organization recognized by the Secretary of
    Veterans Affairs, using VA Form 21-22, ``Appointment of Veterans
    Service Organizations as Claimant's Representative,'' or from a VA-
    accredited claims agent or attorney using VA Form 21-22a, ``Appointment
    of Individual as Claimant's Representative.''

        b. Of the 139 sites using the IDES process, how many have
    representatives from VSOs on site to help Servicemembers with the IDES
    process?
        VA Response. [VA defers to DOD.]
        DOD Response. VA indicates all IDES sites can accommodate VSO's
    that choose to make themselves available to Servicemembers. Some sites
    are able to provide dedicated space for accredited VSOs, while other
    sites accommodate VSOs through temporary meeting space.

        c. Has the Department of Defense (DOD) provided uniform guidance or
    requirements about when Servicemembers should have access to counsel
    during the IDES process? If so, please provide a copy to the Committee.
        VA Response. [VA defers to DOD.]
        DOD Response. Yes. DOD policy (Directive-Type Memorandum (DTM) 11-
    015--Integrated Disability Evaluation System (IDES), December, 2011)
    provided uniform guidance or requirements about when Servicemembers
    should have access to counsel during the IDES process.

        Question 2. In a September 2010 report, VA and DOD identified
    customer satisfaction as a key indicator of IDES performance.
        a. What is currently being done to gauge customer satisfaction with
    the IDES process?
        VA Response. [VA defers to DOD.]
        DOD Response. The IDES Customer Satisfaction Survey was suspended
    as of December 6th, 2011, following funding cuts. Currently the VA and
    DOD are not involved in any systematic data collection efforts for
    customer satisfaction data.
        b. Does DOD plan to use customer satisfaction surveys in the
    future?
        VA Response. [VA defers to DOD.]
        DOD Response. Yes, the DOD plans to resume use of the customer
    satisfaction surveys by October 2012, subject to availability of funds.
        c. If so, when will those surveys begin and what, if any, changes
    would be made to the surveys that were being used previously?
        VA Response. [VA defers to DOD.]
        DOD Response. DOD plans to resume IDES Customer Satisfaction
    surveys beginning in fiscal year 2013. DOD is currently reviewing
    previous IDES surveys to determine whether they can be improved.

        Question 3. The Government Accountability Office (GAO) has
    previously reported that staffing shortages are part of the reason for
    delays during the IDES process.
        a. Of the 139 sites using IDES, how many have enough staff to meet
    all of the agencies' staffing goals for each phase of the IDES process?
        VA Response. VHA uses a flexible approach to providing staffing
    options to Veterans Integrated Service Network (VISN) and facility
    directors. Facilities and VISNs have used Locum Tenens and contract
    providers to supplement their staffs as surges have impacted their
    facilities. They have also managed the schedules of their Compensation
    and Pension (C&P) staff to maximize efforts to meet examination
    demands. This approach has shown results as VHA has in 9 of the past 10
    months exceeded the goals for IDES medical examinations at a time when
    examination demand has more than doubled. Further, VHA's flexible
    approach has allowed it to meet or exceed national standards for
    general C&P examinations as well. This agile approach was proven
    necessary as the services often are challenged in identifying workload
    numbers or impact locations in a timeframe allowing for long-term
    planning/staffing.
        VA is staffed to support the estimated steady state of 27,000 IDES
    claims per year. VA and DOD continue to assess the impact of troop
    movement and drawdown of forces on the IDES program. We will monitor
    resource needs as part of our overall evaluation of the program.
        DOD Response. All the Services are required to provide quarterly
    reports of PEBLO staffing ratios at each IDES military treatment
    facility. Navy indicates that all but two IDES sites are adequately
    staffed, with positions being filled at Naval Hospital29 Palms and
    Naval Hospital Beaufort. Army reports indicate adequate staffing at 21
    sites with hiring actions at the other 15. Air Force reports adequate
    staffing at their 74 sites, though 13 use alternate staff to assist as
    required. Air Force is requesting additional PEBLO assistants for every
    site.

        b. If any sites are not meeting all staffing goals, please provide
    a timeline for when those sites will have sufficient staff to meet all
    goals.
        VA Response. As stated to the previous question, it is important to
    note that a flexible staffing approach is necessary given how surges,
    by definition, ebb and flow. Contractors and Locum Tenens are the best
    approach to these examination needs.
        MSC staffing goals were met at each site as IDES was implemented
    worldwide, and continue to be met at all sites today.
        DOD Response. The Department of the Army projected but did not
    complete hiring of long-term IDES staff at MTFs in July 2012. Army has
    filled over 90% of positions for MEB physicians, PEBLOs, and legal
    assistants. Filling behavioral health positions remains the Army's
    largest challenge--36% currently filled, expected to rise to 69% once
    current candidates are on boarded. The Army continues hiring efforts
    for the remaining positions. In addition, the Army is also establishing
    5-7 remote IDES processing locations to handle peak overflow volume.
    The Air Force projects completing additional PEBLO assistant hiring in
    FY 2014. Navy's hiring actions are currently open and should be filled
    before the end of the fiscal year.

        c. Do the agencies have plans to use sites other than medical
    treatment facilities to expand IDES capacity? If so, please explain.
        VA Response. The term ``medical treatment facilities'' is normally
    associated with health care facilities under the auspices of DOD. VA,
    however, has no plans to conduct IDES C&P examinations at other than
    facilities agreed upon during the initial IDES implementation or
    locations established by our Disability Examination Management (DEM)
    Contractors located within the vicinity of the military installations.
        DOD Response. The Air Force and Navy have no plans to use sites
    other than MTFs to expand IDES capacity. The Army is pursuing a
    strategy to establish 5-7 remote IDES processing locations to handle
    peak overflow volume. The Army anticipates the expansion locations will
    be located near MTFs to allow sharing of administrative support. The
    Army's expansion centers will be located in government facilities or
    leased space adjacent to Army installations.

        d. How many of the 139 IDES sites prepare Narrative Summaries at
    their own locations?
        VA Response. VHA does not prepare Narrative Summaries. This
    question should be redirected to DOD.
        DOD Response. Narrative Summaries are prepared within the MTF at
    all IDES sites.

        Question 4. In May 2011, the Secretary of Defense and Secretary of
    Veterans Affairs committed to revising IDES so that it could be
    completed in 150 days. They also agreed to explore options so it could
    be completed in 75 days. For the record, please explain the status of
    those efforts.
        VA Response. The remodeled Integrated Disability System (rIDES) was
    designed to meet the Secretaries intent of completing the process in
    less than 295 days. However, the Army had concerns about the
    effectiveness of rIDES and wanted to focus their energy on improving
    IDES. At the December 2011 SOC meeting, the decision was made to defer
    rIDES proof of concept. The SOC directed the workgroup to continue to
    focus on IDES improvements, harvest best practices from site visits,
    analyze and test them and continue to move forward.
        DOD Response. We continue to focus on IDES improvements which
    include actions such as:

         IDES site visits by interdisciplinary teams to identify
    and communicate specific refinements across the Services. Those visits
    yielded improvements that have been implemented system-wide, such as a
    locally developed case management tool for tracking medical board
    cases;
         Working closely with VA to develop and implement in 2012
    an IT capability to electronically transfer IDES case files among case
    workers;
         Establishing the task force Secretary Panetta directed to
    review the IDES process by the end of September 2012 on improvement
    recommendations;
         Evaluating ways to improve utilization of our expedited
    evaluation process for catastrophically ill or injured Servicemembers.

        Question 5. As reflected in VA Fast Letter 12-07, IDES examinations
    for members of the Guard and Reserves are being handled closer to their
    current locations.
        a. How and when are the local facilities notified of how many Guard
    and Reserve members they should expect to provide with examinations?
        VA Response. The local facilities are notified of how many Reserve
    Component (RC) members they should expect to provide with examinations
    when the MSC inputs the exam request(s) into the Compensation and
    Pension Records Interchange (CAPRI) system. This occurs after the MSC
    conducts the initial interview with the Servicemember. The request is
    forwarded electronically to the VA facility closest to the RC member's
    home that has the clinical capability to satisfy the examination
    requirements. Currently, predictability of the RC workload and the
    proposed distribution of this workload remains a challenge.
        DOD Response. DOD updates VA on anticipated case flow estimates. In
    addition, DOD and VA require local leaders to communicate anticipated
    changes in case flow or capability and to develop contingency plans to
    meet unanticipated changes in case flow.
        b. When a local facility receives a request to perform an IDES
    examination, does that examination take priority over that facility's
    standard compensation and pension examination workload?
        DOD Response. [DOD defers to VA.]
        VA Response. IDES examinations enjoy the same priority as the C&P
    examinations offered to our Veterans. Facilities do attempt however, to
    get these examinations scheduled and completed as soon as possible to
    remain within the IDES goals for conducting medical examinations.
        As of May 20, 2012, the VHA average for completing IDES medical
    exams was 38 days plus one day for administration; the IDES Program
    goal for examination completion is 45 days.

        Question 6. According to written testimony for the May 23, 2012,
    hearing, the Joint Executive Council (JEC) reviews a monthly report
    regarding the performance of IDES.
        a. Please explain what role the JEC plays in terms of trying to
    improve IDES performance.
        VA Response. The JEC replaced the SOC on January 12, 2012. The JEC
    serves as the primary VA and DOD coordination body for overseeing and
    supporting joint activities, initiatives and wounded, ill and injured
    issues. IDES is one of those joint initiatives the JEC provides
    oversight and guidance to. The JEC recommends to the respective
    Secretaries the strategic direction for joint coordination and sharing
    efforts. The JEC then oversees the execution and implementation of
    those efforts.
        b. Who ultimately has responsibility for IDES decisionmaking and
    fixing any existing problems with IDES?
        VA Response. The Secretaries of the VA and DOD are ultimately
    responsible for decisionmaking and fixing any existing problems with
    IDES. The Deputy Secretary of VA and Under Secretary of Defense for
    Personnel and Readiness serves as co-chairs of the Joint Executive
    Council (JEC) which coordinates and oversees joint VA/DOD initiatives.
        c. Please provide an organizational chart showing all offices
    within VA, DOD, and the military services that are involved in the IDES
    process and the lines of authority for reporting and accountability.
        DOD Response. [DOD defers to VA.]
        VA Response. See Operational Model Diagram (which is displayed
    previously under responses to Senator Murray's Question 3).

        Question 7. According to written testimony for the May 23, 2012,
    hearing, there are currently over 27,000 military personnel going
    through the IDES process.
        a. In total, how many additional military personnel are projected
    to enter the IDES process in 2012, 2013, and 2014?
        VA Response. [VA defers to DOD.]
        DOD Response. Army expects their IDES caseload to continue to
    increase to approximately 30,000 cases by the end of 20 12 and to
    remain steady through 2014, then to decrease back to pre-deployment
    levels of around 12,000. Navy projects 1275 additional cases beyond
    current levels in FY 2012, 541 in FY 2013, and 549 in FY 2014. The Air
    Force projects 400 Servicemembers beyond current levels will enter the
    IDES each year FY 2012-FY2014.

        b. Of those military personnel, what portion is expected to be from
    active components and what portion is expected to be from the Guard and
    Reserves?
        VA Response. [VA defers to DOD.]
        DOD Response. Army has dedicated new resources to assist in
    preparing and processing Reserve Component disability cases and expects
    the percentage of Servicemembers entering the IDES who are from the
    Reserve Components to increase temporarily beyond the current 30
    percent.
        The Army does not yet have an estimate of the proportions of cases
    expected from the Reserve Components from FY 2012 to FY 2014. Of the
    additional expected IDES cases beyond current levels, the Navy expects
    89 Reserve Component members to enter the IDES in FY 2012, 38 in FY
    2013, and 38 in FY 2014. Of the additional expected IDES cases beyond
    current levels, the Air Force expects 60 Reserve Component members to
    enter the IDES each year between FY 2012 and FY 2014.

        c. Are all IDES cases treated with the same priority level or are
    there certain categories of cases that are expedited above other cases?
    For example, are there procedures to expedite cases based on financial
    hardship or if the servicemember has received a civilian job offer?
        VA Response. [VA defers to DOD.]
        DOD Response. The Military Departments expedite the cases of
    catastrophically ill or injured Servicemembers who choose to waive the
    IDES process and participate in the Expedited DES process.
        In addition, the Military Departments, where possible, expedite
    IDES cases of Servicemembers with extenuating circumstances.

        Question 8. According to VA's written testimony, ``VA can deliver
    benefits in the shortest period allowed by law following discharge thus
    reducing the `benefit gap.' ''
        a. For the record, please explain what is the ``shortest period
    allowed by law'' for making VA disability payments following discharge
    or release from the military.
        VA Response. The ``shortest period allowed by law'' for making VA
    disability payments following discharge or release from the military is
    the first day of the second month after a Servicemember separates. 38
    U.S.C. Sec. 5111 states that payment of monetary benefits may not be
    made for any period before the first day of the calendar month
    following the month in which the award became effective. For example,
    if the Servicemember separates on July 27, the award is effective the
    day following discharge, or July 28. Benefits begin to accrue on the
    first day of the next calendar month, or August 1. Payment for the
    month of August occurs on September 1.
        DOD Response. U.S. Code prohibits VA from providing disability
    compensation prior to the first day of the second month following
    discharge or release from the military. For example, if the
    Servicemember separates on July 27, the earliest date VA can compensate
    the Veteran for disability is September 1.

        b. Currently, how long on average is it taking for VA to issue a
    benefits decision after an IDES participant is discharged or released
    from the military? As requested at the hearing, please provide any
    statistics on how long after service IDES participants receive their
    first VA disability compensation payment (not the VA decision letter,
    but the actual arrival of the first check/deposit).
        VA Response. As of June 8, 2012, VA has processed 7,707 disability
    payments for Servicemembers who have completed the IDES process during
    fiscal year 2012. Currently, VA is averaging 54 days from the date of
    separation to process a payment.
        DOD Response. [DOD defers to VA.]

        c. As requested at the hearing, please provide any statistics on
    how long after service IDES participants receive their first VA
    disability compensation payment (not the VA decision letter, but the
    actual arrival of the first check/deposit).
        VA Response. VA's benefits letter is mailed within one business day
    of the date on which the Veteran's compensation award is authorized.
    Payments are released from the Treasury Department within 48 hours of
    award authorization.
        DOD Response. [DOD defers to VA.]
                                     ______

    Response to Posthearing Questions Submitted by Hon. Bernard Sanders to
      Jo Ann Rooney, Acting Under Secretary of Defense for Personnel and
                     Readiness, U.S. Department of Defense
        Question 1. At what point did DOD realize that it needed to 1,400
    additional staff?
        DOD Response. The Army, Navy and Air Force continuously monitor
    their DES staff requirements and implemented hiring actions to fill
    shortages beginning in 2008. After fully implementing theIDES at all
    locations in October 2011, the Military Departments recognized that
    caseload exceeded staff capacity. In response, the Departments
    accelerated hiring in late 2011 and efforts to hire and train the
    additional staff are nearing completion.

        Question 2. What occupations do these additional civilian staff
    members hold?
        DOD Response. The Military Services are hiring additional IDES
    civilian staff as Medical Evaluation Board and Physical Evaluation
    Board members and staff, Physical Evaluation Board Liaison Officers
    (PEBLOs), PEBLO assistants, legal and paralegal professionals,
    physicians, psychologists, social workers, and management analysts.

        Question 3. Were any Wounded Warriors hired for these new
    positions?
        DOD Response. The Services do not have readily available
    information on the numbers of wounded warriors hired for these
    positions. But, the Army reports it hired qualified wounded warriors
    who applied for these positions. The Navy and Air Force report that
    they did not receive any applications from wounded warriors in
    connection with the job announcements advertised for their positions.

        Question 4. What factors determine where these additional staff
    members will be assigned?
        DOD Response. The Military Departments determine the assignment of
    additional staff members based on case workload and complexity, the co-
    location of supporting functions and established MTF staffing models.

        Question 5. What formal training does the PEB Liaison Official
    receive and what is his or her normal caseload?
        DOD Response. DOD policy requires the Military Departments, at a
    minimum, to train IDES personnel on the statutory and policy
    requirements of the DES; the electronic and paper record keeping
    policies of the Military Department; customer service philosophies;
    familiarization with medical administration processes; the role and
    responsibilities of a Servicemember's assigned military legal counsel,
    an overview of the services and benefits offered by the VA; knowledge
    of online and other resources pertaining to the DES, DOD and VA
    departments; knowledge of the chain of supervision and command; and
    knowledge of Inspector General hotlines for resolution of issues.
        DOD policy recommends that PEBLOs manage no more than 20 cases
    simultaneously. Because active PEBLO case management is concentrated in
    the MEB portion of the disability evaluation process, DOD defines PEBLO
    case ratio for a military treatment facility as the number of trained
    PEBLO staff divided by 100/365 multiplied by the total number of new
    cases at the location per year, where 100/365 is the fraction of time
    devoted to active case management during the MEB portion of the IDES
    during the year.

        Question 6. When Reservists and National Guard personnel go through
    the IDES process, are they on Federal active-duty orders?
        DOD Response. Severely ill or injured Reserve Component
    Servicemembers can be on Active Duty orders for the entire IDES
    process. Other Reserve Component Servicemembers may be placed on Active
    Duty orders to complete IDES activities (exams, interaction with
    PEBLO's, participation at boards, etc.) to accommodate their civilian
    job requirements and family commitments.

        Question 7. Why are there two different timelines for active-duty
    and Reservists?
        DOD Response. DOD policy defines different timelines for active and
    reserve component members to provide more time to coordinate active
    duty periods with Reserve and National Guard members, generate active
    duty orders, and gather medical records from Reserve units and civilian
    doctors. Active Component Servicemembers typically do not require this
    additional time and thus have a shorter overall IDES timeline goal.

        Question 8. If a servicemember expresses no desire to remain on
    active-duty at the beginning of the IDES process, is he or she
    processed any differently?
        DOD Response. The IDES process requires that participants be in an
    Active Duty status during all portions of the process to qualify for
    appropriate pay and benefits. Reservists may coordinate periods of
    Active Duty to comply, but generally must be available, and in an
    active duty status (``on orders'') during those portions of the IDES
    process that requires their participation.

        Question 9. When a servicemember exceeds the goal for an IDES
    phase, how is that flagged to draw attention to the delay in that phase
    of the process?
        DOD Response. DOD and VA IDES staff monitor case timeliness through
    a number of reports available from VA's Veterans Tracking Application
    (VTA). These reports identify cases exceeding IDES goals in all IDES
    stages.

        Question 10. Why can't the Medical Evaluation Board and Physical
    Evaluation Board be consolidated into one Board?
        DOD Response. The law (National Defense Authorization Act of Fiscal
    Year 2008, Section 1602(3)(A)), defines the Disability Evaluation
    System as ``A system * * * comprised of medical evaluation boards,
    physical evaluation boards, * * *'' which requires the Department to
    maintain separate medical and physical evaluation board processes.

        Chairman Murray. Mr. Gingrich?

            STATEMENT OF JOHN R. GINGRICH, CHIEF OF STAFF,
                  U.S. DEPARTMENT OF VETERANS AFFAIRS

        Mr. Gingrich. Good morning, Chairman Murray. I have a cold
    so I have to speak up. Ranking Member Burr, Members of the
    Committee, I am pleased to be joined this morning by Under
    Secretary Jo Ann Rooney to discuss the IDES system. We have
    come a long way since the issues of Walter Reed Army Medical
    Center were identified in 2007. At that time, VA and the DOD
    were miles apart. Simply stated, the lack of integration and
    cooperation between the Departments did not serve wounded
    servicemembers well.
        Since that time, together we have committed to achieve a
    seamless transition through a multi-pronged approach with IDES
    as one of the critical initiatives. The joint IDES process was
    designed to eliminate time consuming and often confusing
    elements of the separate disability processes. The goals of the
    joint process were to increase transparency, reduce the
    processing time, improve consistency, and reduce the benefits
    gap.
        To achieve greater transparency for servicemembers, we have
    enhanced our online tools, the My Health Vet and benefits, to
    allow servicemembers in IDES to view appointments and lab
    results and to track their claim. Internally, we have increased
    transparency through the IDES Dashboard that tracks performance
    at each IDES site.
        The Secretaries have charged us to reach a combined
    performance goal of 295 days for 60 percent of the
    servicemembers by the end of this year. To ensure that we reach
    this goal, I hold biweekly reviews with all 116 stations. In a
    relatively short period of time, we have seen positive results.
        In January, the oldest case being worked for proposed
    disability rating was 254 days. Today there are no cases over
    180 days. From February 2011 to April 2012, we have reduced the
    average claim development time by 62 percent and the medical
    examination and admin time by 60 percent.
        On April 5th, I committed to the Army Vice Chief of Staff
    that VA would clear, within 60 days, the entire inventory of
    Army cases awaiting proposed rating decisions. We have cleared
    76 percent of those cases and are well on our way to deliver on
    that promise not only for the Army, but for all the services.
        For both preliminary and final ratings, the combined
    productivity of our three Disability Rating Activity Sites,
    DRAS, increased 15 percent in the last month. We have several
    projects to enhance our efficiency and effectiveness such as
    the Veteran Tracking Application that will increase the flow of
    information electronically from DOD to VA, and the electronic
    case file transfer system.
        We have made progress in improving transparency, improving
    consistency, and reducing process time. But our biggest
    achievement to date has been closing the benefit gap.
    Servicemembers no longer wait six to 9 months to receive
    compensation they have earned. Yet, with all these
    achievements, we are not satisfied because we are not meeting
    the requirement for every single servicemember.
        We will continue to work with DOD to improve our systems
    and processes until we achieve all of our objectives in 100
    days for each servicemember. I will often refer to cases or
    claims here today, but let me assure you, I never lose sight of
    the fact that behind a claim is a servicemember and his or her
    family who depend on VA to get it right.
        We will continue to partner with DOD to effectively and
    efficiently get him or her back to their unit to continue
    military service, or if discharged, provide the benefits they
    have earned. As partners, we will overcome the remaining
    challenges together to achieve the seamless transition
    servicemembers deserve. This is a commitment we must meet.
        I look forward to answering any questions that you may
    have.
        [The prepared statement of Mr. Gingrich follows:]

            Prepared Statement of John R. Gingrich, Chief of Staff,
                      U.S. Department of Veterans Affairs

        Good morning Chairman Murray, Ranking Member Burr, and Members of
    the Committee. I am pleased to be joined this morning by Jo Ann Rooney,
    Ed.D., J.D., Acting Under Secretary for Personnel and Readiness,
    Department of Defense (DOD) to discuss the progress being made by the
    VA and the DOD toward meeting the needs of injured Servicemembers. My
    testimony will focus on the status of our progress toward improving the
    Integrated Disability Evaluation System (IDES) used to transition
    wounded, ill, and injured Servicemembers from DOD to VA or, if found
    fit, return them quickly to their units to continue their military
    service.

                                  INTRODUCTION

        VA and DOD have a shared goal: ensuring that Servicemembers'
    transition between VA and DOD is as smooth as possible and honors their
    sacrifice for the greater good. To create a truly seamless transition,
    we have a multi-pronged approach that includes developing a single
    Integrated Electronic Health Record (iEHR), improving our Federal
    Recovery Coordination Program (FRCP) and having an efficient IDES
    system. If we are to truly achieve the seamless transition that we both
    agree is necessary, it will be through measurable progress in all three
    core programs.
        Our commitment is not to create a program or a process; our
    commitment is to create a new paradigm. The old paradigm of two big
    bureaucracies with completely different processes, systems and programs
    did not work in the past and will not work in the future. Seamless
    transition is the new paradigm; not a slogan. At the James A. Lovell
    Federal Health Care Center (JALFHCC), both Servicemembers and Veterans
    are served by a joint VA/DOD team. JALFHCC embodies this new paradigm.
    While there are still issues that we must work through at JALFHCC, it
    is strong evidence that we can overcome barriers when the needs of
    Servicemembers, Veterans and their families are our priority.
        Our Departments understand that we are responsible for the same men
    and women, though at different periods of their lives, and that
    together our Departments can help improve their transition experience
    as they move from one stage to the next. I will focus my remarks today
    on IDES as one piece of a larger transformation.

                                      IDES

        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. VA's and DOD's joint efforts have resulted in process
    improvements and created an integrated disability evaluation system for
    Servicemembers who are being evaluated for medical retirement or
    separated. 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 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, IDES provides a single set
    of disability examinations and a single-source disability rating, for
    use 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 lag time used to be 6 to 9
    months; it now is reduced to 30 to 60 days, with our goal being to
    reach no more than 30 days. The DOD/VA integrated approach has also
    eliminated many of the sequential and duplicative processes found in
    the legacy system.
        VA is responsible for four core processes within IDES: claims
    development, medical examination, proposed disability rating, and VA
    benefits estimate letter. VA's target for combined processes is 100
    days of the 295 day combined VA/DOD target. While VA is currently
    meeting the 10-day goal for claims development and the 45-day goal for
    medical examinations, VA is not meeting the 15-day goal for completion
    of the proposed rating and the 30-day standard for delivery of VA
    benefits estimate letters, which currently are 46 and 26 days beyond
    the target, respectively. To address increased volume at the rating
    sites during FY 2011, VBA temporarily placed on site help teams at the
    Baltimore and Seattle VA Disability Rating Activity Sites (DRASs) and
    brokered IDES work to other stations. VBA increased the number of
    Rating Veterans Service Representatives (RVSRs) at the Seattle DRAS in
    March 2012 and now has a total of 174 RVSRs dedicated to the IDES
    mission at Baltimore, Providence, and Seattle. Increased staffing
    levels and maturation of skills for newer RVSR trainees will aid VBA in
    meeting the expected goals for the preliminary rating and final
    benefits stages. The combined productivity of the three DRASs for
    completion of preliminary and final ratings was 3,125 for the month of
    April 2012, which represents a 15 percent increase over March
    performance of 2,708 completed cases. VA will begin to receive military
    separation data electronically in Veterans Tracking Application (VTA)
    in June 2012. It is expected this enhancement will reduce the time it
    takes the DRASs to verify separations, character of service, and
    severance or other pay issues, which must be verified prior to issuance
    of VA benefits.
        Both SECDEF and SECVA have directed their respective Departments to
    reduce the combined processing time to 295 days for 60 percent of
    Servicemembers in IDES by the end of this calendar year with the
    ultimate goal of 100 percent. We have already made great progress
    toward that end. For example, at the Disability Rating Activity Sites
    in January 2012, the oldest case being worked for Proposed Disability
    Rating was 254 days. Today, there is not a single case over 180 days.
    Additionally, it is important to note none of these cases are impacting
    DOD's ability to move forward with their fitness decision. Today we
    find ourselves required to process many more claims per month than we
    had originally anticipated. As demand has increased we have adjusted to
    meet the Servicemember's needs. In January 2012 VA completed 1,254
    Proposed Disability Ratings and in April 2012 VA completed 2,363
    Proposed Disability Ratings. That is an 88 percent increase in monthly
    performance, which allowed for a reduction of more than 5,500 of the
    backlogged claims. We are proud of the advancements we have made, but
    to meet the overall 295-day goal, we will need to focus our efforts on
    ensuring accountability through staffing and governance, utilizing
    technology, process improvements, and increased management oversight to
    endure successful delivery.

                                 ACCOUNTABILITY

        First, we have institutionalized accountability mechanisms. At each
    IDES site VA has instituted the concept of a lead VA executive, a
    senior VA official who is directly responsible for the overall IDES
    mission, operations and performance at his/her specific site. With a
    single individual charged with performance responsibility we believe
    management will be able to drive change more quickly and resolve
    problems as they arise. To appropriately track our performance in the
    field, VHA and the Office of VA/DOD Collaboration Service in VA
    developed the ``IDES Dashboard,'' a comprehensive management chart that
    tracks performance in each of VA's four IDES phases at each IDES site.
    Use of the ``IDES Dashboard'' has led directly to improved performance
    tracking and enabled VA's leaders to spot trouble spots and allocate
    resources more effectively.

                              MANAGEMENT OVERSIGHT

        With any project, the appropriate amount of leadership and
    oversight must be applied. VA has elevated oversight to the most senior
    levels of the VA. SECVA and SECDEF meet quarterly, and IDES has always
    been on the agenda and they both receive monthly updates. On a monthly
    basis, I meet with the Vice Chief of Staff of the Army to review
    performance at Army IDES sites. These meetings are attended by senior
    personnel from VA, Office of the Secretary of Defense (OSD), and the
    Army. IDES performance data is reviewed at a very detailed level and
    senior officials in the field are expected to present plans to improve
    performance if standards are not met. Additionally, since May 2011, I
    have been leading a Video Teleconference (VTC) every two weeks with
    senior Veterans Benefits Administration (VBA) and Veterans Health
    Administration (VHA) officials at 116 sites in the field who are
    directly responsible for IDES at their respective sites. During these
    VTCs I review IDES performance at a very detailed level and ask the
    responsible senior official for his/her plan to improve performance.
        VA's office of VA/DOD Collaboration Service also leads a weekly
    telephone conference call with VBA and VHA and a weekly telephone
    conference call with the OSD and the Military Services to review IDES
    performance and problems. Senior VA officials also meet on a monthly
    basis with Navy Bureau of Medicine officials to review performance at
    Navy and Marine Corps IDES sites. IDES performance data is reviewed at
    a very detailed level and senior officials in the field are expected to
    present plans to improve performance if standards are not met. At every
    level of VA, leadership is engaged with our partners in DOD and our
    management team in the field.

                     TECHNOLOGY AND PERFORMANCE IMPROVEMENT

        Our continuous review of the IDES process revealed two consistent
    issues: access to information and reducing the movement of paper files.
    In both instances, we believe technology will play a key role. The next
    series of enhancements to the Veterans Tracking Application (VTA 2.0)
    will leverage our ability to electronically share DD-214 data via VA/
    DOD Identity Repository (VADIR) to automatically trigger work flow in a
    way that will reduce overall processing time. VADIR database was
    established to support a One VA/DOD data-sharing initiative in order to
    consolidate data transfers between DOD and VA to assist in determining
    Veteran benefits. The expanded data feed will also include key data
    elements to assist VA Disability Rating Activity Sites (DRAS) in
    determining entitlements to VA benefits such as: date of separation and
    character of service, among others. VTA 2.0 will also include
    additional reporting capabilities that will allow VBA's Office of Field
    Operations to better manage the workflow of VBA employees and provide
    the ability to record the occurrences of diagnostic differences on IDES
    exams to identify inconsistencies. Based on demonstration performance
    to date, we believe that the new version of VTA, scheduled for release
    in June 2012 will greatly improve performance management.
        VA is also collaborating with DOD to accomplish the Secretaries'
    joint goal of achieving electronic case file transfer (CFT) for IDES by
    July 2012. The planned solution will be a single system that will avoid
    development time and costs. CTF will remove the costly and inefficient
    transfer of paper records from DOD to VA by eliminating the need for
    shipping. Our system will accommodate both computable data and scanned
    paper to ensure that the solution we adopt assists both the younger
    Servicemembers with large portions of their records in electronic
    format and older Servicemembers who may still have a significant
    portion of their records in paper.

                                   CONCLUSION

        Despite these efforts, we know challenges remain, and there is room
    for significant improvement in IDES. VA and DOD are committed to
    supporting our Nation's wounded, ill, and injured Warriors and Veterans
    through an improved IDES, and we are taking steps to prepare for future
    demand for this system. As such, VA believes that its continued
    partnership with DOD is critical and is nothing less than our
    Servicemembers and Veterans deserve.
                                     ______

    Response to Prehearing Questions Submitted by Hon. Richard Burr to VA,
    Office of Policy and Planning, Integrated Disability Evaluation System
         and DOD, Office of Wounded Warrior Care and Transition Policy

        [Due to their interrelated nature, the responses to the pre-hearing
    questions submitted by Senator Burr to the Department of Veterans
    Affairs were merged in with the responses from the Department of
    Defense appearing earlier in this transcript.]
                                     ______

     Response to Posthearing Questions Submitted by Hon. Patty Murray and
          Hon. Richard Burr to the U.S. Department of Veterans Affairs

        [Due to their interrelated nature, the responses to the posthearing
    questions submitted by Senators Murray and Burr to the Department of
    Veterans Affairs were merged in with the responses from the Department
    of Defense appearing earlier in this transcript.]
                                     ______

    Response to Posthearing Questions Submitted by Hon. Bernard Sanders to
     John R. Gingrich, Chief of Staff, U.S. Department of Veterans Affairs

        Question 1. From the VA perspective, what would you change in the
    IDES process?
        Response.
        a. Implement some of the remodeled IDES improvements concepts
    identified below:

         Reduce the number of physical case-file handoffs from 8 to
    3.
         Make fitness decision for further military service up
    front, before VA enters into the process.
         Ensure VA receives a complete case-file from the Military
    Services after the fitness decision is made.

        b. Automate the IDES process from beginning to end, and enhance the
    management reporting capabilities to enable IDES sites to effectively
    manage their cases.
        c. Identify and implement best practices and implement electronic
    data sharing throughout the IDES process.

        Question 2. What formal training does a VA case manager receive and
    what is his or her normal caseload?
        Response. VA Military Service Coordinators (MSCs) receive the same
    core technical training for claim processing as Veterans Service
    Representatives (VSRs) as well as IDES process training. Disability
    Rating Activity Site (DRAS) personnel receive the same national level
    training as all other claims adjudicators in a regional office. As a
    guide for determining sufficient resources, VA uses a staffing model in
    which each MSC has 30 new cases per month.

        Question 3. Are servicemembers enrolled in the VA health care
    system upon completion of the IDES process?
        Response. No. However, the enrollment in the VA health care system
    is highly encouraged to Servicemembers receiving disability
    examinations through IDES. VA has worked closely with DOD to implement
    an online VA Form 10-10EZ, Application for Health Benefits, which is
    completed by Servicemembers at the time of demobilization or
    termination of service. Additionally, active duty Servicemembers
    transitioning through TAP are briefed routinely by VA staff and
    informed on how to apply for VA benefits, including enrollment in the
    VA health care system.

        Question 4. How is a servicemember discharged with mental health
    issues seamlessly transferred from DOD to VA mental health care
    providers?
        Response. VA has a formal process in place to transition wounded,
    ill and injured Servicemembers from DOD to VA. VA has 33 VA Liaisons
    for Healthcare, registered nurses or licensed social workers, stationed
    at 18 Military Treatment Facilities (MTFs) with concentrations of
    recovering Servicemembers returning from Iraq and Afghanistan to
    transition ill and/or injured Servicemembers from DOD to the VA system
    of care. VA Liaisons are co-located with the DOD case managers at the
    MTFs, and provide onsite consultation and collaboration regarding VA
    resources and treatment options. Each referral from the DOD treatment
    team, including referrals for Servicemembers being medically discharged
    with mental health issues, utilizes a standardized referral form
    completed by the DOD Nurse Case Manager identifying the ongoing
    treatment needs. In addition, each referral to a VA medical center
    (VAMC) includes supporting medical documentation such as progress notes
    and narrative summaries. While VA Liaisons participate in discharge
    planning at the MTF, they are dependent on a referral from the DOD case
    manager prior to engaging with Active Duty Servicemembers to coordinate
    ongoing healthcare needs at VA. At MTFs without an onsite VA Liaison,
    DOD Case Managers refer Servicemembers directly to the Operation
    Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/
    OND) Program Manager at the Servicemember's home VAMC. These referrals
    also utilize the standardized referral form identifying the ongoing
    treatment needs as well as the supporting medical documentation.
    Servicemembers may elect to seek care in the private sector using
    TRICARE, in which case they would not be referred to VA and the
    transition not managed by the VA Liaison.
        In addition, OEF/OIF/OND Clinical Case Managers screen all
    returning combat Veterans for the need for case management services,
    including those referred from an MTF as well as those, self-presenting
    for initial care at a VAMC. This screening identifies Veterans who may
    be at risk so VA can intervene early and provide assistance before the
    Veteran is in crisis. In addition to prevalent medical and mental
    health issues related to deployment such as Post Traumatic Stress
    Disorder (PTSD), this screening includes the risk factors for
    psychosocial issues such as homelessness, unemployment, and substance
    abuse. Case management needs are identified early, a plan of care is
    developed, and follow up is provided as long as needed. OEF/OIF/OND
    case managers are experts at identifying and accessing resources within
    their health care system as well as in the local community to help
    Veterans recover from their injuries and readjust to civilian life.

        Question 5. What outreach services does VA provide veterans
    immediately after discharged through the IDES process?
        Response. Like all Servicemembers, individuals released through
    IDES receive the Welcome Home Package, which contains information about
    all VA benefits for which they may be eligible. VA also assigns case
    managers, who assist in outreach services, to individuals whom DOD
    classified as seriously injured before discharge.

        Chairman Murray. Thank you very much. Mr. Bertoni?

     STATEMENT OF DANIEL BERTONI, DIRECTOR, EDUCATION, WORKFORCE,
       AND INCOME SECURITY, U.S. GOVERNMENT ACCOUNTABILITY OFFICE

        Mr. Bertoni. Chairman Murray, Ranking Member Burr, Members
    of the Committee, good morning. I am pleased to discuss the
    Departments of Defense and Veterans Affairs' efforts to improve
    the performance of their Integrated Disability Evaluation
    System, or IDES, which is now the standard process for
    assessing servicemember disabilities worldwide.
        Since its start, GAO has monitored the evolution of this
    process and made several recommendations to address design and
    other challenges. My statement today is based on our ongoing
    work for this Committee and focuses on the extent to which IDES
    is meeting key performance goals and ongoing efforts to improve
    performance.
        In summary, we found that overall timeliness has worsened,
    with the average number of days to complete claims for active
    duty servicemembers increasing from 283 days in 2008 to 394
    days last year, which is well above the stated goal of 295
    days. During the same period, the proportion of active duty
    cases that met timeliness goals also decreased very steeply
    from 63 percent to just 19 percent.
        With the exception of the physical evaluation board phase,
    IDES claims also fell consistently short of interim timeliness
    goals with the medical evaluation board, transition, and
    benefits phases. Processing delays were most significant in
    completing the medical evaluation board process. In 2011, only
    20 percent of active duty cases met the targeted goal for
    obtaining a medical board decision.
        In addition to timeliness, DOD and VA assess servicemember
    satisfaction via telephone surveys, which we found to have
    shortcomings in both design and administration such as unduly
    limiting who actually receives a survey and computing average
    scores in a way that may overstate satisfaction, and limit the
    usefulness of this data as a performance management tool.
        In fact, using an alternative calculation that eliminates
    neutral responses, we found satisfaction rates several times
    lower than DOD reports. DOD and VA have undertaken a number of
    actions to address IDES challenges, many of which we have
    identified in prior work.
        For example, per our recommendation top leadership has
    developed a more robust monitoring and oversight process to
    improve communication and accountability, which includes more
    frequent contacts between the Secretaries of the Departments to
    discuss progress in various fronts, regular meetings chaired by
    the Army's Vice Chief of Staff and VA's Chief of Staff that
    include reviews of site performance and a forum for local and
    regional facility commanders to provide feedback on best
    practices and current challenges.
        VA also holds its own biweekly conferences with local staff
    responsible for their portion of the process. The Departments
    are also working to address long-standing medical board and VA
    rating staff challenges. In fact, the Army is in the midst of a
    hiring effort to more than double medical board staff,
    including liaisons, physicians, and support personnel, while VA
    has more than tripled staffing at IDES rating sites.
        The Departments are also working to address limitations in
    their automated systems, including taking steps to improve the
    ability of local facilities to electronically track and monitor
    case progress, and to improve the quality of case data which we
    found to be problematic. However, key upgrades are still
    pending and various sites continue to rely on ad hoc, local,
    and potentially redundant processes to manage their cases.
        Moreover, despite efforts by DOD and the services to
    improve data quality, the current IDES tracking system lacks
    controls to prevent staff from entering erroneous data; thus
    keeping caseload data accurate will remain a challenge going
    forward.
        And finally, in order to further improve and expedite case
    processing, DOD has initiated an in-depth business process
    review to better understand how each step impacts processing
    times and identify further IDES streamlining opportunities.
    Such an effort could yield short and long-term recommendations
    for improvement. However, a timetable for completion is yet to
    be established.
        In conclusion, the merger of two duplicative disability
    evaluation systems shows promise for expediting benefits to
    servicemembers. However, nearly 5 years out, delays continue to
    affect progress and their causes are not fully understood.
    Recent initiatives to improve processing and isolate
    bottlenecks are promising; however, it remains to be seen what
    their long-term impacts will be.
        And we will continue to assess DOD's and VA's progress in
    these areas as we proceed to do this work for your Committee.
    Chairman Murray, this concludes my statement. I will be happy
    to answer any questions you might have. Thank you.
        [The prepared statement of Mr. Bertoni follows:]

     Prepared Statement of Daniel Bertoni, Director, Education, Workforce,
           and Income Security, U.S. GovernmentAccountability Office

    Response to Posthearing Questions Submitted by Hon. Bernard Sanders to
      Daniel Bertoni, Director, Education, Workforce, and Income Security
                    Issues, Government Accountability Office

        Question 1. In your opinion, are the IDES Process and Timeliness
    goals realistic?
        Response. More information is needed to determine if and how the
    current IDES timeliness goals can be met. While IDES processing times
    increased as the system expanded, the contribution of various factors
    to timeliness is complex and not fully understood. In its testimony and
    in previous work, GAO highlighted issues, such as insufficient staffing
    and logistical challenges, that contributed to delays in processing
    cases. In the meantime, the number and range of IDES facilities and
    enrolled cases steadily increased since the inception of IDES in 2007
    through the completion of its worldwide deployment in 2011,
    complicating the understanding of whether IDES goals are reasonable.
    DOD and VA are now increasing resources devoted to IDES and are at
    various stages of implementing process improvements. Some of these
    changes are in their early stages and it is too soon to know their
    impact on timeliness. DOD is also undertaking a business process
    review, which may allow it to better understand how different IDES
    processes and resource levels contribute to timeliness. These efforts,
    along with a fully deployed and more stable IDES process, may provide
    the departments with an opportunity to reassess resources and
    timeframes, and make adjustments if needed.

        Question 2. Is there any reason why active-duty and Reservists
    should be held to a different timeline in the IDES Process?
        Response. DOD guidance allows for more time in some parts of the
    IDES process to accommodate additional work that may be needed to
    address circumstances that reserve component servicemembers
    (reservists) face. Overall, DOD and VA established a goal of 305 days
    for reservists as compared to 295 days for active duty servicemembers.
    In the medical evaluation board (MEB) phase--during which records are
    compiled and exams conducted--timeliness goals allow an additional 40
    days for processing reservists' cases. The additional MEB time is to
    accommodate reservists that may need to be placed on active duty orders
    and travel to military treatment facilities to undergo the IDES
    process. Also, additional time may be needed to compile medical records
    for reservists. While the MEB goal for reservists is 40 days longer,
    the 30-day goal for the VA benefits phase does not apply to all
    reservists and therefore was subtracted from the reservist overall goal
    for the IDES process. As such, the net effect is that the overall
    reservist goal (305) is 10 days longer than for active component
    servicemembers (295).

        Chairman Murray. Thank you very much, Mr. Bertoni.
        I just wanted to let our Committee Members know that
    following the revelation that possibly hundreds of soldiers at
    Joint Base Lewis-McChord had their PTSD diagnosis changed
    because a group of people did not want to spend money on the
    care and benefits that these servicemembers would receive, I
    asked our Committee staff to conduct an investigation into the
    Joint Disability Evaluation System.
        We are at an interim point in this investigation. Up to
    today, staff have reviewed 121 cases from 23 different IDES
    sites. They have focused on cases involving mental health
    diagnosis in general and PTSD diagnoses in particular.
        I am very troubled by what they found. They have found
    evaluations that focus on perceived malingering or exaggeration
    of symptoms, similar to what we saw at Madigan, without
    documentation of appropriate standardized interview techniques.
    They have encountered inadequate VA medical examinations,
    especially in relation to Traumatic Brain Injury, and VA rating
    decisions issued as part of this joint process contained
    errors, which in some cases impacted the level of benefits the
    veteran should have received.
        So before we begin today's questions, I am entering the
    results of this interim investigation into the record at this
    point and there will be more to come.

        [The report referred to follows:]

        Chairman Murray. Dr. Rooney, let me start with you. We have
    had discussions in the past regarding this Joint Disability
    Evaluation System and the number of challenges servicemembers
    face while they are going through this process. Recently, it
    has come to my attention that some of our servicemembers
    involved with the disability evaluation process are facing
    retribution and unsupportive behavior from their chains of
    command while on limited duty and waiting for a disability
    decision.
        I have heard from servicemembers who were forced to
    participate in activities in direct violation of doctors'
    orders, who have been disciplined while struggling with
    behavioral health conditions, and who have struggled to get
    access to care because their leadership would not cooperate
    with their treatment requirements.
        I think you agree with me that is completely unacceptable.
    Whether in a Warrior Transition Unit or not, leaders have to
    understand these medical issues and the difficult process that
    these servicemembers are going through and they have to provide
    the leadership and support that these men and women need.
        So I wanted to begin with you by asking you, Dr. Rooney,
    what needs to be done to provide supportive and compassionate
    leadership for these injured servicemembers that are forced to
    wait for a disability decision?
        Ms. Rooney. Senator, clearly the information you just
    shared is troubling on many levels, and I would be very
    interested in speaking with you or your staff or that we can
    actually determine where those issues are occurring and make
    sure that, in fact, the leadership does know, which is the
    Department's position and the leadership at many levels that I
    am familiar with, that that cannot be tolerated, that we must
    understand what is necessary for the care, that there are no
    stigmas associated with being able to address behavioral health
    or mental health issues, and that really is the Department's
    position.
        So in those cases, if there are those substantive issues
    that you mentioned, not only do we need to find out where those
    are so we can work directly with that leadership and correct
    that situation, but we will continue with our ongoing work at
    all levels of commands, not just at the senior level in the
    Department, but we understand that needs to go right through
    the command level of every installation to ensure that, in
    fact, the situations you have described are not occurring.
        Chairman Murray. Well, we need to make sure that is
    happening, because as we all know, these are very challenging
    situations for these soldiers and any kind of retribution
    should not be tolerated, whether it is one case or many. But I
    will share those with you. But I want to make sure that
    systemwide, that leaders throughout the chain of command all
    the way to the bottom, are clearly understanding what these
    soldiers are going through and are not having any kind of
    repercussions on those individuals.
        Ms. Rooney. Absolutely.
        Chairman Murray. Mr. Gingrich, from the perspective of
    someone who has served in many leadership positions within the
    military, what can we do to educate our military leaders on not
    only this process, but really on the medical issues facing so
    many of these young men and women?
        Mr. Gingrich. Madam Chairman, I see a lot of things the
    Army is doing and I know that because I have been to their
    BTCs. They have started, as we were told by GAO, they are now
    bringing in layers all the way up to the Vice Chief of Staff.
    So they have involved the colonel level discussion groups,
    brigadier general, major general, all the way up, and they have
    included VA in every one of those discussion groups.
        So I think getting the information out is the biggest key
    that we have got to go and the biggest challenge we have. The
    Secretary right now, yesterday, spoke to the Sergeant Major
    Academy in the Army and the sergeant majors are now
    understanding that this is a problem that we have to take on as
    two Departments and not just as one, and I think that education
    is happening.
        Chairman Murray. Well, we still have a lot of work to do.
        Mr. Gingrich. Yes, ma'am, we do.
        Chairman Murray. OK. Dr. Rooney, there is no doubt that the
    events at Madigan have shaken the trust and confidence of
    servicemembers who are in the disability evaluation system. I
    believe that transparency and sharing information about the
    ongoing reevaluations that are happening today, and actions
    that the Army and DOD are taking to remedy this situation will
    go a long ways toward restoring some trust in this system.
        I wanted to ask you today what we have learned from the
    investigations that the Army is conducting into the forensic
    psychiatry unit at Madigan.
        Ms. Rooney. Well, as you pointed out earlier, there have
    been 196 reevaluations completed to date, of which 108 of those
    have been diagnosed as having PTSD where before they had not.
    We also identified----
        Chairman Murray. Let me just say that they had been
    diagnosed with PTSD. When they went through the evaluation
    system, they were told they did not. Now going back and re-
    evaluating them once they have gone out, we are saying, yes,
    you did indeed have PTSD.
        Ms. Rooney. Correct. 108 of those 196.
        Chairman Murray. More than half.
        Ms. Rooney. Correct. There are 419 that have been
    determined to be eligible for reevaluation, 287 from the
    original group that was looked at, and as you know, the Army
    actually opened the aperture up to see anybody else that would
    have gone through the process while forensic psychiatrists were
    being used. So that was 419 totally eligible for reevaluation.
        And at this point, there are three in progress and 12 being
    scheduled. So what we have learned from that is clearly that
    the process that was put into place at that time did not
    function as originally designed. Evidence did not show that
    there was a mean-spirited attempt, but really to create similar
    diagnoses. Obviously that was not something that occurred.
        So the Army has taken the lessons from here and is actually
    going back to 2001 to reevaluate all of the cases where we
    might have a similar situation. What we are doing from that
    point is not only learning from what Army is doing and looking
    at these reevaluations where we are using the new standards, in
    many ways advances in the medical and the behavioral health
    areas to better diagnose PTSD, but also then we will be taking
    those lessons learned across the other services as well.
        So since Army has the greatest majority of people going
    through, currently about 68 percent of the people in the
    disability evaluation process are from Army, we will take the
    lessons learned from there and apply those across to all of the
    services.
        Chairman Murray. Well, I really appreciate the Army's
    announcement that they are now going to do a comprehensive
    review of PTSD and behavioral health systemwide throughout the
    Army. I believe that is a first and important major step for
    the Army to be doing.
        But I did want to ask you, Dr. Rooney, I had been told by
    Secretary McHugh about the issues that we were seeing at
    Madigan were not systemwide. And then the Secretary announced a
    comprehensive review across all systems. So if we did not
    believe this was a systemwide problem, what led the Army to
    look into a comprehensive review?
        Ms. Rooney. Secretary McHugh and I have had numerous
    conversations, and I believe the use of the forensic
    psychiatrists was primarily isolated to Madigan, and that is
    where I believe that comment of that it was not systemwide,
    because that type of additional part of the process----
        Chairman Murray. So the forensic system was not systemwide,
    but systemwide we have issues with people who are not being
    diagnosed correctly?
        Ms. Rooney. What we want to do is look across the system
    and ensure if we do have issues, that we identify those and we
    are able to get those individuals back into the system. So I
    believe at this point, it was very much a forward leaning
    approach to say, We need to look across the system, not that we
    are convinced that similar problems existed, but that it is the
    right thing to do for the individuals, since as you pointed
    out, we saw a number of these reevaluations ended up with
    diagnoses changed. So it is the right thing to do for our
    people to look across.
        Chairman Murray. OK. I think it is extremely important that
    we find anybody who was misdiagnosed and get them care. So we
    will be continuing to focus on this.
        Ms. Rooney. Absolutely.
        Chairman Murray. With that, let me turn it over to Senator
    Boozman.
        Senator Boozman. Yes, ma'am. With your permission, what I
    would like to do is go ahead and defer to Senator Burr and then
    come back when it is appropriate.
        Chairman Murray. OK, great.
        Senator Burr. I thank my colleague. Madam Chairman, thank
    you for this hearing, and Mr. Gingrich, I share your cold. It
    is not fun.
        Dr. Rooney, do you disagree with the GAO's testimony today?
        Ms. Rooney. Sir, we look at the GAO as a partner to help us
    evaluate how we are doing. I think they brought up some very
    good points in their report. Of course, when you are using
    statistics, we may look a little differently at a particular
    statistic.
        However, I will say that there was nothing in there that we
    did not think really helped us further understand where our
    emphasis needs to be, that there are improvements. We have been
    very open about saying that this is a system that needs
    significant improvements. I think the GAO very much said the
    same thing.
        So we are looking to continue to work with them, take the
    information they provided, and it gives us a roadmap to make
    sure, as we are putting resources to it, we take their report,
    plus our own internal analysis that goes even deeper than
    theirs, to ask, are these improvements making--are the
    resources making improvements to this system, which we all know
    and totally agree is not where we want it to be.
        Senator Burr. Mr. Gingrich, do you disagree with any of the
    testimony of GAO?
        Mr. Gingrich. No, sir. In fact, I look forward to the
    discussions we had before the testimony and the report, because
    I believe any time that somebody gives you insights into what
    you are doing, that you can take care of one more veteran or
    servicemember to make their life better in this transition
    process, we need to look it and make it happen.
        Senator Burr. So we are all in agreement that we are just
    south of 400 days in the cycle of an applicant being processed,
    395, I think, 394. In May 2011, the Secretary of Defense and
    the Secretary of Veterans Affairs committed to revising the
    IDES so that it could be completed in 150 days, and went
    further to agree to explore options for it to be 75 days.
        Now, I have had too many of these hearings. We have them
    every year. And we hear the same thing, Oh, gosh, look at what
    we are doing. I have heard the most glowing progress report
    from both of you. And then I get the realities that the days
    had not changed. You have met some improvement in certain
    areas. I commend you on that, the timeliness goals in areas
    have been better.
        But the reality is that we have got a broken system, and we
    are 5 years into it. And I hear testimony where we are starting
    to begin to review our business processes. Well, you know, why
    did it take 5 years to get to this? What can you convey to me
    today that is concrete that tells me a year from now we are not
    going to be at 393 days?
        When you said earlier we are instituting IT changes this
    summer that will improve our times by 30 or 40, I thought you
    were going to say percent, and you said days. So now my
    expectations are that if we implement what you just said, we
    are going to be down to 360 days, which exceeds the DECSEF
    (Secretary of Defense) and Secretary of VA by 110 days over
    what their goal was for today.
        So share something with me that will tell me we are
    actually going to do this.
        Ms. Rooney. Sir, that was one of the steps. The IT
    solutions are not the only steps. In addition, it was
    indicating that Army has hired 1,218 people, so we are also
    adding people to the process.
        Senator Burr. Are these the first individuals that we have
    hired in the 5 years to plus up?
        Ms. Rooney. It is the largest group of people that we have
    hired.
        Senator Burr. OK. We have hired people, we have plussed up,
    and the overall time of completion went up, not down.
        Ms. Rooney. Many of these changes, sir, are fairly recent.
        Senator Burr. OK. Lt. Gen. Bostick, the Army Deputy Chief
    of Staff, recently called the IDES process fundamentally
    flawed, adversarial, and disjointed. Do you agree with him?
        Ms. Rooney. I have sat next to my colleague many times, and
    we have had these discussions. I believe that we are both
    acknowledging that it is a system that, while initially
    conceived to be one that was smooth, transparent, and easy, we
    have not achieved that result.
        Senator Burr. So what are we doing to change it?
        Ms. Rooney. As my colleague and I have indicated, at this
    point we are literally looking case-by-case. We are following
    cohorts through each step of the process to see when we add
    people to it, are we actually improving the times? I am not
    saying that we are not able to improve it for those already in
    the system, but we have to make sure that we are also tracking
    the new ones in to say, Did we, in fact, cut that time down?
    And it is going step-by-step through that process.
        Senator Burr. I do not want to seem adversarial, doctor. I
    think we are all after the same goal. But you just agreed with
    a statement that General Bostick made where he basically said
    that this system cannot be fixed. Now, if you agree with that,
    my question is very simple.
        Is it time for us to start over again, to take a blank
    sheet of paper and say, How do we design this in a way for the
    benefits of the servicemembers--the number 1 priority and the
    number 1 priority for both, I do not question that--who are
    caught in a system that is unacceptable today from a standpoint
    in the length of time, from a standpoint of the accuracy that
    Senator Murray talked about.
        I guess, you know, my question to you would be, if given a
    blank slate, would the Army design IDES the same way or would
    you do it differently? And if your answer is differently, then
    for God's sakes, let us do it. Tell us what we can do to be
    partners to change this in a way that it works, versus to keep
    a structure of something that individuals who are involved in
    like General Bostick says, is ``Fundamentally flawed,
    adversarial, disjointed.'' That is not the relationship we want
    with our servicemembers that are going through this.
        The Chairman has been very kind to me. I just want to ask
    one last question and this is to Mr. Gingrich. You made the
    statement, I think, in your testimony that VA has the capacity
    to make compensation as early as they choose to after a
    servicemember is discharged. Is that accurate?
        Mr. Gingrich. We can make compensation the day after they
    are discharged. That is correct, Senator.
        Senator Burr. The day after they----
        Mr. Gingrich. Right. By law, we cannot do compensation
    until they have been discharged.
        Senator Burr. How long, on average, is it taking for the
    first VA check to arrive after a servicemember who went through
    the IDES is discharged from the military, not the decision
    letter from the VA, but the actual check?
        Mr. Gingrich. Right now it is taking too long. It is taking
    about 60 days. Part of the reason--and it is not an excuse--but
    part of the reason is we do it by month. So if the person is
    discharged before the pay system is set up, you have eaten 30
    days. We are working through that, and I think one of the
    things that the VTA will give us is that they will give us the
    information we need electronically at the discharge so that we
    can speed that process up.
        I am very confident that we are going to get very close to
    the 30-day goal. By the way, VTA--Dan and I talked--VTA will be
    in place in June and that process will not only allow us to
    track the payment, it will also allow us to track the ratings
    and the discrepancies in the ratings.
        Senator Burr. The Chair has been very kind, and I
    appreciate it. I would ask, would you share with us the data
    that shows us that 60-day average for payment?
        Mr. Gingrich. I will do that, sir.
        Senator Burr. Thank you. Thank you, Chair.

        [The information requested during the hearing follows:]
    Response to Request Arising During the Hearing by Hon. Richard Burr to
     John R. Gingrich, Chief of Staff, U.S. Department of Veterans Affairs

        Question. Ranking Member Burr requested data showing that there is
    an average 60-day time period for a discharged Servicemember whose
    claim has been processed by IDES to begin receiving compensation.
        Response. As of June 8, 2012, VA has processed 7,707 disability
    payments for Servicemembers who have completed the IDES process during
    fiscal year 2012. Currently, VA is averaging 54 days from the date of
    separation to process a payment. The ``shortest period allowed by law''
    for making VA disability payments following discharge or release from
    the military is the first day of the second month after a Servicemember
    separates. For example, if the Servicemember separates on July 27, the
    earliest date the Servicemember could be paid is September 1. If
    payment is due at the time of award authorization, it is released from
    the Treasury Department within 48 hours of award authorization.

        Chairman Murray. Thank you very much. Senator Tester?
        Senator Tester. Thank you, Madam Chair. I want to go back
    to what Senator Burr was asking about, and I will start with
    you, Dr. Rooney. Do things need to be changed in IDES?
        Ms. Rooney. Yes.
        Senator Tester. Mr. Gingrich, do things need to be changed
    in IDES?
        Mr. Gingrich. Yes, sir.
        Senator Tester. Could you--and I do not want to know them
    now, but could you get back to the Committee with your
    recommendations on what needs to be changed in IDES?
        Ms. Rooney. Yes.
        Mr. Gingrich. Yes, sir.

        [The information requested during the hearing follows:]

     Response to Request Arising During the Hearing by Hon. Jon Tester and
     Hon. John Boozman to Jo Ann Rooney, Acting Under Secretary of Defense
            for Personnel and Readiness, U.S. Department of Defense

        Question. Senator Tester and Senator Boozman requested that Dr.
    Rooney give recommendations to the Committee on what changes need to
    made to improve IDES.
        Response. IDES is a significant leap forward for our Servicemembers
    and Veterans, but more can be done. Since 2007, IDES has allowed the
    Departments of Defense (DOD) and Veterans Affairs (VA) to
    simultaneously complete disability evaluations before DOD separates a
    Servicemember so both Departments can provide disability benefits at
    the earliest point allowed under law. It is faster, equitable, and has
    greatly reduced the pay gap that disabled Veterans previously
    experienced following their separation from military service and the
    start of Veterans compensation benefits. Secretary Panetta directed
    that an internal DOD task force review the IDES process, with VA's
    support, and report to him by the end of September 2012 on improvement
    recommendations. The task force is:

         Examining methodologies to stratify IDES groups and thus
    reflect different outcome based measurements depending on the nature of
    the group.
         Analyzing the current IDES population and those that have
    completed it since the launch of the pilot effort in 2007 to determine
    both the points in the process where the most failures occur and
    correlating process events with the illness/injuries of the
    Servicemember.
         Reviewing the current Expedited DES process to identify
    methods to increase its usage rate among qualified Servicemembers.

        Separately, DOD and VA are developing an end-to-end strategy IDES
    Information Technology (IT) to enhance case management and data
    sharing.

        Senator Tester. OK. I would anticipate that those changes
    would add to this simplifying and consolidating as your goals
    were when this was set up between the VA and DOD, would it not?
    I just want to make sure that changes would add to the
    simplification.
        Ms. Rooney. Yes.
        Mr. Gingrich. Yes, sir.
        Senator Tester. Mr. Bertoni, as you look at IDES right now,
    its goal was to simplify and consolidate. Has it simplified,
    was the first question?
        Mr. Bertoni. I would say yes.
        Senator Tester. OK.
        Mr. Bertoni. When you look at what was happening under the
    Legacy system versus now, it is much more simple.
        Senator Tester. Much simpler. Is there an opportunity
    through this system to get feedback from servicemembers and
    address their questions and concerns about this? Is that part
    of the system?
        Mr. Bertoni. There is a survey mechanism whereby
    servicemembers are surveyed after each phase of the process,
    the medical evaluation board, physical evaluation board, and
    transition phase, yes.
        Senator Tester. OK. And so--and that is pretty user-
    friendly from your perspective?
        Mr. Bertoni. I do not know about user-friendliness. It is
    four questions per phase, 12 questions. Our concern is the
    limited number of folks who are actually receiving that survey.
    In principle, everyone is eligible to receive it, but if you do
    not opt to do that early on at the med phase, you are excluded
    at the latter phases.
        So we are really limiting the number of folks who are
    having an opportunity to weigh in here on their experience in
    regard to timeliness, transparency, and some other factors.
        Senator Tester. Do you think it is important to get that
    input?
        Mr. Bertoni. Absolutely.
        Senator Tester. Should we be expanding those opportunities?
        Mr. Bertoni. I think it would be absolutely a good idea to
    revise and relook at how they are surveying servicemembers
    right now.
        Senator Tester. I do not want to get out of my lane here,
    but I am going to for a second with Madigan. You said there was
    198 folks, 108 had their diagnosis changed. Were those people--
    was their rating done under IDES?
        Ms. Rooney. Many of them were. Some of them were under the
    old process, so those that were before roughly 2008 would have
    been under the old process.
        Senator Tester. OK. So how many of the 198 were--do you
    have those figures broken out? I guess what I want to get at
    is, to have over half the folks not get the proper rating, to
    say that it does not match up with our goals, is an
    understatement. The question is, is IDES actually doing an
    accurate job of making the assessment for the disability, or is
    it not doing as good a job as the old system?
        Ms. Rooney. Actually those people before, since I said most
    of them were before 2008, that would be the old system, and it
    also was adding the forensic psychiatrists in it, which was a
    different aspect of the system. So the new process, and
    frankly, the protocols and the fact that our Departments have
    an integrated mental health strategy for how to do this, should
    have, and by all data that we have seen, improve that
    significantly under the new process.
        Senator Tester. OK. So does that mean all the folks that
    got rated before 2008 we should call them back up and have them
    re-rated?
        Ms. Rooney. In essence, that is what the Army is doing at
    this point, and we are going to take the lessons learned, as I
    indicated to Senator Murray, and see if we need to do that
    across the other services.
        Senator Tester. And what about the other branches of
    government?
        Chairman Murray. Senator, let me just clarify: a large
    number of the ones who were misdiagnosed, or had their
    diagnosis changed inaccurately, were after 2008, after the
    forensic psychology system was put in place.
        Senator Tester. OK. Appreciate that. I mean, we get a lot
    of calls on this kind of stuff, and although I appreciate folks
    calling their Senator to get this squared away, I mean, what it
    tells me is there is an inherent problem here. And then when
    you combine that with the fact that we have got misdiagnosis
    over 50 percent, that is not acceptable. It has got to be
    fixed.
        And if it is the fact that we bring in a forensic
    psychologist and that fixes the problem, that tells me then we
    are talking one person, right?
        Ms. Rooney. Actually that was the issue, was adding that
    additional layer. That is when the initial diagnoses were
    changed and then we had a review again. So that piece, adding
    forensic psychiatrists in the process, has been stopped and
    that does not occur any place across the Department.
        Senator Tester. OK. All right. I mean, look, I have got a
    lot of questions and my time is long passed. Well, I look
    forward to your recommendations on what can be done to improve
    IDES. I certainly appreciate the work you are trying to do, but
    we are not where we need to be, by a long shot, and so, I mean,
    when I heard your testimony, there was good stuff here, and you
    should be touting the stuff you do well. But man, oh man, we
    have got a long ways to go, do you not think?
        Ms. Rooney. Absolutely.
        Senator Tester. And so, how do we get to a point--I mean,
    what do we need to do? Is it manpower? Is it more professional
    people? What is it? I mean, we have got folks coming back and
    the numbers are going to get more and more with the Afghanistan
    drawdown. But the question is, these folks need help, they need
    help early. That really saves money long-term, especially with
    unseen injuries, and where do we go? I mean, where do we go to
    get this fixed?
        Ms. Rooney. Sir, as you indicated earlier on, I believe we
    are going to get back to you with specific recommendations that
    we are seeing from our teams going out as to how we continue to
    move this forward.
        Senator Tester. I look forward to that. Thank you very
    much. Thank you for your testimony. Thank you for your work.

        [The information requested during the hearing follows:]

     Response to Request Arising During the Hearing by Hon. Jon Tester to
     John R. Gingrich, Chief of Staff, U.S. Department of Veterans Affairs

        Question. Senator Tester and Senator Boozman requested that Mr.
    Gingrich give recommendations to the Committee on what changes need to
    be made to improve IDES.
        Response:

              a. Implement some of the remodeled IDES improvements
            identified below:

                     Reduce the number of physical case-file
                    handoffs from 8 to 3.
                     Make fitness decision for further military
                    service up front, before VA enters into the process.
                     Ensure VA receives a complete case-file from
                    the Military Services after the fitness decision is
                    made.
              b. Automate the IDES process from beginning to end, and
            enhance the management reporting capabilities to enable IDES
            sites to effectively manage their cases.
              c. Identify and implement best practices and implement
            electronic data sharing throughout the IDES process.

        Chairman Murray. Thank you very much.
        Senator Boozman?
        Senator Boozman. Thank you, Madam Chair. Mr. Bertoni, who
    is in charge of this? We have DOD here, we have VA. Is there a
    person that is actually in charge of the whole process?
        Mr. Bertoni. I would say the Secretaries would say that
    they were in charge of this process.
        Senator Boozman. The Secretary of Defense and the----
        Mr. Bertoni. In partnership with capable folks under them
    tasked with doing a very difficult----
        Senator Boozman. So I guess the question I have got,
    generally, things work better when there is a person to
    oversee. Is there a person that the Secretary of Defense and
    the Secretary of VA have designated to have the authority to
    get some of these things worked out?
        Mr. Bertoni. I know Mr. Gingrich has been pegged as the man
    to address many aspects of this process.
        Senator Boozman. So do you have authority over DOD, also,
    or just VA?
        Mr. Gingrich. Sir, I do not have authority over DOD, but we
    have been working remarkably well in partnership, and I do not
    say that loosely. As I sit down with the Vice Chief of Staff of
    the Army, for example, because that is 68 percent, and we sit
    down monthly. We sit down at different levels in VA with the
    Army, and we are working through this.
        I think part of the issue to address the problem is, we did
    not have a very good dashboard mechanism prior to when we fully
    implemented IDES in September of last year. We now have a
    mechanism. We can go to every single facility, 116 of our
    senior executives get up on the--for my VTCs, the Army has the
    same thing where we do it together. We can go installation by
    installation, individual by individual, which we could not
    track before.
        And I know it sounds something like we are not moving, but
    when we get the VTA in place, we will be able to track every
    single individual, where they are in the system, what kind of
    rating they got, and where they are going. We have got----
        Senator Boozman. I do not mean to interrupt. I guess, you
    know, in business and in general things, you like for a person
    to be accountable.
        Mr. Gingrich. I am accountable directly to Secretary
    Shinseki for the VA portion of this.
        Senator Boozman. I understand that, but I guess I would
    like to see somebody accountable for the whole system. And you
    may be that person, but it is not fair to you, you know, if you
    really do not have the authority to see it through. So I
    personally think that the two Secretaries need to designate
    somebody that has got the authority.
        Now, we do not do that very well in government at all, but
    that is a basic thing. Where do you see the bottleneck, Mr.
    Bertoni? Is it that they cannot be seen or is it a
    decisionmaking process after they are seen?
        Mr. Bertoni. I think going--I have sat here many times
    since 2007 and talked about this whole program process. It
    comes down, I think, to three critical things: people,
    processes, and technology. On many of these sites, there was a
    sense of urgency following Walter Reed. There was a rush to
    stand them up.
        They did not have proper technology, did not have proper
    people and sufficient processes in place. Staff to
    servicemember ratios was insufficient in many respects. They
    were stood up anyway. The servicemen came, they were
    overwhelmed, and I think this system is paying for it to this
    day.
        Processes. We have identified throughout the last several
    years areas of the process that appeared to be inefficient.
    Clearly, we are causing backlogs in inefficiencies. In
    partnership, DOD and VA have addressed some of them; not all.
    We keep pressing that they do.
        And last, technology. We have an Integrated Disability
    Evaluation System, but the system's part has not caught up. We
    have processes that are combined, we have decisionmaking that
    is combined, but the systems have not caught up with the
    process or the demands of the end user.
        Senator Boozman. So do you feel like, in followup to Mr.
    Burr's comments, do you feel like the framework that we have
    now, the IDES, is such that we can meet the goals that we are
    wanting to get to?
        Mr. Bertoni. It is a simpler system. It is more transparent
    in how it operates. It is sort of like a funnel. If you take a
    funnel, you pour water into it, water comes out the other end,
    it works. But if you pour water in that funnel too quickly, too
    fast, you will very quickly find out where the inefficiencies
    are. That is what is happening.
        We have had rapid increases in inputs, in enrollments, and
    the inefficiencies and bottlenecks in this system are becoming
    readily apparent, and they need to get behind that with some of
    this mapping and business process redesign.
        Senator Boozman. My concern is, you know, that we have a
    culture somewhat that just is difficult to deal with these
    things. I am approached by people all the time that are just
    separating out of VA, just retiring, and it is not uncommon,
    you know, to wait a year before you start drawing your
    retirement. That is without all of this other stuff going on.
        So again, I think we have got some real problems that we
    need to look at, and I would welcome, also--and I think it is
    important that you understand that I am with you, but I do
    think that it is important that we get some feedback as to how
    we can help you to streamline that process and similar
    processes. Thank you. Thank you, Madam Chair.
        Chairman Murray. Thank you. Senator Johanns?

                    STATEMENT OF HON. MIKE JOHANNS,
                        U.S. SENATOR FROM NEVADA

        Senator Johanns. Madam Chair, thanks for holding this
    hearing. You can tell the frustration of the Committee Members.
    In this town sometimes it is hard to find bipartisanship, as we
    all know. I will guarantee that frustration here is very
    bipartisan. Everybody is frustrated, regardless of which end of
    the dais you sit on.
        Here is my concern. I was looking through some of the
    numbers and, Mr. Bertoni, you talked about them a little bit in
    your testimony. Overall average time to complete IDES active
    components of military, the goal is 295 days; we are at 395.
    But at Fort Belvoir, it is 537 days. That is stunning. I cannot
    even believe that. Percentage of active duty members who
    complete IDES within the 295-day goal, the goal is 60 percent;
    actual results are 18 percent. At Fort Meade, it is 0 percent,
    nobody, nobody.
        Overall average time to complete IDES for Guard members,
    excluding those who return to duty, agency's goal is 305 days;
    408 days is the actual. 651 days at Fort Carson. It is just
    nearly embarrassing to go through these statistics.
        The concerning thing for me is that I do not hear anything
    today that makes me feel, Gosh, we are going to turn the corner
    here. In fact, I must admit quite the opposite. I am going to
    walk away from this hearing very, very worried that the system
    is imploding, that whatever we have done to try to get on top
    of this system just is not working.
        So, Mr. Bertoni, let me ask you just a very, very direct
    question. How long is it going to take, 1 year, 2 years, 5
    years, to actually see progress in meeting these goals?
        Mr. Bertoni. I cannot give you a specific timeframe. I
    would say that one thing that the services and VA are dealing
    with is enrollments are up significantly, doubling each year.
    In 2009, there were 4,000 enrollments; 2010, about 9,000; and
    last year, 19,000. So we have multitudes coming into this
    program very rapidly and that is going to increase going
    further.
        So they really do need to continually look at their
    processes and look for streamlining opportunities. We have said
    all along they need to get their staff to servicemember ratios
    aligned with what they think they need to be doing.
        Again, automation. You can leverage so much with
    automation, accounts for many people. So there are things in
    play. They must continue to look at what they are doing and to
    look for efficiencies. And to their credit, more recent data in
    the MEB phase shows that the data is trending more positively
    over the last 6 months.
        The VA medical exam, they had never been able to meet that
    goal. At the time of our review it was 70 days. As of this
    month, they are at 39 days, under the 45-day goal. So there is
    some positive trending in MEB. That is the good news.
        The bad news is, those cases are being pushed further to
    the PEB, and those processing times are rapidly increasing.
    They have a 120-day goal and they are starting to push against
    that threshold. So what is going on in the PEB, what is causing
    inefficiencies there, what did they do in the MEB to create
    efficiencies, what can you learn from those?
        This mapping exercise, this process, re-engineering
    exercise, I think, could be valuable. Should they have done it
    earlier? Yes, they could have done it before each major phase,
    and I think they would have been in a better position. So I
    cannot give you a timeframe, but I am hopeful next year the
    numbers will be better, if I am here.
        Senator Johanns. Do you agree with--let me ask the two
    other witnesses. Do you think you are turning the corner?
        Mr. Gingrich. Sir, I am absolutely convinced we are turning
    the corner. We have gotten our production up where we are going
    to do about 2,500 cases a month, which we believe is looking at
    the flow that is coming in and the flow that is going out, that
    it is about 2,500. If we can sustain that starting in August,
    we will be able to move forward.
        He is right. We did not get our claims--none of our
    processes in VA last year were meeting the standard. We are now
    62 percent, in April, of the servicemembers that we processed
    in the process were on time. That is up from 20. Now, one of
    the things we have done to take some risk here is we decided,
    with at least the Army, to say, Let us get all the old jobs--
    that is why I said the one at 254 days--and let us get them out
    of the system because they are just holding up everybody and it
    is extending it.
        So numbers will go up a little bit when you start taking
    the older cases out, but those individuals have been in the
    system way too long. And so, I think we are making progress
    into a turning phase. Will we get to 295 days and 60 percent of
    the servicemembers by 31 December? There are risks there, but I
    think the services and DOD and VA, as partners, have come
    together and said, How are we going to get there?
        The Secretary said to us 3 months ago now when we were
    sitting at the meeting of the two Secretaries, We want to get
    to 60 percent. We want to get to 100 percent, but instead of
    trying to bite the whole thing, let us get to 60 percent by
    December 31st and then we will take on the rest of it to get to
    100 percent.
        Because every single one of these servicemembers we are
    doing this to, when they become veterans, as we have talked
    before, we have had them for 50, 60, 70 years and we have got
    to get them in the system right. We have got to take care of
    them and make sure they transition correctly.
        The other part that I would say, to answer your question,
    if we do not get this right by this summer, we are going to be
    challenged when we go to the VOW Act, because this is 10
    percent of the population going through, and the VOW Act that
    you--that Congress so graciously gave us to be able to
    implement, will have a process that is even bigger.
        And I think the things that we are putting in place today
    in VA and DOD will help us get both those systems done
    correctly.
        Senator Johanns. I have run out of time, so I hate to cut
    you off, Dr. Rooney, because I am sure you had a thought here,
    too. Feel free to submit that in writing if you would like. But
    I will just wrap up my questions with a request to Mr. Bertoni.
    I think it would be good if you could assess this for us on
    some kind of periodic basis, just to give us some indication
    that progress is, in fact, being made.
        It would be terribly unfortunate if we showed up in 6
    months and nothing is happening, and that would be terribly
    unfortunate. So that would be my individual request. The Chair
    runs the Committee, but it would be something that I certainly
    would like to see.

        [The information requested during the hearing follows:]
    Response to Request Arising During the Hearing by Hon. Mike Johanns to
     Daniel Bertoni, Director, Education, Workforce, and Income Security,
                     U.S. Government Accountability Office
        Question. Senator Johanns requested periodic assessments on whether
    VA and DOD are making progress in improving IDES.
        Response. At this time GAO does not plan to conduct ongoing
    assessments of IDES. We will continue to work with your staff to assure
    that GAO is meeting the needs of the Committee regarding our review of
    IDES.

        Mr. Bertoni. And we have been in this mix since it was a
    tabletop exercise in 2007. I have testified numerous times,
    multiple products. It would be worse, I think, if we were not
    in there. And I think in regard to your issue of diagnostic
    differences, 2 years ago, I said this was an issue. It could be
    problematic in terms of the treatment of servicemembers in
    terms of backlogs of the cases.
        If you have a diagnostic difference, you have to keep going
    back, new exams. You get caught on this medical exam hamster
    wheel and cases age out, you have to do it all over again. We
    asked that this issue be looked at. A consultant went in and
    looked at it, but did not do what we thought should be done.
        What should have been is what you are doing now, in-depth
    case file reviews to get extent of nature and extent of these
    diagnostic differences. Then you have guidance around that, you
    have training around that, and then you capture data going
    forward so you can identify hot pockets in trouble areas going
    forward.
        Had VTA been in place with the data indicating where they
    were having diagnostic differences, it would not have taken
    servicemembers to come forward making noise about treatment at
    Madigan. You could have that MI data at your fingertips and
    decide whether you need to get out there, see what is going on,
    do some remedial training, et cetera.
        Senator Johanns. Thank you.
        Chairman Murray. And I would just add, Senator Johanns, as
    a result of what we have looked at at Madigan, that is being
    reviewed back to 2007, I believe, all cases. But Army-wide now,
    as a result of the work I have done, they are now going back to
    2001 to review all Army cases. But it still is not systemwide.
    And I think that that has to be part of it. So it is something
    I am very focused on. We will work with you on making sure we
    continue to stay on top of this.
        I want to go back, Dr. Rooney. I am very concerned about
    what I continue to hear about the Warrior Transition Units and
    the IDES experience itself. I hear from servicemembers who are
    in the disability process, that they are languishing in this
    process without any meaningful or productive things to do.
        Servicemembers tell us that they feel that their commanders
    are out to get them. And on the other hand, we hear from
    commanders that they feel these servicemembers are being
    deliberately obstructive in delaying the process in order to be
    more difficult. That kind of adversarial relationship cannot be
    beneficial for either the unit or the servicemember who is
    trying to move on with their life.
        And worse, frankly, I continue to hear about servicemembers
    who are overdosing on drugs, committing suicide, committing
    serious crimes, and at Joint Base Lewis-McChord in my homestate
    of Washington, six servicemembers have died from suicide, auto
    accidents, or drugs while they are in the IDES process. That is
    happening at bases across the Nation.
        So I hope you share my belief that we can do this better,
    but I wanted to ask you, what is the Department going to do to
    make sure that there is an effective, supportive leadership at
    all levels to make sure that this is not happening?
        Ms. Rooney. Some of the specifics you pointed out, in terms
    of making sure that we are looking at that transition process
    proactively, working with those servicemembers going through
    that process so that they can identify skills and possible
    career opportunities, those programs, some of those are already
    in place. We will be doing more and piloting more not just for
    those in the disability process, but throughout transition, as
    we have talked before, starting this summer. That is one piece
    of it.
        The second one, as we indicated earlier, is really making
    sure that the communication is not just at the senior
    leadership, but absolutely is translated down through the
    chains of command right to the base. I believe Mr. Gingrich
    pointed out some meetings with the Sergeant Majors and other
    senior enlisted and that is going on in the Department as well.
        Each of the service chiefs have been going out to meet
    directly with various commands. As you know and I have
    mentioned to you, I spend probably about half of my time on
    issues surrounding this and have been back out to Washington
    State, have been down to San Antonio and others so that I could
    also go out to the bases and help reinforce and see what is
    happening there so we can identify where there are those
    disconnects and get that message consistently across the
    Department.
        So it is not only across DOD, but it is also with our
    partners in VA that we are continually sending the message and
    working at this, and where there are issues, not looking aside
    from those, but going right out and identifying where are they,
    what is the problem. And whether that is because there seems to
    be a backlog in cases and why is that at certain installations,
    we will target efforts to find out, is that a process issue, is
    it a command issue? What are the various pieces to do this? And
    we do have it broken down that succinctly and that is the way
    we are following through.
        Chairman Murray. I appreciate that, and I appreciate your
    sitting before this Committee and saying this. We want results
    from this, as I am sure you do, too. So it has to be a lot more
    than just testimony before this Committee. It has to be real
    action all the way down and we will be closely following that.
    We cannot have these hearings every 6 months or every year and
    keep hearing the same things.
        One of the things that I hear most often from
    servicemembers in this joint process is that they do not have
    any idea of when they are going to separate from the service.
    They want to make plans to move or go to school or get back
    with their families or whatever they are doing, and as we heard
    today, those numbers of days keeps rising.
        Last fiscal year, the average processing time, as we heard,
    was 394 days for active duty, 420 for Guard and Reserve. That
    is unacceptable for someone who is just waiting to figure out
    what they are going to do with the rest of their lives.
        I really believe that these servicemembers would benefit
    from knowing what the time is actually going to be at the
    installation where they are, rather than just saying we have a
    goal here of so many days, but what is it at your installation?
    We need an honest approach even if it is not what we like, but
    at least telling them a real number.
        I would like both of your Departments to look into that and
    report back to this Committee on the possibility of having real
    information for these men and women.

        [The information requested during the hearing follows:]

    Response to Request Arising During the Hearing by Hon. Patty Murray to
     John R. Gingrich, Chief of Staff, U.S. Department of Veterans Affairs

        Question. Chairman Murray requested that Mr. Gingrich report back
    to the Committee on giving Servicemembers in WTU's a realistic estimate
    of how long it will take for their claims to be processed at their
    installation and for them to be discharged.
        Response. Currently, VA is averaging 54 days from the date of
    separation to process a payment. VA does not have control over the
    discharge dates.

        Chairman Murray. Let me also say that the only way that we
    are going to restore trust, which is really important, is by
    focusing on consistency and accuracy of decisions, and I hope
    that both the VA and the DOD have really learned from VA's
    claim system struggles with how important it is to get the
    disability decisions correct the first time.
        I am concerned because Committee oversight has revealed, as
    I talked about earlier, IDES rating decisions with errors.
    Given that the military relies on the disability level assigned
    by the VA, these errors could impact the benefits that
    servicemembers will receive from the military, and also the
    benefits from the VA.
        So, Mr. Gingrich, when the VA identifies an error in a
    rating decision, do you alert DOD that the error can be fixed
    before separation?
        Mr. Gingrich. Madam Chairman, there are two things we do.
    If it is before separation, we notify the PEB and we notify the
    individual, and we get the correction done before. If it is
    after and the person is now a veteran and we discover it--we
    know one case so far we found, that the individual had a
    discrepancy in the rating and they would have changed the
    rating, we have helped that individual and gone back to the
    service and helped that individual get their records corrected.
        Chairman Murray. If a servicemember believes that there is
    an incorrect rating or whose claim has been identified as
    incorrect, what recourse do they have to go back and get the
    DOD rating changed?
        Mr. Gingrich. If we substantiate it, it would be fairly
    simple for them to get it corrected. If it is not a mistake
    that we made or it is not an error that was made at the time
    and it is the condition that has changed later, then it would
    be very much more difficult.
        But we talked about it yesterday, and we decided that we
    needed to make sure the process is such that the veteran or the
    active duty servicemember does not have to do anything. We take
    care of it and we do it for them. To get it started, we give
    them the information they need and then they work the system.
    So we will be proactively involved in any of these that we
    find.
        Chairman Murray. OK. Well, we will have more information on
    what we are finding and expect to work with you on that.
        Mr. Gingrich. And ma'am, we look forward to that and we
    will work each and every case you give us.
        Chairman Murray. OK. I have several other questions for the
    record, but I did want to focus on the Integrated Electronic
    Health Record. We know that delays in IDES are driven, in part,
    by problems accessing information and sharing paper files
    between the Departments. Those challenges are not unique to
    IDES, but they do affect every aspect of a servicemember's
    transition to VA, including how their health and benefits
    information is shared.
        Now, we have heard a lot of talk from VA and DOD that they
    are making progress on data sharing through their work on the
    Integrated Electronic Health Record and the Virtual Lifetime
    Electronic Record. But according to this week's press release,
    only two sites will have initial joint electronic health record
    capabilities by 2014, with 2017 actually being the target date
    for implementation of this.
        Now, the Departments have both said that the key to their
    collaboration and key to the success or failure of disability
    evaluations and transition are these electronic health records.
    It seems to me that this should be a priority for absolutely
    everybody. The project has been plagued, as you well know, by
    false starts and budget issues, and planning is not complete.
        I understand that a lot of positions at the office
    responsible for staffing and managing these projects are
    unfilled yet. I understand it is only 30 percent staffed. But
    how can the Departments say this is a priority when it is only
    30 percent staffed, and we are talking about 2017 as the target
    date?
        Ms. Rooney. I believe regarding staffing--and we will get
    you the most recent numbers--we continually add staff so that
    we are fully staffed up, but that is not impeding progress at
    the current point. There has been substantial progress made in
    terms of this Inter-Agency Program Office with a new director
    actually named within the past 3 months with extensive
    experience.
        And you are right. Both Secretaries announced jointly this
    week that by 2014, both in San Antonio and at Hampton Roads, we
    will have initial operating capability of this system, which
    will have multiple areas from pharmacy on down to medical
    records that are functional.
        I think they also pointed out when they announced it that
    we are moving forward, but we are also moving forward
    deliberately because we cannot afford to have any errors in
    these actual records going forward. So this is both safety and
    concern for individuals, to be able to get this right.
        We do have some systems currently and one of the things
    that both Secretaries viewed when they were in north Chicago
    was an example where we have been able to use existing systems,
    and it is not the long-term solution, but it is one that is
    working now, and begin to exchange data much better. So we are
    learning from that and integrating that into this electronic
    health record.
        So it is a priority. We are growing the staff, but we also
    want to make sure that there is no chance for errors because
    these are people and their information, and we cannot afford to
    have any errors.

        [The information requested during the hearing follows:]

    Response to Request Arising During the Hearing by Hon. Patty Murray to
      Jo Ann Rooney, Acting Under Secretary of Defense for Personnel and
                     Readiness, U.S. Department of Defense

        Question. Dr. Rooney stated she would provide the most recent data
    to Chairman Murray on number of new hires to more quickly implement the
    integrated electronic health records system.
        Response. Below is an extract from a larger, more detailed
    presentation that was delivered to SVAC staff to satisfy a due-out from
    a 23 April 2012 SVAC/SASC briefing.
        The following provides a staffing summary as of 31 July 2012:

         IPO TOTAL FILLED = 48 DOD + 58 VA = 106 / 236 = 44.91%

            - DOD Total Filled = 48 / 116 = 41.37%.

            - VA Total Filled = 58 / 120 = 48.33%.

              o VA-OIT Total = 2 filled, 31 detailed = 33 / 120 = 27.5%.

                    - 31 Details to be extended until transfer or hiring
                    action completed.

              o  VA-VHA Total = 25 pending reassignment in June 16, 2012 +
            1 additional detailed (not pending assignment) = 25 / 120 =
            20.83%.

          The chart below illustrates that the IPO will achieve
    100% staffing (236 FTE's) by March 2013.

          Currently the IPO staffing level is evaluated and tracked
    on a monthly basis, and progress is evaluated by the following
    criteria:

            - Red:  >25% under staffing projections over time.
            - Yellow:  12.5% < Yellow < 25% (half the red criteria).
            - Green:  <12.5%.

        Chairman Murray. Mr. Gingrich, do you want to comment?
        Mr. Gingrich. I agree with Secretary Rooney. This is a
    priority of this Department. The Secretary has made it his
    number 1 priority. He has pushed it hard. And we do see--it
    sounds like it is not much, but its ability to be able, with a
    single sign-on, be able to look at a screen and get data from
    either VistA or Alta and be able to do a medical evaluation, it
    is clear, it is clean, and it is doable.
        We are looking at how do we do that other places. I also
    think the integration of the hospital pharmacy has to be done,
    as we are going to talk about. That is very complicated, but
    they are doing it there, and they are making it work. So we are
    making progress. Are we making progress as fast as both
    Secretaries like? Probably not, but we are making progress, and
    we are pushing it.
        That is why we talked about things like the VTA. That is
    not the electronic health record, but it will inform the
    electronic health record and it will also inform VBMS and
    things like that that we will have. So we are doing little
    pieces as we are going along in addition to the full electronic
    health record, ma'am.
        Chairman Murray. Senator Boozman?
        Senator Boozman. Well, I really do not have any more
    questions, but I think the point that you made, Madam Chair,
    about if we could really give these folks a realistic idea of
    what is going on, I know in my life, I think all of our lives,
    the most difficult time is when you are in a period of
    uncertainty. And, you know, these are professionals that are
    used to bureaucracy and this and that, being in the service
    they have been in, but I do think that that is such a little
    thing, but it is a huge deal. And so, if we can work on that?
        The other thing is, is that we have a situation where this
    is the number 1 goal of the Secretaries and things to try and
    get this sorted out. They are meeting on a monthly basis.
    Something that we might consider is maybe you and the Ranking
    Member, Senator Burr, and perhaps Chairman Miller, Ranking
    Member Filner--I know they are as concerned as we are about
    this--that maybe on some sort of a basis--maybe monthly, bi-
    monthly, whatever--you all feel is appropriate, or somebody
    that you designate, for you all to get together and basically,
    you know, let us talk about how things are going.
        And the other thing is how we, as a Congress, if there are
    things that we can do to again facilitate and just really all
    work together--I know that you all want, in all of your
    capacities, to get this worked out as much as anybody, and
    certainly we want to be there to help you. But it is something
    that we have to get worked out. Thank you, Madam Chair.
        Chairman Murray. Thank you very much. Let me just say that
    ensuring an accurate, efficient, and seamless disability
    evaluation process for our servicemembers really is a critical
    part of making sure that they receive the care and benefits
    that they deserve.
        Clearly, there is a lot more work to be done. We have seen
    some steps in the right direction, but it is going to take
    continued engagement and cooperation from both Departments to
    get this right. So that is the message that I would really urge
    both of you, Dr. Rooney and Mr. Gingrich, to share with
    Secretaries Shinseki and Panetta.
        We also need to share this message with the lower levels,
    too. It is very clear squad member leaders and squad leaders
    who interact every day with these servicemembers need to get
    the message as well. So I hope you follow up on that. This
    system has been experiencing a lot of challenges for a very
    long time, but we owe it to our military members who have
    served this country to get this right and that is what this
    Committee is focused on, and we want to urge you to really,
    really, from the top all the way to the bottom, work to get
    this done right.
        So thank you very much for your testimony today and your
    work on this. With that, this hearing is adjourned.
        [Whereupon, at 11:34 a.m., the hearing was adjourned.]

                                A P P E N D I X

                                  ----------

              Prepared Statement of Paralyzed Veterans of America

        Chairman Murray, Ranking Member Burr, and Members of the Committee,
    Paralyzed Veterans of America (PVA) appreciates the opportunity to
    submit a Statement for the Record regarding Seamless Transition of
    servicemembers to veteran status and the effect the Integrated
    Disability Evaluation System (IDES) is having on the transition
    process. This is not only important to PVA, but was also an issue
    identified in The Independent Budget that was recently published by
    AMVETS, Disabled American Veterans, PVA and the Veterans of Foreign
    Wars. While in many ways the IDES can provide benefits to veterans, PVA
    has identified potential serious issues with the system.
        When the President's Commission on Care for America's Returning
    Wounded Warriors recommended that the Department of Defense (DOD) and
    the Department of Veterans Affairs (VA) create a single, comprehensive,
    standardized medical examination that DOD would administer, Veterans
    Service Organizations (VSO) supported the recommendation. This exam
    would serve DOD's purpose of determining fitness for duty and VA's
    purpose of determining initial disability level. PVA believes this
    should be a mandatory examination and an integrated element of the
    military separation process and VA should be responsible for handling
    this duty as VA has the expertise to conduct a more thorough and
    comprehensive examination.
        The Disability Evaluation System (DES) is the mechanism used to
    evaluate a servicemember for fitness for duty by the DOD and to
    compensate for injury or disease incurred in the line of duty which
    inhibits a servicemembers' ability to perform their duties. DES
    includes a medical evaluation board (MEB) which is an informal process
    of the medical treatment facility, a physical evaluation board (PEB)
    which is an informal and formal fitness for duty and disability
    determination, an appellate review process, and a final disposition. A
    PEB Liaison Officer (PEBLO) is assigned to assist the servicemember
    through the process. The PEB recommends the servicemember either return
    to duty, be placed on temporary disabled/retired list, separate from
    active duty, or be medically retired. While the DOD Legacy DES process
    only rates those disabilities that directly impact continued military
    service, the VA evaluation takes into account all disabilities incurred
    or aggravated during military service warranting a disability rating of
    10 percent or higher.
        The DES pilot project premised on the President's Commission on
    Care for America's Returning Wounded Warriors recommendation was
    launched by the DOD and VA in 2007. Based on servicemembers' high
    satisfaction rates with the revised program, the DOD and VA designed an
    integrated disability evaluation system (IDES), with the goal of
    speeding the delivery of VA benefits to all transitioning
    servicemembers. The current 27 locations participating in the pilot
    program examine about 47 percent of servicemembers (12,735 in 2010) who
    enter the DOD disability evaluation system annually.
        The IDES allows servicemembers to file a VA disability claim when
    they are referred for evaluation. VA provides a disability rating for
    each condition found during the medical exam, and the PEB uses these
    ratings to determine the type of separation or retirement for which the
    member is eligible. Under the system, the DOD can only consider
    conditions that are unfitting when determining disability ratings,
    while VA determines disability ratings for all service-connected
    conditions, even the ones that would not result in a finding of unfit
    for continued military service. The DOD uses the VA disability
    percentages for each condition, but may have a different combined
    disability rating than VA awards because conditions that are not
    unfitting are not considered in the DOD calculations. Thus, a
    servicemember's disabilities and their functional impact must be
    delineated for accurate evaluation against the VA Combined Rating
    Table. PVA is concerned that the system does not ensure servicemembers'
    records accurately describe numerous possible disabilities.
        While VSOs have been pleased at the progress of the IDES to date,
    servicemembers who are participating in the new approach to discharge
    evaluation are not systematically being encouraged to seek
    representation from a VSO Service Representative. Most are relying
    instead on the advisory services of military counsel, yet each service
    provides access to military legal counsel in different manners and
    circumstances.
        From the outset, PVA does not believe the system was set up for
    success. VA and DOD engaged in working groups early on that did not
    include input from the VSO community. It appears that attorneys and
    paralegals, who function under Title 10, replaced the function of VSO
    Service Officers, who derived their authority from Title 38. But since
    active duty servicemembers fall under Title 10 authority, VSOs are
    essentially cutoff from these men and women until they become veterans.
    This creates a problem where VSOs are essentially left to clean up and
    attempt to correct a improperly completed claim that was preventable
    with adequate initial counseling and claims development.
        IDES attempts to reconcile the PEB and Compensation and Pension
    (C&P) processes by having the servicemember submit to one medical exam
    or series of exams serving both purposes. The problem is PEB is meant
    to determine fitness for duty while C&P determines total disability for
    compensation purposes. Conditions that are often not regarded for PEB
    purposes, such as diabetes, sleep apnea, mild musculoskeletal
    degeneration, and tinnitus for examples, can have major implications in
    a VA disability rating. When a question or conflict arises, it is
    unclear whether VA or DOD has jurisdiction to resolve the matter before
    it flowers into a protracted, system-clogging appeal once the veteran
    realizes the mistake. This is often only after later consulting with a
    VSO service officer. Not only will this potentially delay proper
    compensation for the new disabled veteran, it adds an additional strain
    to an already horribly backlogged claims system.
        Finally, PVA questions whether those designated as Soldiers Counsel
    possess the requisite knowledge of VA law and the claims processes to
    adequately function as accredited representatives. Servicemembers have
    no choice but to rely on the expertise ostensibly wielded by these
    individuals. If knowledge is lacking, the effects are felt downstream,
    after the servicemember is discharged and it's too late. What level of
    training are these individuals required to undergo, both initially and
    continually, that meets the same standard directed under Title 38 for
    service officers? While there is no doubt that these are dedicated and
    conscientious individuals, if the MEB staff and PEBLOs are expected to
    participate in the development of a servicemember's co-existent
    fitness-for-service evaluation/VA claim, then these individuals should
    also have some familiarity with the VA claims process insofar as their
    intervention could impact entitlement to benefits. The end result is a
    severe disservice to the discharged veteran.
        The most important issue should be the best care and support to the
    servicemember. With this goal, PVA recommends that the DOD and VA
    provide greater information to all military personnel going through
    IDES about the advantages and benefits of using a VSO service officer.
    They should be provided the option to choose between the legal counsel
    offered by the military and that available at no cost through the
    system of national service officers of chartered Veterans Service
    Organizations.
        To facilitate this process, it will be critical that DOD allow
    access to military installations for chartered Veterans Service
    Organizations to provide services to active duty personnel. This should
    include their incorporation in all Transition Assistance Programs. This
    is in no way to detract from the services being provided by the
    military, but should be one more resource to better prepare
    servicemembers for their transition to veteran status.
        And finally, even as the current military conflicts drawdown,
    members of the Reserve and National Guard continue to play a major role
    in military operations and deployments. The DOD mandatory separation
    physical examination should be required for all demobilizing National
    Guard and Reserve members, not just active duty personnel. In many
    ways, this may be even more important to these servicemembers who
    rapidly depart from the support and medical care structure of active
    duty and return to their communities, often widely dispersed rural
    areas with limited medical care opportunities.
        PVA supports the IDES and believes it is an important program that
    benefits transitioning servicemembers. As with many programs, once
    implemented unforeseen issues and consequences begin to appear and need
    to be addressed. It is critical that America's military be provided the
    best services and support as they leave the military and we ask
    Congress to ensure that both DOD and VA work to correct these issues so
    that our newest veterans have the best opportunity for a new life and
    brighter future as they transition to the civilian community.