[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]



 
   PTSD CLAIMS: ASSESSING WHETHER VBA IS EFFECTIVELY SERVING VETERANS

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

                                HEARING

                               before the

       SUBCOMMITTEE ON DISABILITY ASSISTANCE AND MEMORIAL AFFAIRS

                                 of the

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                     ONE HUNDRED FIFTEENTH CONGRESS

                             FIRST SESSION

                               __________

                         TUESDAY, JULY 25, 2017

                               __________

                           Serial No. 115-26

                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
       
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]       
       


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

                    U.S. GOVERNMENT PUBLISHING OFFICE
                   
 30-372                      WASHINGTON : 2018              
         
         
         
         
         
                     COMMITTEE ON VETERANS' AFFAIRS

                   DAVID P. ROE, Tennessee, Chairman

GUS M. BILIRAKIS, Florida, Vice-     TIM WALZ, Minnesota, Ranking 
    Chairman                             Member
MIKE COFFMAN, Colorado               MARK TAKANO, California
BRAD R. WENSTRUP, Ohio               JULIA BROWNLEY, California
AMATA COLEMAN RADEWAGEN, American    ANN M. KUSTER, New Hampshire
    Samoa                            BETO O'ROURKE, Texas
MIKE BOST, Illinois                  KATHLEEN RICE, New York
BRUCE POLIQUIN, Maine                J. LUIS CORREA, California
NEAL DUNN, Florida                   KILILI SABLAN, Northern Mariana 
JODEY ARRINGTON, Texas                   Islands
JOHN RUTHERFORD, Florida             ELIZABETH ESTY, Connecticut
CLAY HIGGINS, Louisiana              SCOTT PETERS, California
JACK BERGMAN, Michigan
JIM BANKS, Indiana
JENNIFFER GONZALEZ-COLON, Puerto 
    Rico
                       Jon Towers, Staff Director
                 Ray Kelley, Democratic Staff Director

       SUBCOMMITTEE ON DISABILITY ASSISTANCE AND MEMORIAL AFFAIRS

                     MIKE BOST, Illinois, Chairman

MIKE COFFMAN, Colorado               ELIZABETH ESTY, Connecticut, 
AMATA RADEWAGEN, America Samoa           Ranking Member
JACK BERGMAN, Michigan               JULIA BROWNLEY, California
JIM BANKS, Indiana                   KILILI SABLAN, Northern Mariana 
                                         Islands

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.

                            C O N T E N T S

                              ----------                              

                         Tuesday, July 25, 2017

                                                                   Page

PTSD Claims: Assessing Whether VBA Is Effectively Serving 
  Veterans.......................................................     1

                           OPENING STATEMENTS

Honorable Mike Bost, Chairman....................................     1
Honorable Elizabeth Esty, Ranking Member.........................     2

                               WITNESSES

Mr. Ronald S. Burke, Assistant Deputy Under Secretary, Office for 
  Field Operations, Veterans Benefits Administration, U.S. 
  Department of Veterans Affairs.................................     3
    Prepared Statement...........................................    20

        Accompanied by:

    Mr. Bradley Flohr, Senior Advisor, Compensation Service, 
        Veterans Benefits Administration, U.S. Department of 
        Veterans Affairs

    Ms. Patricia Murray, Chief Officer, Office of Disability and 
        Medical Assessment,Veterans Health Administration, U.S. 
        Department of Veterans Affairs

    Dr. Stacey Pollack, National Director, Program Policy 
        Implementation, Veterans Health Administration, U.S. 
        Department of Veterans Affairs

Mr. Gerardo Avila, Deputy Director, Medical Evaluation Board/ 
  Physical, Evaluation Board/Department of Defense, Correction 
  Board, National Veterans Affairs and Rehabilitation Division, 
  The American Legion............................................     5
    Prepared Statement...........................................    21

Mr. Martin Caraway, Associate Member and National Partner, 
  National Association of State Directors of Veterans Affairs....     6
    Prepared Statement...........................................    24

                        STATEMENT FOR THE RECORD

John Towles, Deputy Director, National Legislative Service, 
  Veterans of Foreign Wars of The United States..................    27

                        QUESTIONS FOR THE RECORD

Chairman Mike Bost to: U.S. Department of Veterans Affairs.......    28
HVAC Minority to: U.S. Department of Veterans Affairs............    30
HVAC Majority to: U.S. Department of Veterans Affairs............    35


   PTSD CLAIMS: ASSESSING WHETHER VBA IS EFFECTIVELY SERVING VETERANS

                              ----------                              


                         Tuesday, July 25, 2017

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
                      Subcommittee on Disability Assistance
                                      and Memorial Affairs,
                                                   Washington, D.C.
    The Subcommittee met, pursuant to notice, at 10:30 a.m., in 
Room 334, Cannon House Office Building, Hon. Mike Bost 
[Chairman of the Subcommittee] presiding.
    Present: Representatives Bost, Coffman, Bergman, Esty, and 
Brownley.
    Also Present: Representative Walz.

       OPENING STATEMENT OF HONORABLE MIKE BOST, CHAIRMAN

    Mr. Bost. Good morning. Welcome everybody to this morning's 
hearing. The Subcommittee on Disability Assistance and Memorial 
Affairs will now come to order.
    Last month the Full Committee held a hearing on treatment 
options for veterans who have Post Traumatic Stress Syndrome. 
The Subcommittee hearing will review whether the VBA 
compensation process for PTSD is effectively serving our 
veterans.
    Today there are 940,000 veterans receiving disability 
compensation for PTSD and the number of veterans who apply for 
service-connected PTSD is growing. In fiscal year 2006 VA 
received about 100,000 PTSD claims. This number increased to 
240,000 in fiscal year 2016, more than double the number of 
claims within ten years. One reason that more veterans are 
seeking benefits is probably because VA has improved its 
outreach to veterans who may be experiencing PTSD, which I 
appreciate.
    VBA has also made some changes to the PTSD claim process. 
For example, in 2010 VA updated its regulations to make it 
easier for veterans who develop PTSD as a result of military 
sexual trauma or from a fear of hostile military or terrorism 
activities to prove that they had a traumatic event or stressor 
during their service. This change has helped many veterans 
receive the compensation that they are entitled to by law. But 
at the same time, we want to ensure that only veterans who are 
disabled as a result of their service are receiving 
compensation payments for PTSD. Unfortunately from what I read 
in today's written testimony, it looks like VA still has to 
work on better quality control.
    For example, both our VSO witnesses have raised concerns 
about VA's use of the evaluation builder tool. I understand the 
purpose of the tool is to improve consistency. But each veteran 
is an individual and particularly with PTSD claims a one-size-
fits-all approach will not work. Raters should have the 
flexibility to deviate from the tool if it is warranted without 
having to worry about being called on an error.
    I am also concerned about some allegations that examiners 
are not sufficiently trained or may not be spending enough time 
with each patient to do a proper assessment.
    The hearing may also turn into another issue that came up 
during last month's Full Committee hearing on PTSD. That was 
that some veterans are not seeking the health care need because 
they are worried that if they get better they will lose their 
benefits. Moreover, the average evaluation assigned to the 
veteran and service-connected PTSD in the last ten years has 
increased from 37.4 percent to 51.4 percent. I am hoping that 
the department can shed light on this aspect. We should 
encourage our veterans to get treatment and resume a normal 
life.
    It troubles me that our current compensation benefits 
program may discourage veterans from seeking treatment. I am 
looking forward to hearing from the department and the VSO 
witnesses on these and other issues so that we can all be sure 
that veterans who have developed PTSD based on their service 
receive the compensation they have earned.
    Again, I want to thank everyone for being here today. I now 
call on Ranking Member Ms. Esty for her opening statement.

 OPENING STATEMENT OF HONORABLE ELIZABETH ESTY, RANKING MEMBER

    Ms. Esty. Thank you, Mr. Chairman. And thank you for 
holding this important hearing today. As you know, this is a 
subject of particular interest to me. I hear the same message 
over and over again from veterans in North, Northwest, and 
Central Connecticut, who have filed a claim for disability 
compensation with Post Traumatic Stress Disorder related to 
military service.
    Now before we get going too far, I want to take time to 
recognize that some of the improvements over the past seven 
years, and recognize the importance of those, and the people 
who have contributed to these efforts. But Mr. Chairman, 
veterans in Connecticut do not understand the criteria VA uses 
to judge their claims. That their lives are severely impacted 
by PTSD as well as if their claim includes treatment. They do 
not believe that their rating or treatment can be determined 
largely based on a 15-minute interview with a doctor. They do 
not see that VA has a fair timeline for what will happen once 
they submit a claim for PTSD. And they struggle constantly on 
how to reconcile their courageous efforts to recover and live 
productive lives with the necessity of proving that they have a 
mental illness in order to not be downgraded for appearing too 
healthy, too normal.
    I know that this is a difficult task for the VA and I see 
and respect the efforts to get on top of this. With the 
national work queue fully functional now, and without the 
requirement that DoD provide a documented combat related 
stressor, I think we see progress. And these are important 
elements of progress and I want to acknowledge those and 
support those. But today I want and I believe the Chairman and 
I am sure our fellow colleagues want to get some answers to the 
questions that veterans have raised with me since I was first 
elected in 2012.
    I want to thank the witnesses for being here today and I 
want to pay tribute to the veterans across the country who are 
struggling with the effects of Post-Traumatic Stress Disorder. 
PTSD is a normal, human reaction of a normal person to abnormal 
circumstances. For those whose PTSD is the result of military 
service, we owe you fair compensation in a reasonable amount of 
time. We owe you the chance to understand the VA process. This 
requires including an explanation in lay terms when a decision 
is made. And most importantly, we owe you an opportunity to 
consider your descriptions of the impact, the struggle that 
PTSD has on your life as evidence in this process.
    Thank you, Mr. Chairman, and I yield back.
    Mr. Bost. Thank you, Ms. Esty. I ask that all other Members 
waive their opening remarks as per the Committee's custom. And 
I once again welcome the witnesses seated at the table. Again, 
thank you for being here. Our first witness is Ronald Burke, 
the Assistant Deputy Under Secretary of the Office of Field 
Operations for VBA. Mr. Burke is accompanied by Bradley Flohr, 
a Senior Advisor with the Compensation Service of VBA; Patricia 
Murray, the Chief Officer of the Office of Disability and 
Medical Assistance for VHA; and Dr. Stacey Pollack, the 
National Director of Program Policy Implementation for the VHA. 
Also joining us today is Gerardo Avila, I will say it right, 
Avila. Got it. Okay. Who is the Deputy Director of the Medical 
Evaluation Board/Physical Evaluation Board/Department of 
Defense Correction Board for the American Legion? Finally we 
are also joined by Martin Caraway, who is the Associate Member 
and National Partner of the National Association of State 
Directors of Veterans Affairs. Welcome all. I want to remind 
all the witnesses that your complete written statement will be 
entered into the hearing record. Mr. Burke, you are now 
recognized to present the department's testimony for five 
minutes.

                  STATEMENT OF RONALD S. BURKE

    Mr. Burke. Thank you, sir. Chairman Bost, Ranking Member 
Esty, Members of the Subcommittee, thank you for the 
opportunity to discuss how the Department of Veterans Affairs 
manages veterans' Post Traumatic Stress Disorder disability 
compensation claims. My testimony will provide an overview of 
VA's processing of these claims, its training and quality 
assurance efforts, and the use of disability benefits 
questionnaires to capture relevant medical evidence used to 
evaluate PTSD claims.
    With me today are Mr. Brad Flohr, the Senior Advisor for 
Compensation Service for VBA; Ms. Patricia Murray, Chief 
Officer, Office of Disability and Medical Assessment for VHA; 
and Dr. Stacey Pollack, National Director of Program Policy 
Implementation for VHA.
    There are currently over 940,000 veterans who are service-
connected for PTSD and receive a monthly benefit payment. This 
population equates to approximately 22 percent of all veterans 
receiving disability compensation benefits. This is a 172 
percent increase compared to the end of fiscal year 2008, when 
approximately 345,000 veterans were service-connected for PTSD.
    The increase is a result of veterans' increased awareness 
and understanding of PTSD and several associated changes VA has 
implemented. In 2010 VA took actions to make it easier for 
veterans to obtain disability compensation benefits associated 
with PTSD by placing greater evidentiary weight on lay 
statements to establish the required in service stressful event 
if related to fear of hostile military or terrorist activity. 
VA previously required documentary evidence from the Department 
of Defense or other sources to verify an in service stressful 
event related to the veteran's PTSD symptoms unless it was 
verified that the veteran engaged in combat with the enemy or 
was a prisoner of war, which is generally sufficient in and of 
itself to establish an occurrence of an in service stressful 
event.
    For the evaluation of PTSD claims where the stressor is not 
combat related, or there is no initial evidence of combat 
participation, VBA has provided claims processing personnel 
with special tools to research veterans' stressor statements. A 
Web site has been developed that contains a database of 
thousands of declassified military unit histories and combat 
action reports from all periods of military conflict. In many 
cases evidence is found in these documents to support the 
veteran's stressor statement or confirm combat participation. 
Nationwide training was conducted on this database and other 
official Web sites that can aid with stressor corroboration. 
Thus VA has illustrated in various ways our commitment to 
understanding and assisting veterans with PTSD claims.
    There are currently 16 VBA training courses focused on 
processing PTSD specific claims, including military sexual 
trauma, geared to VA claims processors, including both 
interactive online training sessions and classroom based 
instructor led courses. Additionally there are nine courses 
covering the topics of requesting disability medical 
examinations, also known as compensation and pension or C&P 
exams, and sufficiency of examination reports. Again, these are 
delivered both online and in classroom settings.
    VA's challenge training for new veteran's service 
representatives and rating veterans service representatives 
including two courses regarding examination requests and 
examination sufficiency. There is also specific instruction on 
PTSD claims.
    VA's national training curriculum for fiscal year 2017 
requires five courses of PTSD training for VSRs and ten courses 
for RVSRs. Also error trend analysis drives local instructor 
led training on examination requests and examination 
sufficiency for individual stations as well as training during 
compensation service oversight visits. Error trend analysis has 
also led to the development of new national level training 
involving examination sufficiency that was released in the 
field in June of 2017.
    VA reviews PTSD claims as part of its National STAR 
program. From the start of fiscal year 2016, which is October, 
2015 through February of 2017, accuracy of processing on PTSD 
claims was 94.2 percent, 94.57 percent for those claims not 
PTSD related.
    VA claims processors request disability medical 
examinations, or C&P exams, specific to PTSD. Trained 
examiners, whether at VHA or one of VA's contract exam vendors, 
document the exam findings on DBQ templates, which are 
considered by VA claims processors in making decisions on 
disability compensation claims.
    Running short on time, I will add my closing remarks. VA 
remains committed to providing high quality and timely 
decisions on entitlement to disability compensation benefits, 
with PTSD being one of the primary conditions claimed by 
veterans. VA will continue to update training materials, as 
well as the schedule for rating disabilities, regarding this 
condition and its impact on our Nation's heroes and their 
families.
    This concludes my testimony and I am pleased to address any 
questions you or other Members of the Subcommittee may have.

    [The prepared statement of Ronald S. Burke appears in the 
Appendix]

    Mr. Bost. Thank you, Mr. Burke. Mr. Avila, you are 
recognized for five minutes to give the testimony for the 
American Legion.

                   STATEMENT OF GERARDO AVILA

    Mr. Avila. Post-Traumatic Stress Disorder has been labeled 
as the signature wound of the conflicts in Iraq and 
Afghanistan. Today we meet to improve the way VA adjudicates 
claims for service-connection due to PTSD that ensure those 
suffering from this condition are properly compensated 
according to their symptoms. Good morning, Chairman Bost, 
Ranking Member Esty, and distinguished Members of the 
Subcommittee. On behalf of Commander Charles Schmidt and over 
two million members of the American Legion, we thank you and 
your colleagues for allowing the American Legion to present our 
views on the processing of PTSD claims.
    The American Legion would like to acknowledge and thank VA 
for its July, 2010 regulation liberalizing the evidentiary 
standards for veterans claiming service-connection due to PTSD. 
Due to this change in regulation, thousands of veterans are 
being properly compensated and have gained access to medical 
treatment through the Veterans Health Administration.
    Despite the change in regulation, the American Legion has 
the following concerns. Development of PTSD claims caused by 
military sexual trauma, VA reported in May, 2015 that 25 
percent of female veterans and one percent of male veterans 
experienced MST when screened by a VA provider. Despite these 
percentages, American Legion service officers often submit lay 
statements from family members corroborating the incident only 
to have the statement ignored. The lay statements are crucial 
when there is lack of law enforcement and medical records to 
corroborate the incident. Failure to utilize these key 
documents is harmful to veterans. The American Legion has heard 
complaints from veterans that their compensation and pension 
examination lasted all of 15 minutes.
    Additionally, the level of social impairment provided 
during the examination did not align with the level of severity 
reported in the disability benefit questionnaire. Conducting a 
proper C&P examination is critical in determining the service-
connection and the correct level of disability. It is essential 
that C&P examiners conduct a thorough review of the record to 
include lay statements to establish the level of disability 
within the VA schedule of ratings.
    Failure to recognize secondary conditions related to PTSD 
continues. While research exists that link exposure to trauma 
and poor physical health that can have a negative impact on the 
individual's cardiovascular, gastrointestinal, and 
musculoskeletal systems, sadly veterans are denied the 
opportunity to have a C&P examination to determine the 
relationship between the physical condition and PTSD. Younger 
veterans diagnosed with PTSD will endure years of suffering 
which will cause or aggravate physical conditions. The American 
Legion believes that determining the nexus between the physical 
disability and PTSD should be made by a trained medical 
professional and not a VBA employee.
    Due to the serious effects of PTSD, unfortunately some 
veterans will not have the ability to gain and maintain 
meaningful employment. When a veteran is not able to work due 
to a service-connected condition, they could qualify for total 
disability due to individual unemployability. However, unless a 
veteran specifically applies for the benefit TDIU will not be 
granted. This was the issue in a recent case involving a Marine 
veteran at the Cleveland Regional Office. Despite being awarded 
an increase in his PTSD rating to 70 percent and providing 
documentation from the Social Security Administration 
indicating he was unable to work, TDIU was never awarded. This 
case highlights the importance of doing a thorough review of 
the records so veterans are not forced to wait to receive 
proper benefits.
    VBA created their evaluation tool to develop uniform 
decisions across all regional offices. A rater at one regional 
office should in theory reach a similar decision as all other 
regional offices. Caution should be used not to solely depend 
on the tool. The American Legion understands that pertinent 
information that can be crucial to establish a claim, such as 
lay statements, continuity of symptoms, and outside privileged 
evidence, is not considered. While we believe that the tool can 
be a great asset in assisting raters, flexibility and 
consideration must be given to the entire record.
    We would like to thank you and the Committee once again for 
the opportunity to testify on this important topic. I would be 
happy to answer any questions.

    [The prepared statement of Gerardo Avila appears in the 
Appendix]

    Mr. Bost. Thank you, Mr. Avila. I see that Ranking Member 
Walz has joined us. I want to ask unanimous consent that 
Ranking Member Walz be allowed to sit on the dais and ask 
questions. Hearing no objections, so ordered.
    Mr. Caraway, you are now recognized for five minutes to 
give the testimony for the National Association of State 
Directors of Veterans Affairs.

                  STATEMENT OF MARTIN CARAWAY

    Mr. Caraway. Thank you, sir. Chairman Bost, Ranking Member 
Esty, and Members of the Committee, I am honored to be here on 
behalf of NASDVA President Randy Reeves and the State Directors 
from across the Nation. Accompanying me today is Texas 
Commission and NASDVA District Vice President Colonel (Retired) 
Tom Palladino.
    State Directors, their staff, and veteran's service 
officers at the county and local level are literally on the 
front line serving veterans every day. As a county veteran's 
service officer, I assist veterans in the PTSD claims process 
daily. I witness the pain in the veterans' faces and sometimes 
the tears in their eyes as we discuss the stressors that affect 
their ability to carry on their daily life. I hope our 
conversation will help continue improvement of the process for 
these veterans.
    The process for an initial PTSD claim can be quite 
cumbersome, especially if the veteran's DD Form 214, their 
discharge from military service, does not indicate a combat 
award. The law allows for VA examiners to determine the 
diagnosis and whether in their professional medical opinion the 
stressors the veteran presented were in fact congruent with the 
time, place, and scope of the veteran's military service. When 
the examiner renders a supporting opinion, VA should rate the 
case in favor of the veteran. But we are finding many times in 
these cases that the VA instead of issuing that decision will 
develop the case for more evidence by sending the veteran a VA 
Form 21-0781, a statement in support of a claim for service-
connection for PTSD so they may utilize their internal systems 
to attempt to verify the stressors from DoD. This actually 
removes a veteran's claim from the fully developed claims 
process, delaying the benefit.
    Veterans often feel discarded and frustrated when they 
receive this document because they have gone through the 
initial PTSD examination where they have provided the exact 
same information. A potential best practice to resolve this is 
currently being performed by the Texas Veterans Commission. 
With every claim for PTSD where the veteran does not have a 
combat award documented on their DD-214, the TVC is assisting 
the veteran in completion of the VA form 21-0781. This does not 
completely prevent the feeling of duplication from the 
veteran's point of view, but it will keep the claim in the FDC 
process for faster adjudication of the claim.
    The disability benefits questionnaires, DBQs, allow for 
streamlined examination directly touching pertinent information 
that will impact the rating of the claim. VA utilizes a DSM-5 
DBQ for PTSD claims for increases or reevaluation of the 
disability. If the veteran wishes to obtain a private 
examination at their own expense, only the DSM-4 DBQ is made 
publicly available for use by private physicians and providers. 
Releasing the DSM-5 DBQ for PTSD so it can be used by private 
physicians and providers would greatly benefit the veteran 
claimants in the submission of evidence that could impact the 
claim to their benefit.
    Veterans that continuously seek care at the VA for PTSD 
that are also going through the claims process are more times 
than not rejected when they ask their provider to assist in the 
completion of a DBQ. Providers routinely cite time and conflict 
of interest as their reasoning to decline. When considering a 
diagnosis such as PTSD and quantifying the symptoms to align 
with the VA rating criteria is to say the least a difficult 
task. Instructing these providers to complete a DBQ would allow 
for the opinions of a medical professional with intimate 
knowledge of the impacts of the diagnosis to be weighed in the 
rating process and that would greatly enhance the process for 
the veteran.
    To answer the bottom line question is VA handling PTSD 
claims in the best way possible? I would argue they are not, 
only because the apparent conflict between 38 C.F.R. and the M-
21 manual in the concession of PTSD stressors.
    Mr. Chairman and distinguished Members of the Committee, 
NASDVA and its partners deeply respect and appreciate the 
important work you are doing to ensure America's veterans 
receive the service, care, and compensation they have earned 
through their sacrifice. Working together with VA and all 
stakeholders, we can improve this process and define a culture 
that is committed to providing due process of the law to those 
men and women that have served, protected, and defended this 
Nation.
    My written testimony goes into much more detail than time 
will allow here and I do look forward to answering any 
questions you may have.

    [The prepared statement of Martin Caraway appears in the 
Appendix]

    Mr. Bost. Thank you, Mr. Caraway. And we are going to go on 
with questioning and I am going to recognize myself first for 
five minutes. Mr. Burke, during the, and let me tell you that I 
was shocked when this actually came out. But during the June 7, 
2017 hearing of the Full Committee, a veteran by the name of 
Brendan O'Byrne testified that his PTSD improved with 
treatment. But when he had contacted the VA to ask that his 
disability rating be reduced, and I have never heard of that 
before, he was told that VA could not reduce his payment at his 
request. Now we are dealing with a unique situation, the fact 
that many disabilities, if a person has the loss of a limb, 
loss of hearing, loss of eyesight, it will only get worse with 
time. We hope that with this, that it would get better in time. 
So my question is, and my staff, you know, we have since 
learned that the only way for a veteran that can be diagnosed 
with a disability compensation, the only way they can have it 
reduced is totally ignore it and say, never mind, I do not want 
to receive it at all. Can you verify, you or Mr. Flohr, confirm 
whether now the VA has a process to lower the disability rating 
on a veteran's request if they claim their condition has 
improved?
    Mr. Burke. Yes, sir. Thank you for that question, and also 
thank you for your interest in this matter. We are as deeply 
committed and interested in the topic of PTSD as everyone in 
this room.
    There are actually several different ways that a veteran 
can have their evaluation reduced. One is a renouncement of 
benefits, which is basically when a veteran comes in and 
renounces the entire benefit. They cannot renounce parts of it. 
They have to renounce the entire benefit. The other is to come 
in and actually ask for a reevaluation if they consider their 
condition has improved. In that instance we would either look 
at the available medical evidence or schedule an examination to 
ascertain the current level of disability and then make a 
disability determination commensurate to what the evidence 
shows.
    In many cases on the initial grant of service-connection 
for PTSD we set a veteran up for what is called a routine 
future examination. That is to ascertain where we think there 
may be a likelihood of improvement, we will set an examination 
for three years in the future, schedule that veteran for an 
examination, call him or her in, do another reevaluation, and 
see if the evidence does show that the disability has improved 
through treatment or other means. Again, in that instance, sir, 
we would take a look at the evidence from that new examination 
and render a new disability determination.
    Mr. Bost. Okay. The concern I have is to see if you are 
looking into any other possibilities. Because I see the concern 
of, okay, if all of a sudden a veteran does not renounce, but 
knows they still need a little help, and maybe they realize 
they do not need that level. But then coming before a hearing 
could be reduced to a level that is lower than what they feel 
they should receive. Do you think that would discourage them 
from coming in?
    Mr. Burke. I think we are doing a lot now, sir, to educate 
veterans, and stakeholders for that matter, on the entire 
process. The examination is not a `gotcha' process. It is a 
vehicle to allow us, in addition to other medical evidence, it 
is a vehicle that allows us to ascertain the current level of 
severity. And in some cases, a veteran may think he or she, you 
know, warrants a disability evaluation lower than what the 
medical evidence shows. It is not meant to persuade anyone from 
coming in to get a reevaluation.
    Mr. Bost. Okay. Also I want to ask you, are you confident 
VSRs and the RVSRs are always identifying PTSD examination 
results that are not adequate for rating purposes?
    Mr. Burke. So VA does place focus and importance on 
training our individuals to look at the adequacy of 
examinations. In fact when a rating specialist or a veterans 
service representative denotes an examination that is not 
adequate for rating purposes, we do have a process and a 
vehicle to return those inadequate examinations to the, whether 
it is VHA or a contract provider. That is an example when we do 
find some of those. It is a perfect example of some of the 
checks and balances that we have in the system working. So any 
instance that we do see an examination that is inadequate, our 
claims processors will reach out to the provider of that exam, 
whether it is asking for clarification or filling in something 
that is missing. We do have that opportunity.
    Mr. Bost. And that gives you the confidence you feel that 
there does not need to be any changes or retraining or anything 
like that?
    Mr. Burke. Well, sir, I think we constantly look for ways 
to improve our process. While the processing of PTSD claims 
accuracy is at 94.2 percent, we are not content with that. We 
think the process is working but as with everything else we are 
in the business of doing the best for our veterans that they 
deserve and this is one we continually look for ways to improve 
our quality of processing.
    Mr. Bost. One more quick question. I know I am close on, or 
actually out of time, but I really do want to know this. How 
often do claims processors ask for clarification of the PTSD 
exams that are not adequate for rating purposes? Did you 
understand that while I stuttered it out?
    Mr. Burke. Yes, sir. I think I have your question. So I 
have some numbers from fiscal year 2016. Basically the amount 
of claims that our rating veterans service representatives, or 
VSRs, sent back to a provider for clarification of an 
examination was about one percent or less. But again, that is a 
good example of the checks and balances, whether they are 
detected by our claims processors or even by our VSO partners 
as well.
    Mr. Bost. Thank you. I will turn the questioning over to 
Ms. Esty for five minutes.
    Ms. Esty. I would defer and allow the Ranking Member to go 
ahead of me, since I will be staying through the duration. 
Ranking Member Walz, are you ready to go?
    Mr. Bost. Are you--
    Mr. Walz. I'll pass.
    Ms. Esty. Oh, all right. Well then I will proceed. Thank 
you very much. Let me get my papers here. Just a second. I want 
to return to some of this question about the exams themselves. 
Because I am finding from the veterans I represent, they are 
often confused by the notices. So they go in, they know they 
have an exam, they assume it is going to be PTSD. They are 
finally ready to tell their story. They go in, they tell their 
story, and halfway through they get shut down because actually 
they are seeing a podiatrist who is asking about their good. 
This seems like something we can address because in fact if we 
do not address this you are going to have an appeal based on 
that exam. Which if we have greater clarity about what is the 
purpose of this exam, so that a veteran knows going in you are 
being examined for PTSD or not as part of this particular exam. 
So I would ask, you know, that is one issue I would like you 
all to talk about. Because I can tell you for sure we are not 
doing a good enough job because people tell me about their 
frustration. And feeling disrespected when they actually tell 
their story and they are shut down. So we need to do a better 
job of explaining what is happening with exams. So I would 
like, I would like to at least have you all answer that. If you 
think we are doing a good job or what can we do better on that 
front?
    Mr. Burke. Thank you for that question, ma'am, and 
certainly I will ask my partners at the table to jump in as 
well. It is an area that we can do better in. In fact, over the 
past year or so VA has been asking veterans for their feedback 
after they have gone through the examination process and we are 
gleaning some information from there. It lets us know that 
while in many cases veterans are satisfied with the process, 
there are areas that need improvement.
    As part of VA's modernization plan, one of the things that 
we are gearing up to do with the help of our stakeholders is to 
refine the way that we collect and analyze that feedback. And 
that is going more direct to the source, getting more accurate 
feedback from them. But I think we are doing a good job. I also 
think there is room for improvement. And I will ask anybody 
from the panel to jump in as well.
    Ms. Murray. Sure. So again, thank you for that question. We 
do monitor the satisfaction of our veterans on a biweekly 
basis. We are sending out questionnaires every two weeks, those 
that have come in over that period of time, to ask them about 
their satisfaction in the clinic, what things we can improve, 
what areas of concerns they have. And so we get a lot of 
feedback from our veterans. And we trend that data. We look at 
it across the system. If we see something specific at a 
facility we will contact that facility and ask them to look at 
it. So we follow up very closely on our satisfaction survey 
data.
    Ms. Esty. I would appreciate it if you could show me what 
some of those notices look like to see if we need to work with 
our VSOs or if in fact we could have greater clarity. Because, 
again, we know that the amount of money and time that goes into 
reviewing claims when we would all like to see help being given 
to our veterans. So if we can reduce unnecessary appeals that 
would be good for everybody and would reduce time. So I would 
like your commitment on that.
    I want to follow up a little bit on what Chairman Bost 
asked about reducing rating but with perhaps a slightly 
different take. What I hear are two different concerns. One is 
people are being coached that they actually have to look 
physically a wreck before they can go in for PTSD and they are 
encouraged not to bathe, not to shave, to really, not to sleep 
so that they can establish that physically they are looking 
that bad. And that is not a good situation, I think we can 
agree, if that is what our VSOs are coaching the folks I 
represent. So that is one piece.
    And the other is, what do we do about a situation in which 
there is a belief, and it may be founded, that if they do not 
get a sufficient rating, they will lose access to treatment? 
Our goal should be getting our veterans back on their feet and 
productive members of society. So there is an inherent tension 
that I think we are somewhat papering over, particularly on 
PTSD, in terms of if you believe and if you need to get a high 
rating of disability in order to get treatment, we are setting 
up a no end scenario for our veterans. And I believe that to be 
the case for some of the veterans I represent. That is the way 
they see it. They see it that they will lose access to 
treatment unless they prove they are not doing well and not 
getting better. And we have got to address that. And I see you 
nodding your head a little bit, Mr. Avila, so if you have got 
thoughts on this from the perspective of the Legion I would 
appreciate your weighing in. Thank you.
    Mr. Avila. So you are correct and there has been a debate 
whether the percentage of disability, the veterans are afraid 
they might lose their benefit if they get better. So that has 
always been a concern. But even if it goes, as long as they 
still have the service-connection, and they have that access to 
the health care, they should not fear of losing that. Yes, on 
the monetary side they can be reduced a couple of dollars. But 
hopefully the condition still stays as recognized as service-
connected and that will still get them access into the health 
care system so they can continue receiving the treatment.
    Mr. Bost. Thank you, Ms. Esty. And I now recognize Mr. 
Coffman for five minutes.
    Mr. Coffman. Thank you, Mr. Chairman. First of all, just 
from a veteran perspective, I am concerned about the nature of 
the treatment, modality of treatment that we offer our 
veterans, our combat veterans. It seems to be that it is kind 
of, that it is drug centric and that is not helping anybody get 
better. It seems like they, that people get worse that go into 
treatment than better. And can somebody address that concern?
    Ms. Pollack. Certainly. Thank you for the question. 
Certainly drugs are one treatment for Post-Traumatic Stress 
Disorder but we really use the clinical practice guidelines 
developed by VA and DoD for treatment of PTSD. And the first 
line treatments for Post-Traumatic Stress Disorder are actually 
prolonged exposure as well as cognitive processing therapy, 
which are two talk based therapies. We also in recent years 
have implemented a variety of complementary and alternative 
treatments for PTSD. Lots of veterans have not wanted to 
participate in those types of treatments due to the fact that 
they involve exposure to one's trauma and one of the hallmark 
symptoms of PTSD is avoidance of trauma or avoidance of what 
reminds you of the trauma. So things like yoga, mindfulness 
based stress reduction, all sorts of other things. So drugs are 
only one part of the treatment.
    Mr. Coffman. This is more of a Department of Defense 
question. I am Subcommittee Chairman for Military Personnel on 
the Armed Services Committee. And we are not going to go back 
to the selective service system. We are ultimately going to do 
away with it. So our backup reserve, so to speak, is going to 
be those who are discharged from active duty and still have a 
remaining commitment up to eight years. And I think that 
certainly the Marine Corps, I know, was heavily reliant upon 
going into their inactive reserves during the height of the 
Iraq and Afghanistan Wars. If somebody receives a permanent 
disability for PTSD, whether it is ten percent or it is 100 
percent, are they exempt from further military service? And I 
know you are more on the VA side. Maybe the American Legion 
might know the answer to that.
    Mr. Avila. Mr. Coffman, so this is an area that we have 
done some work. So you can have a disability and still continue 
your service in whatever branch as long as you meet the medical 
standards of the respective branch. Whenever you have, you can 
even have a permanent disability but when it becomes a red 
flag, is this disability impacting or having a negative ability 
to complete your job or to do your duties in the military? Then 
there can be a concern that maybe you are not fit to continue 
your service. And that is when it kind of raises the issue and 
to maybe be separated through a med board process.
    Mr. Coffman. Well I think that is why we need to focus more 
on treatment as a country. And I think we have an obligation to 
our veterans, and from a national security standpoint. I was an 
infantry officer in the United States Marine Corps, and I can 
tell you that if somebody is so traumatized by combat that they 
are going to have a percentage of disability, they are not 
going back into the fight. That is all there is to it. And that 
compromises the national security of this country given the 
fact that we are not going to go back to the selective service 
system and we are going to rely on those inactive reserve 
forces. And so I think we, the VA has to do a better job about 
treatment. And I yield back.
    Mr. Bost. Thank you, Mr. Coffman. And Members need to be 
advised, I think we are going to go to a second round. So if 
you want to stay around for other questions. With that, Mr. 
Bergman, you are recognized for five minutes.
    Mr. Bergman. Thank you, Mr. Chairman. I see some familiar 
faces at the table. I would like a show of hands how many of 
you at the table feel a sense of urgency in this? Good, at 
least we are getting 100 percent on this hearing.
    Mr. Flohr, in 2010 the VA lowered the standard approved for 
some veterans who file claims for PTSD. The lower standard is 
intended to make it easier for some of those veterans, such as 
those who have experienced fear of a terrorist attack or 
hostile military activity, to receive benefits even though the 
incident was not documented in their records. What safeguards 
are in place to basically make sure that, you know, the 
pendulum has not swung and we have people gaming the system?
    Mr. Flohr. Thank you, sir, for that question. We did that 
as a result of a belief by Secretary Shinseki at the time and 
Under Secretary Admiral Dunn that there were veterans who were 
serving, or servicemembers serving in Iraq and Afghanistan that 
were not combatants but yet who feared potential injury or 
death due to terrorist activity. And DSM-4 changed the criteria 
for PTSD from being exposed to a stressor that would cause 
symptoms in almost anyone to a more individual based stressor, 
recognizing that individuals react differently to stress. So we 
gathered actually a lot of people in the Secretary's office on 
three occasions from DoD, private providers, and talked about 
this. And we determined this was the right thing to do, was to 
recognize that if somebody developed PTSD diagnosed by a 
clinician and the stressor was fear of hostile military or 
terrorist activity, that we should take action to grant that 
claim.
    We as far as making sure that it is not, someone is not 
gaming the system, of course we review all the evidence we 
have. If there should be a reason to question someone's 
statement, we would follow up on that if we felt--
    Mr. Bergman. Okay. I am going to cut you off here. Because 
I want to get to another question.
    Mr. Flohr. Okay.
    Mr. Bergman. But thank you. Thank you. Does the VA maintain 
data on what you have been accumulating over the suitability if 
you will of people for service, especially either after a 
traumatic event that has potentially caused PTSD, or fear of a 
traumatic event that has caused it? It does not make any 
difference what the cause is. But does the VA maintain data, 
not necessarily by individual name, but data that would suggest 
solutions going forward? As you heard Mr. Coffman say we are 
going away from the selective service system eventually. But as 
we look at comparing data that exists based upon 15 years at 
war to apply to future selection criteria, if you will, or 
evaluating criteria for enlistment. When we had the selective, 
we still do, you could go 1A or down to 4F, with a lot of other 
classifications in between. But does the VA have a database 
that says, here we are, and here is how we might compare this 
to what we might be looking at on the front end for 
understanding the young men and women who really have the best 
chance of being successful in in this case military service?
    Mr. Burke. So sir, I will take that one. I do not know that 
we have the data teased out for future, you know, for modeling 
if you will for future considerations. But if you will allow us 
to take that back, we can get back to you on that one, sir.
    Mr. Bergman. Yes, well you know even if you do not have it 
modeled out at this point, if the cases that you are dealing 
with are being recorded, again nameless because we are not 
trying to assign a name to this, but so that we know here we 
are in the 21st Century. We know that we are going to need 
strong, mentally strong, physically strong men and women to 
serve our country in many different forms. So that is where I 
am driving with this. So if you have that, I believe we can 
take a next step. Yes, doctor?
    Ms. Pollack. Well some of the information that we do have, 
it is not specific data, but there has been a lot of research 
done into what sort of causes Post Traumatic Stress Disorder. 
And we really do not know why one person develops PTSD and one 
person does not. Two people can be exposed to the same trauma, 
one may develop Post Traumatic Stress Disorder, one may not. 
But we do know there are certain risk factors. The number of 
traumas an individual is exposed to, PTSD is more common in 
women than in men, we know that social support is really 
important, you know, someone who does not have that social 
support as they are going through traumatic event will be more 
likely to develop PTSD. So there is research out there looking 
at those risk factors.
    Mr. Bergman. Okay, thank you. Thank you, Mr. Chairman. My 
time is expired, I see.
    Mr. Bost. Thank you, Mr. Bergman. Going around on our 
second questions here, Mr. Avila, based on your experience, do 
you believe that the raters have the capability to review the 
evaluations and then properly assign a rating based off of the 
examiner's description of symptoms? And then also, are the 
raters sending back questionable exams when necessary?
    Mr. Avila. So we do believe they do have the ability, the 
capability to do it. I guess the question would be how often do 
they do it? From our experience in visiting the VA regional 
offices, if an examiner indicates a specific box on the DBQ, 
the rater more or less just concurs with that decision. So if 
this is the case, then essentially the examiners are 
adjudicating the claims if the rater is not questioning the 
decision. We have seen cases where a veteran presents symptoms, 
severe symptoms such as suicide ideology, which is a key 
component of a 70 percent rating and he is only given maybe a 
30 or a 50 percent. And the raters do have the ability to send 
back an examination for clarification. But once again from our 
experience, this does not happen a lot. So essentially and if 
it does happen you can also be dealing with long years dealing 
with an appeal.
    Mr. Bost. Mr. Caraway, do you have anything to add to that?
    Mr. Caraway. Yes, sir. I think the raters when they are 
using the rating tool, they have the ability to go one rating 
higher or lower than the appropriate, well then the median 
result that comes out of the rating tool. So in the case of a 
suicide ideation, while that could be a 70 percent, the rating 
tool also allowed the rater a 50 percent evaluation or a 30 
percent evaluation depending, and it will say that this is a 
suggestion only. And so what we are finding is that the raters 
are going to go down the middle of the road to prevent any 
error codes coming up later down the road. And us as state and 
CVSOs and VSOs at the regional offices, we are going to submit 
an appeal on that and based off of the rater's decision or 
their inability or lack of desire to go out and err on the side 
of the veteran based off of that C&P examination.
    Mr. Bost. Okay. And staying with that line of questioning, 
with you, Mr. Caraway, please if you can so can you go into 
detail why NASDVA is concerned with the quality of disability 
examinations on this particular issue?
    Mr. Caraway. Yes, sir. Thank you for that question. The 
state directors, and I am a county veteran's service officer so 
I work in partnership with the state directors across the 
Nation. And the reason why we are concerned about this is 
because veterans will come into their examinations expecting, 
the Ranking Member said, to tell their story. Well if you show 
up at a 1:00 appointment you are probably not going to be seen 
until 1:30, and presumably because the examiner is evaluating 
and going over your C file. But then you are going to go in at 
1:30, when you are called in, you are going to have 15 minutes 
to tell your story. And those boxes, what is happening is the 
examiners are skimming over and going through as quickly as 
they can so then they have time to dictate that examination to 
get it back to the VA so they have a timely examination.
    Mr. Bost. Mr. Avila, would you like to expand on, comment 
on that as well?
    Mr. Avila. So I think the biggest issue, sir, is, or the 
biggest concern we have is the review of the records. And some 
of these records can be quite extensive. So as a matter of 
fact, my colleague just put it the other day saying if you show 
up and the examiner has not reviewed the record, it is like 
showing up to class and you have not done your reading. You are 
kind of a little behind the power curve. So it does not give a 
full picture of the whole situation and that just can be based 
on the disability benefit questionnaire or on that short 
appointment during the C&P.
    Mr. Bost. Okay. Because I am down to one minute here on my 
own self, would someone from the VA please try to explain to me 
how you verify these medical experts and spending all this time 
trying to figure out how to check boxes and not actually 
listening to the individual? And I mentioned that in my opening 
statement, to the individual on their own case and their own 
situation. And I know we try to put it in a uniform box with a 
check. But how do you allow for something like this not to be 
heard out on an individual case?
    Mr. Burke. So thank you for that and I am going to ask my 
friends from VHA to jump in when I am finished as well. But we 
believe that whether it is VHA or a contract vehicle, that 
adequate time is allotted for these exams. It should be 
differentiated that the initial PTSD exam is typically longer 
than a claim for increase based on the amount of gathering of 
evidence.
    I do want to make one point very clear for VBA. When we 
rate it is on the totality of evidence, it is not just the 
information from the VA examination. So whether it is private 
statements, outpatient treatment records, or any other evidence 
submitted, the VA exam is but one piece of what is reviewed and 
used in the overall determination. So I want to ask if VHA 
wants to add anything to that at all?
    Ms. Pollack. The only thing I would add is that these 
examinations are being done by psychiatrists and psychologists 
who have extensive obviously mental health training in the 
provision of those assessments and care. And I know myself, as 
someone who did C&P exams for many years, at the beginning of 
any examination we spend time talking to that veteran about 
what that examination would entail and that while we were going 
to be asking questions about trauma, there may be times also 
that we would redirect the veteran for a variety of reasons 
that we do not need to get into every nitty-gritty detail of 
everything that happened because this is not a treatment 
assessment. It is really an assessment to make sure that we get 
the information that is needed so that VBA can make, can 
adjudicate their claim. And I think, you know, examiners, and 
maybe we need to be doing a better job training examiners to 
make sure that they really are starting all of the examinations 
as we talked about, letting the veterans know what to expect. 
Because I think if someone understands to expect that I am not 
going to be asking you every detail and here is why, I think 
they are okay with that.
    Mr. Bost. Okay. I am way over on my time. Mr. Ranking 
Member, would you--okay. Ms. Esty? You are recognized.
    Ms. Esty. Thank you, Mr. Chairman. I think I am going to 
probably pick up with that. But I do want to quickly flag how 
important this hearing is but we are scratching the surface of 
some really important issues. Given that the number one 
clinical, the only clinical priority of our new Secretary is 
reducing military and veteran suicide, we have not talked about 
that. We have not talked about other than honorable discharge. 
So I hope we can have an opportunity, have a separate hearing 
on those critically important issues. Because I think those are 
incredibly important and intimately related. But I am not going 
to go there now because I think we need to focus on what has, 
we have plenty of things already on the table.
    A couple of thoughts, Dr. Pollack, I think what you just 
said about laying the table for the veteran is tremendously 
important. I would hope that that is part of the training and 
that people are actually evaluated on that. Because I think, 
again, it is really important. Because, you know, for a veteran 
who is suffering with this, that is going to be a really hard 
distinction? And I think that needs to be made early and often, 
up front, this is not a treatment interview. Really, we are 
trying to determine a level of disability for this piece. There 
is a different piece and all of this material is going to be 
relevant for that. So that is one.
    The second was the issue several of you have raised about 
on the adequacy of the exam. It is not just the time with the 
patient. Is there time to do the homework? Is there time to 
review the file in full? And how, that has to do with the time 
pressures. And I am particularly concerned for people doing 
this under contract. Are they under such time pressure that in 
fact they are not given the time to properly review the file? 
Because, again, if they are not given the time to review the 
file, we should not be surprised if they are not doing it. If 
that is the incentive, that they have no time to review the 
file, we should not be surprised that they then review. And I 
will just say with a little window into this on the treatment 
side, I have a brother-in-law who was a contract physician 
through Kaiser for the VA. And he was given 15 minutes to do 
treatment, ten minutes to do treatment. You are not doing 
talking treatment when you are doing ten minutes. You are 
prescribing drugs and you are sending them right out the door. 
I want to make sure that in the concern about moving people 
through the system, we are not doing them a disservice and 
ensuring they are going to be right back in the door. So I put 
a bunch of things out and I appreciate your comments. Thank 
you.
    Mr. Burke. So again, thank you for your concern, ma'am. All 
valid points, all things that we continue to focus on. To your 
issue of the Secretary's goal of veteran suicides, reducing 
will not be good enough for us. It is eliminating. A very, very 
sensitive topic for all of us in this room, including all of 
our stakeholders.
    We continue to take a look at the feedback we are getting 
from the veterans that go through these examinations, feedback 
from our stakeholders, our partners. And as we go to modernize 
VA, we want to make sure that we are putting our veterans first 
and making sure that we are taking their feedback as to what 
they need instead of us determining what we think they need. It 
is kind of the bid push. Our Secretary is determined to make 
sure that we are putting the needs of the veterans first and 
the exam process is huge. The examination process touches the 
bulk of our pending claims. And so for us to get that right is 
extremely important and we are committed to doing that.
    Mr. Caraway. I wanted to touch again on the examinations. 
When veterans walk into the C&P examination, while they expect 
to tell their story to some degree one of the things, and it 
also will revert back to a statement that you made earlier 
about VSOs coaching veterans before the C&P examination. One, 
we are not allowed to coach. That is against the law. And if 
people are doing that, they should be ashamed of themselves. 
But we do educate. And what I will say is you are going to walk 
into an examiner and you have months or years of dealing with 
your symptoms and you have one chance to meet with this 
examiner. I mean, think about how you go into your doctor. Your 
doctor has learned over a period of time how a diagnosis is 
impacting your life as they move into treatment. When you walk 
into this appointment the veterans need to be told that you 
need to bring it to the third and fourth appointment 
immediately. You take off the uniform, put your pride aside, 
and you are going to have to open up and explain how this is 
actually impacting your day to day life. And I thought that I 
would make that point known. Because we do not ever allow or 
teach coaching but we do have to educate the veterans on what 
to expect in those examinations and to bring themselves to a 
level where they can be able to explain how the diagnosis is 
impacting them.
    Ms. Esty. Just a quick question, how do you do that? 
Because I think there is the human need to, you know, how do 
you get to the third visit when it is the first visit? I mean, 
let us think realistically. How does a human being who has 
been, had this bottled up, how do they do that? And are we 
doing an adequate job, all of us, doing an adequate job to 
recognize someone is going to have to go, you cannot jump over 
those phases, right? So are we doing what we need to be doing 
to get at least the preliminary work done so that someone can 
adequately present their appropriate case when they are in that 
C&P exam?
    Mr. Caraway. And thank you for that. Because one of the 
easiest ways is to try to allow time for the treating providers 
at the VA medical centers or contracted providers if veterans 
are going outside in community care to fill out those DBQs. But 
because they cite the time limits, when I talk to medical 
professionals at a CBOC they will tell us, well, if you are 
going to tell VA to create 27 hours in a day for me, I will be 
more than happy to do a DBQ. And so that is a concern for me. 
Because you are taking the treating provider's opinion out of 
the equation, when they know more intimately about how the 
diagnosis is affecting them. So how do we do it? And is the 
veteran really able to come to the third appointment on the 
first time? No. But at least they can recognize that they have 
to try.
    Ms. Pollack. And from a clinical perspective I think again 
it is important to recognize so much of this comes into play in 
sort of the introduction of the purpose of the evaluation, why 
you are here, that we need to get to this information, and 
really just recognizing how hard it is to talk about these 
issues, you know, how hard it is to build rapport and to 
differentiate, again, that this is different than if I was in a 
clinical evaluation, where we would be spending weeks getting 
to know each other. This is a one-time evaluation and really I 
need a lot of information in a short time. I recognize it is 
going to be difficult for you to share that with me. But I 
think, you know, over the years clinicians learn techniques to 
work with veterans who are often sort of resistant to share 
what is often very difficult personal information. I can use as 
an example, lots of time saying to a veteran who has PTSD, my 
guess is you find it very difficult to go out to a restaurant 
and when you do you need to sit with your back to a wall? And 
all of a sudden just by saying that simple statement, I cannot 
tell you how many veterans that I have worked with said, how do 
you know that? How do you know me? And I think that really sort 
of helps in terms of that rapport. Being able to say I 
understand PTSD. I understand what you are going through. And 
we can work together to make this evaluation as comfortable for 
you as possible.
    Mr. Bost. Okay. With that, we have pretty well run through 
this. But one thing I do want to do is I want to thank 
everybody for being here. But I do want to let the Ranking 
Member have any closing remarks that she might want to make at 
this time, and then before we close this out.
    Ms. Esty. Well again, I want to thank you for joining us 
here today and let me be very clear. I know everyone is trying 
to get to the same place. Everybody's heart is in the right 
place. And people have jobs to do and they have time pressures 
and a lot of veterans to serve. And I know everyone is well 
intentioned. I think we are just trying to figure out how we 
can do our job in Congress to provide you the resources but 
also the incentives and the clarity.
    So for example, I want to follow up with you, Mr. Caraway, 
you noted that there is some inconsistency out there with forms 
being present or not present. That creates confusion. We want 
to do everything we can to make this simple.
    Dr. Pollack, you clearly are an experienced, caring 
professional. But we have people doing contract work. We have 
people who are fresh to this. I worry about how someone new to 
this is going to be able to appropriately evaluate, put a 
veteran at ease in their C&P exam. And I worry a lot about 
that. And we have seen a tremendous number of increase because 
we are doing outreach but we also know from the tale that it 
tends to peak about six years after exposure, which is no 
surprise why we are seeing those numbers going up now. So we, 
it does make me worry about adequate preparation for the people 
doing the exams. Where if you are not experienced, you may not 
be doing right by the veterans in front of you. And they do not 
deserve to be the training wheels for a new examiner. And so, 
again, thoughts on what we can better do with that.
    Because, again, I want to say I know people are trying 
hard. But each and every veteran, for them the only exam, the 
only treatment that matters is what they get. And that is as it 
should be. And we want to make sure that that experience is a 
good one, an accurate one, and we are providing the care that 
our veterans need and the accuracy that the public demands.
    So again, I want to thank you for your service and your 
ongoing commitment. And thanks again the Chairman for his 
holding this important hearing. Thank you very much, and I 
yield back.
    Mr. Bost. And thank, I want to thank the Ranking Member for 
what she said earlier, which is we were just scratching the 
surface here. And early on in this process I said that as with 
any other disability, you can truly identify it. That does not 
mean it is not difficult, and each person deals with that, does 
have a difficult job. But when we are dealing with a human mind 
that has been damaged by some really, really bad experiences, 
to be able to analyze that and do it in a way, that is why it 
makes it so difficult. But we have got to do the best job we 
can.
    I believe everybody in this room wants to do that, whether 
it is the VSOs, or the agency. I believe that our veterans are, 
we are trying. But each one of us as Members know this. When we 
are back in our district, we hear from them on a regular basis. 
Concerns from both sides, hey, I feel like somebody is trying 
to push me to say I have got it. And hey, I have got this 
issue, and doggone it, they are not listening. And so somewhere 
in there is that balance that we can truly take those 
individuals and, you know, they truly are our heroes. They have 
served us. They have stepped out into the fire for us. And so 
we are going to keep working on this.
    But I do want to thank all the witnesses again for being 
here today. And as I said at the very beginning of the hearing, 
the complete written statement of today's witnesses will be 
entered into the hearing record. I ask unanimous consent that 
any written statement provided for the record will be placed 
into the hearing record. I also ask unanimous consent that all 
Members have five legislative days to revise and extend their 
remarks and include extraneous material. Hearing no objections, 
so ordered. With that, this hearing is now adjourned.

    [Whereupon, at 11:33 a.m., the Subcommittee was adjourned.]



                            A P P E N D I X

                              ----------                              

                   Prepared Statement of Ronald Burke
Opening Remarks

    Chairman Bost, Ranking Member Esty, and Members of the 
Subcommittee, thank you for the opportunity to discuss how the 
Department of Veterans Affairs (VA) manages Veterans' post-traumatic 
stress disorder (PTSD) disability compensation claims. My testimony 
will provide an overview of VA's processing of these claims, its 
training and quality assurance efforts, and the use of Disability 
Benefits Questionnaires (DBQs) to capture relevant medical evidence 
used to evaluate PTSD claims. With me today are Mr. Brad Flohr, Senior 
Advisor for Compensation Service, VBA; Ms. Patricia Murray, Chief 
Officer, Office of Disability and Medical Assessment, VHA; and Dr. 
Stacey Pollack, National Director, Program Policy Implementation, VHA.

PTSD Claims Processing

    There are currently over 940,000 Veterans who are service connected 
for PTSD and receive a monthly benefit payment. This population equates 
to approximately 22 percent of all Veterans receiving disability 
compensation benefits. This is a 172-percent increase compared to the 
end of fiscal year (FY) 2008, when approximately 345,000 Veterans were 
service connected for PTSD. The increase is a result of the veterans 
increased awareness and understanding of PTSD and several associated 
changes VA has implemented. In 2010, VA took actions to make it easier 
for Veterans to obtain disability compensation benefits associated with 
PTSD by placing greater evidentiary weight on lay statements to 
establish the required in-service stressful event if related to fear of 
hostile military or terrorist activity. VA previously required 
documentary evidence from the Department of Defense or other sources to 
verify an in-service stressful event related to the Veteran's PTSD 
symptoms, unless it was verified that the Veteran engaged in combat 
with the enemy or was a Prisoner of War, which was generally sufficient 
in itself to establish occurrence of an in-service stressful event.
    For the evaluation of PTSD claims where the stressor is not combat-
related or there is no initial evidence of combat participation, VBA 
has provided claims processing personnel with special tools to research 
Veterans' stressor statements. A website was developed that contains a 
database of thousands of declassified military unit histories and 
combat action reports from all periods of military conflict. In many 
cases, evidence is found in these documents to support the Veteran's 
stressor statement or confirm combat participation. Nationwide training 
was conducted on this database and other official websites that can aid 
with stressor corroboration. Thus, VA has illustrated in various ways 
its commitment to understanding and assisting Veterans with PTSD 
claims.

Training

    There are currently 16 VBA training courses focused on processing 
PTSD specific claims (including Military Sexual Trauma) geared to VA 
claims processors, including both interactive online lessons and 
classroom-based, instructor-led courses. Additionally, there are nine 
courses covering the topics of requesting disability medical 
examinations-also known as Compensation and Pension or C&P 
examinations-and sufficiency of examination reports. Again, these are 
delivered in both online and classroom settings.
    VA's Challenge Training for new Veteran Service Representatives 
(VSRs) and Rating Veteran Service Representatives (RVSRs) includes two 
courses regarding examination requests and examination sufficiency. 
There is also specific instruction on PTSD claims.
    VA's National Training Curriculum for FY 2017 requires five courses 
of PTSD training for VSRs and 10 courses for RVSRs. Also, error-trend 
analysis drives local instructor-led training on examination requests 
and examination sufficiency for individual stations as well as training 
during Compensation Service oversight visits. Error-trend analysis has 
also led to the development of new national-level training involving 
examination sufficiency that was released to the field in June 2017.

Quality Assurance

    VA reviews PTSD claims as part of its national Systematic Technical 
Accuracy Review (STAR) program. From the start of FY 2016 (October 
2015) through February 2017, accuracy of processing on PTSD claims was 
94.2 percent, which is comparable to VA's overall 12-month issue-based 
accuracy of 94.57 percent through April 2017.
    PTSD claims are reviewed under the same criteria as all rating 
claims through the STAR program. This includes a review for appropriate 
development of the claim; whether the grant or denial of issues was 
correct; whether the appropriate evaluation was assigned; and whether 
the effective dates and payment rates were correct. It also considers 
whether appropriate notification, both of VA's duty to assist and the 
decision, were provided to the Veteran and representative. Finally, it 
considers whether appropriate medical examinations and opinions were 
requested and conducted where necessary. This review does not 
differentiate claims based upon the stressor type (combat, military 
sexual trauma, etc.).

DBQs

    VA claims processors request disability medical examinations, or 
C&P examinations, specific to PTSD. Trained examiners, whether at 
Veterans Health Administration or at one of VA's contracted examination 
vendors, document the exam findings on DBQ templates, which are 
considered by VA claims processors in making decisions on disability 
compensation claims. It is important to note that DBQs are intended to 
capture information necessary to evaluation of a claimed condition 
under the VA Rating Schedule for Disabilities; thus, DBQs are a tool 
designed to support a forensic assessment of a Veteran's claimed 
condition, not for treatment purposes. The initial examination for 
PTSD, where a diagnosis is made, must be conducted by a psychiatrist or 
psychologist.

Closing Remarks

    VA remains committed to providing high quality and timely decisions 
on entitlement to disability compensation benefits, with PTSD being one 
of the primary conditions claimed by Veterans. VA will continue to 
update training materials and the Schedule for Rating Disabilities 
regarding this condition and its impact on our Nation's heroes and 
their families.
    This concludes my testimony. I am pleased to address any questions 
you or other Members of the Subcommittee may have.

                                 
                  Prepared Statement of Gerardo Avila
    The Department of Veterans Affairs (VA) National Center for Post-
Traumatic Stress Disorder (PTSD) defines PTSD as ``a mental health 
problem that some people develop after experiencing or witnessing a 
life-threatening event, like combat, a natural disaster, a car 
accident, or sexual assault. \1\ `` The nature of serving in the armed 
forces is inherently dangerous; fear of hostility, combat operations, 
military sexual trauma (MST), and the dangers of training operations 
are only some of the causes that could eventually lead to a PTSD 
diagnosis.
---------------------------------------------------------------------------
    \1\ National Center for PTSD
---------------------------------------------------------------------------
    PTSD affects each generation of veterans. The National Center for 
PTSD estimates 11-20 percent of veterans of Operation Iraqi Freedom 
(OIF) and Operation Enduring Freedom (OEF) suffer from the condition; 
an estimated 12 percent of Operation Desert Storm veterans have PTSD, 
and 15 percent of Vietnam War veterans also suffer from PTSD, according 
to the most recent VA study conducted in the late 1980s. VA estimates 
that 30 percent of Vietnam War veterans have suffered from PTSD at some 
point during their life \2\.
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    \2\ PTSD: National Center for PTSD
---------------------------------------------------------------------------
    Chairman Bost, Ranking Member Esty, and distinguished members of 
the Subcommittee on Disability Assistance and Memorial Affairs (DAMA), 
on behalf of National Commander Charles E. Schmidt and The American 
Legion; the country's largest patriotic wartime service organization 
for veterans, comprising over 2 million members and serving every man 
and woman who has worn the uniform for this country; we thank you for 
the opportunity to testify regarding The American Legion's position on 
``VBA's Processing of Claims for Benefits Based on Post-Traumatic 
Stress Disorder''.
                               Background
    In July 2010, VA took significant strides towards assisting 
veterans suffering from PTSD. The liberalization of regulations relaxed 
the need for veterans to provide proof of a PTSD stressor; instead, 
veterans only needed to prove a ``fear of hostility.'' Former VA 
Secretary Eric Shinseki recognized the importance of the liberalization 
and added, ``This final regulation goes a long way to ensure that 
veterans receive the benefits and services they need.'' The American 
Legion concurred with the former Secretary and lauded the efforts to 
streamline the access to benefits.
    While The American Legion acknowledges advancements in this area, 
we also know there is significant room for improvement. From 
development of PTSD claims, through compensation and pension (C&P) 
examinations, to ultimate adjudication, American Legion accredited 
representatives routinely see errors throughout the process. 
Furthermore, if a veteran seeks service connection for a physical 
condition that manifested secondary or was aggravated by PTSD, veterans 
routinely are faced with a difficult journey.
                       Development of PTSD Claims
    Improvement in the development of PTSD claims improved 
significantly following the July 2010 liberalization and has led to 
greater uniformity in relating PTSD to being deployed to hostile areas. 
VA's veterans service representatives are more likely to request C&P 
examinations, leading veterans to not receive VA disability 
compensation but gain access to VA healthcare.
    The July 2010 liberalization was not the first instance of relaxing 
standards for PTSD. VA relaxed the standard for gaining service 
connection for PTSD related to military sexual trauma (MST) in 2002. 
The frequency and impact of MST among servicemembers and veterans is 
intolerable. VA reported in May 2015 that 25 percent of female veterans 
and one percent of male veterans experienced military sexual trauma 
when screen by a VA provider \3\.
---------------------------------------------------------------------------
    \3\ Military Sexual Trauma
---------------------------------------------------------------------------
    Though VA relaxed MST-related PTSD claims, the implementation and 
effectiveness of that relaxation has not been enjoyed in the same 
manner as combat related PTSD claims. Recent reports have highlighted 
the complications regarding reports associated with MST. Command cover-
up, lack of military or civilian law enforcement records, and lack of 
medical records are some of the myriad reasons why claimants are 
unsuccessful in gaining service connection.
    It is extremely frustrating to veterans that experience such 
degradation by fellow servicemembers and then receive a denial of 
benefits post-service. American Legion service officers often submit 
lay statements from family members or friends that corroborate the 
incident, only to have the lay statements ignored or disputed. PTSD 
caused by MST often can only be corroborated by family members or 
friends, and VA's failure to regularly utilize these key documents is 
harmful to veterans.
                            C&P Examinations
    The PTSD disability benefits questionnaire (DBQ) has created a 
uniform examination process that provides medical professionals with a 
list of symptoms and severity of symptoms experienced by the veteran. 
DBQs have proven a useful way to providing a uniform method of 
providing the necessary questions and ensuring the appropriate 
information is transferred to the Veterans Benefits Administration 
(VBA) for establishing the level of service connection. In theory, the 
veteran in Los Angeles should be receiving the same C&P examination for 
PTSD as the veteran in Atlanta.
    Complaints pertaining to C&P examinations from veterans do not 
generally surround the DBQ; it surrounds the manner and method the 
examinations are conducted. Veterans have complained of C&P 
examinations that last 10-15 minutes and examiners that question the 
veracity of their symptoms or severity. Additionally, examiners have 
detailed significant and severe symptoms; however, when evaluating the 
level of occupational and social impairment provide a response that do 
not align with the level of severity reported in the DBQ.
    A recent issue has developed regarding C&P examinations provided by 
VBA contracted examinations. Within the last six months, American 
Legion service officers have noted the quality of re-examinations for 
PTSD. Despite having months of continual treatment by VA for the 
condition with records indicating the severity of the condition, some 
contracted examiners indicate the veteran's symptoms are significantly 
less severe than indicated by VA treatment records. Ironically post-C&P 
examination, VA treatment records continue to show the previously 
indicated more severe symptoms.
    The impact of C&P exams are highly critical in determining service 
connection and the level of disability. Symptoms experienced and the 
severity of the symptoms are the foundation of establishing the level 
of disability within the VA Schedule for Rating Disabilities. Due to 
this fact, it is absolutely essential that C&P examiners conduct a 
thorough review of records, to include lay statements, to ensure 
veterans' conditions are properly evaluated.
                  Secondary Conditions Related to PTSD
    The National Center for PTSD published an article by Kay Jankowski, 
Ph.D., regarding the impact of PTSD upon physical health. Dr. Jankowski 
acknowledged ``a growing body of literature has found a link between 
exposure to trauma and poor physical health'' and added research exists 
regarding the relationship between PTSD and cardiovascular, 
gastrointestinal, and musculoskeletal conditions. \4\
---------------------------------------------------------------------------
    \4\ National Center for PTSD
---------------------------------------------------------------------------
    Veterans are often diagnosed with PTSD at a relatively young age. 
Years of suffering with the condition could cause or aggravate physical 
conditions, as suggested by Dr. Jankowski. Unfortunately, veterans are 
often denied or not even provided the opportunity to have a C&P 
examination to determine the relationship between the physical 
condition and PTSD.
    Sadly, some within VBA do not believe that a relationship exists, 
despite the fact that VA has published articles suggesting the 
existence of the relationship. In 2015, The American Legion met with 
senior leaders at a VA regional office (VARO). The topic of the 
relationship between cardiovascular health and PTSD was discussed, as 
we noticed frequent remands from the Board of Veterans' Appeals 
regarding this issue. The veterans service center manager declared no 
relationship exists and added that her husband was unsuccessful at 
connecting the two conditions for his VA claim. Perhaps he should have 
enlisted the help of an American Legion service officer.
    When further pressed on the issue, she demanded to produce a 
medical study discussing the relationship. The American Legion 
immediately provided a study suggesting the relationship issued by VA's 
Published International Literature on Traumatic Stress. We realize that 
each case is different; we realize that medical professionals may have 
different opinions. However, we believe a trained medical professional 
should make that determination and not a VBA employee.
      PTSD and Total Disability Due to Individual Unemployability
    An unfortunate impact of PTSD is that it can eventually lead to a 
veteran's inability to gain and sustain meaningful employment. This 
leads to the veteran qualifying for total disability due to individual 
unemployability (TDIU) benefits. Unfortunately, unless the veteran 
specifically applies for this benefit, TDIU may not be awarded.
    Annually, The American Legion conducts VARO visits as part our 
Regional Office Action Review (ROAR) program. In March 2016, The 
American Legion visited the Cleveland VARO to review recently 
adjudicated appealed claims.
    During the visit, we reviewed a claim of a Marine veteran that 
filed to increase his 50 percent PTSD disability rating in March 2010 
and stated he could not work due to PTSD. His wife provided a letter in 
May 2010 indicating the veteran's inability to work due to PTSD and 
documentation from the Social Security Administration (SSA) indicating 
he is unable to work due to a psychiatric disorder. Eleven months 
later, the veteran received a rating decision stating, ``Social 
Security records dated February 3, 2010 noted your isolation and 
irritability. The examiner on your Mental Residual Functional Capacity 
Assessment provided that you are unable to work in proximity to other 
people due to extensive social discomfort and you are unable to 
complete work behaviors in a typical work environment due to your 
psychiatric conditions. You are currently receiving Social Security for 
your affective disorders and your anxiety related disorders.''
    In March 2012, the veteran filed a notice of disagreement, and 
nearly four years later, in February 2016, he received a decision 
increasing his disability rating for PTSD to 70 percent. Unfortunately, 
the veteran still was not receiving TDIU; however, he continued to 
receive social security disability benefits.
    The American Legion reviewed the appeal in March 2016. The 
veteran's documentation strongly suggested consideration for TDIU 
existed, and we demanded VA to take action. VA conducted a C&P 
examination in April 2016, and the examiner agreed with SSA and opined 
the veteran's PTSD caused unemployability. The American Legion's 
questions combined with a positive opinion indicating the veteran's 
PTSD caused unemployability led to an eventual grant of the benefit. VA 
did retroactively award the benefit to May 2010 and received a 
retroactive award in excess of $96,000.
    Had The American Legion's ROAR team not visited this location and 
reviewed the appeal, this veteran may have never received TDIU, and if 
he did, it is uncertain if he would have received the same effective 
date. This case serves as an example of the need for VBA employees and 
C&P examiners to perform a careful and thorough review of the record. 
This veteran should not have had to wait four years to have an appeal 
adjudicated, and he certainly should not have had to wait six years for 
the proper awarding of his TDIU benefits.
                        Evaluation Builder Tool
    The creation and implementation of VBA's Evaluation Builder tool 
has also led to improper denials or an under evaluation of claims. VBA 
created the tool to develop uniform decisions; a rater at one VARO 
should have similar decisions as a rater at a different VARO. 
Unfortunately, nearly whole dependence on the tool has created missed 
opportunities.
    In 2017, The American Legion has asked VBA employees during ROAR 
visits about the tool. Raters have the capability to disregard the 
tool's suggestion; however, the local quality review team is notified, 
and many fear reprisal if they continually challenge the tool's 
suggestion. Quite simply, they do not want to a label of being a 
difficult employee.
    No concern would exist if the tool were 100 percent effective. The 
American Legion understands that not all information receives 
consideration in the tool. Lay statements, continuity of symptoms, or 
outside private medical evidence may not be considered and 
significantly influence a decision.
    The American Legion believes the Evaluation Builder tool could 
greatly assist raters. However, there requires flexibility. Raters 
should be encouraged to challenge the tool and not fear reprisal. In 
fact, challenges to the tool's system would lead to better development 
of the product; VA should welcome this input. Finally, the decisions 
should not solely reflect the suggestion of the tool; it is essential 
consideration of all pertinent records occur.
                              Conclusion:
    The American Legion has long recognized the impact of PTSD within 
the veterans' community. We have worked with those that have been 
affected by horrors of combat and MST. During our 96th National 
Convention in 2014, we resolved to, ``Urge the VA to review military 
personnel files in all MST claims and apply reduced criteria to MST-
related PTSD to match that of combat-related PTSD'' \5\. VA has taken 
significant strides in improving its recognition of veterans deployed 
to hostile lands; however, VA still needs improvement in MST-related 
PTSD claims, C&P examinations, and evaluations of disabilities. The 
American Legion thanks this committee for their diligence and 
commitment to our nation's veterans on this topic. Questions concerning 
this testimony can be directed to Derek Fronabarger Deputy Director in 
The American Legion Legislative Division (202) 861-2700 or at 
[email protected].
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    \5\ American Legion Resolution No. 67: (2014): Military Sexual 
Trauma

                                 
             Prepared Statement of Martin ``Marty'' Caraway
    Mr. Chairman and distinguished members of the committee, my name is 
Martin Caraway. I am an Associate Member of the National Association of 
State Directors of Veterans Affairs (NASDVA) and I am here at the 
request of and on behalf of NASDVA President, Randy Reeves and NASDVA's 
Executive Committee. I currently serve as the Redwood County Veteran 
Service Officer in southwestern Minnesota and am also honored to serve 
as the 1st Vice President of the National Association of County 
Veterans Service Officers. The strong relationships and partnerships 
we, as County Veteran Service Officers, have with our individual State 
Directors across the Nation is a force multiplier and enabler for 
service and care to our Veterans. Here with me today is Colonel 
(retired) Thomas Palladino, Executive Director, Texas Veterans 
Commission and NASDVA Southwest District Vice President.
    State, County and National Veteran Service Officers assist Veterans 
every day who suffer from Post-Traumatic Stress Disorder (PTSD). We not 
only see their needs and the difficulties they may encounter with daily 
life, we also see the frustration and confusion they sometimes feel in 
dealing with the VA claims process. I sincerely hope the ``ground 
level'' perspective I present will be helpful in improving the process 
for our Veterans.

    Specifically:

    1. VA's accuracy in processing PTSD claims (including those with an 
exception to the requirement of a verified stressor).

    It is our general observation that VA employees (VSR/RVSR) are, for 
the most part, doing a good job in handling the complex claims of 
service connection for PTSD. However, there are parts of the process 
that require review (and correction). For example, 38 CFR 3.304 (f)(3) 
states ``... If a stressor claimed by a veteran is related to the 
veteran's fear of hostile military or terrorist activity and a VA 
psychiatrist or psychologist, or a psychiatrist or psychologist with 
whom VA has contracted, confirms that the claimed stressor is adequate 
to support a diagnosis of post-traumatic stress disorder and that the 
veteran's symptoms are related to the claimed stressor, in the absence 
of clear and convincing evidence to the contrary, and provided the 
claimed stressor is consistent with the places, types, and 
circumstances of the veteran's service, the veteran's lay testimony 
alone may establish the occurrence of the claimed in-service 
stressor...''. Even though the guidance appears to be clear, in these 
cases VA is still sending a VA Form 21-0781 Statement in Support of 
Claim for Service Connection for post-traumatic stress disorder. The 
employees are following the M21 4.ii.d, Claims for Service Connection 
for Post-Traumatic Stress Disorder, which states ``...service 
connection (SC) for posttraumatic stress disorder (PTSD) associated 
with an in-service stressor requires credible supporting evidence that 
the claimed in-service stressor actually occurred...'' Given that 
information, the VA VSR's and RVSR's are adequately performing their 
jobs per VA guidance. The M21 is requiring the credible supporting 
evidence, i.e. the VA Form 21-0781. When this process takes place it is 
considered further development and the veteran's case is removed from 
the Fully Developed Claim process, and then placing more burden of 
proof on the veteran. We have heard from VA staff that if a 21-0781 is 
not received, they will not grant service connection for the claim, 
despite 38 CFR guidance. Failure(s), like this, to follow prescribed 
guidance and apparent disparities between law and VA guidance must be 
addressed and steps must be taken to ensure the process is consistent 
for all our Veterans.
    We further observe that the Department of Veterans Affairs (VA) 
does not distinguish between drill-down for numbers on individual 
conditions like PTSD. A ``best practice'' example can be seen in Texas, 
where the VA Regional Offices are working with the Texas Veterans 
Commission (TVC) Strike Force Teams to ensure a VA Form 21-0781 
(Statement in Support of Claim for Service Connection for PTSD) is 
completed for the PTSD stressor or the combat related stressors are 
verified on the DD 214s (Purple Heart or Meals w/ V Device, etc.).

    2. Efficacy of DBQs used to evaluate PTSD claims (ability of DBQs 
to produce intended result).

    The VA does not use DBQs on initial examinations for PTSD. They can 
however, use them on claims for increases or routine future 
examinations. In many instances, VA physicians refuse to fill out DBQ's 
because they believe it is a ``conflict of interest''. The veteran, of 
course, can take the DBQ to a private physician if they wish, but 
feedback from many veterans is that the cost is exorbitant. Sadly, 
based on individual veterans' financial situations, ``exorbitant'' or 
cost-prohibitive can be reality, therefore disadvantaging some veterans 
based on their ability to pay.
    DBQ's are designed to streamline the examination process, allowing 
examiners to ask pointed questions that specifically address 
symptomology and severity of those symptoms. Without question, a claim 
for service connection for PTSD is complex. VA is attempting to draw 
out what the individual veteran fights daily to suppress. Examiners, 
more specifically those whom are contracted and not employed by VA, 
seem to have a tendency to ``skim'' through the DBQ form. There are 
many potential reasons for this, but it appears it is to see as many 
patients as possible throughout the day. Reports back from veterans are 
eerily similar, in that the exams start later than the scheduled time 
(most likely because the examiner is reviewing the claims folder) and 
conclude well before the scheduled appointment is scheduled to end 
(most likely to complete the dictation of DBQ). Most PTSD appointments 
are scheduled for one hour, with (generally) a mere 15 minutes of face 
to face time between the veteran and provider. The pressure of trying 
to accurately gauge the effect of PTSD on someone's life in that short 
time (15 minutes) is not in the veteran's best interest nor frankly in 
the best interest of VA and the integrity of the system. Veterans tend 
to walk away feeling like they had little or no opportunity to really 
discuss how their life is impacted. Reading hundreds (even thousands) 
of these examinations, they all read very similar; examiners are 
capturing one or two quotes from the veteran and inserting them into 
the dictations to present a (seemingly) thorough examination that is 
then used to rate the case.
    VA and VA contracted providers are given DSM V DBQ's to complete 
for PTSD claims. Private mental health providers are restricted to only 
filing out DSM IV DBQ's if the veteran wanted or needed to appeal the 
initial decision, based on a poor or incomplete examination. This 
inconsistency often questions the integrity of the private examination. 
To expand: VA examiners are taking the aforementioned time (1 hour 
total) to review the veteran's claim file, where in contrast the 
private examiner may have spent multiple sessions with the veteran and 
often has intimate knowledge of the impact of the diagnosis on the 
veteran's life. If the veteran goes through a FOIA request for a copy 
of their claims file for the private examiner to review, they run a 
significant risk of missing critical deadlines due to VA's untimely 
turnaround time on FOIA requests. If the private evaluation does not 
cite the claims file, the VA RVSR's and DRO's give relative equipoise 
to the internal examiner solely based on review of the C-file.

    3. VA's quality review measures.

    There is a six-page Rating Veterans Service Representative (RVSR) 
quality checklist that is followed for quality review measures. Two key 
points on the checklist are: error description on exams; and medical 
opinions. One of the most common disability claims is PTSD. Due to the 
large number of claims, that allows for a larger number of errors in 
quality.

    Examples of errors in quality:

      Insufficient examination dealing with the issue of nexus.
      Effective date assigned.
      All needed evidence not on record when the exam was 
ordered.

    For the last couple of years, since the VA has allowed for internal 
Quality Review Teams (QRT), we are finding QRT personnel utilizing the 
rating builder's disclaimer, ``The mental calculator produces a 
suggestion only, based on the data entered. However, this suggestion is 
not meant to replace the judgement of the decision maker and a review 
and weighing of the evidence is required.'' This vividly highlights the 
subjectivity individual raters and, in these cases, the veterans' 
representative/VSO is usually told to appeal the case instead of VA 
correcting the decision at the local level. This is counterproductive, 
adds to the time the veteran waits for a decision and, functionally, 
shifts the workload from claims to appeals; this is inefficient if the 
aim is to decide/solve cases at the lowest possible level.
    Since VA is now relying heavily upon contracted C&P examiners we 
believe there should be more oversight on these contractors. To 
illustrate this point: extensive review of multiple DBQ's, from 
multiple examiners (and on different veterans), look like the 
(multiple) DBQ's completed on that these veterans were the exact same 
person, written by the same provider. It is alarming when we see these 
``boiler-plate'' DBQ's completed so similarly and yet face time with 
the veteran is continuously shortened by the examiners. This needs 
critical review.

    4. Guidance and Training for VSRs and RVSRs to identify PTSD 
examination results.

    The VA provides compensation templates to assist raters in 
evaluations. Upon review of claims, it has been discovered that the 
templates are not being utilized. It appears underutilization of this 
tool may be the leading cause of errors in quality. We believe it can 
be argued that if these templates were used during evaluation of PTSD 
examination results and in preparation of rating decisions, the number 
of decisions in favor of veterans would increase.
    We contend it should be standard practice for VA employees to 
resolve in favor of the veteran in cases of conflict; especially when 
``higher level'' guidance (i.e. 38 CFR) exists. Specifically, VA's 
directive(s) outlined in the M21 Manual seem to directly contradict the 
proper application of the legal provision(s) of 38 CFR as it relates to 
utilizing exception to the requirement of a verified stressor. VA 
should not negatively scrutinize VSR's and RVSR's who resolve doubt in 
favor of the veteran by carrying out 38 CFR 3.304(f) in lieu of 
following the M-21 Manual and subsequently issuing the VA Form 21-0781, 
which may or may not come back as a verifiable stressor by citing 38 
CFR 3.102-Reasonable Doubt.
    Mr. Chairman and distinguished Members of the House Subcommittee on 
Disability, Assistance and Memorial Affairs, NASDVA and its partners 
deeply respect and appreciate the important work you are doing to 
ensure America's Veterans receive the service, are and compensation 
they have earned. Working together, with VA and all stakeholders, we 
can make this process better.
    Thank you for including NASDVA in this very important hearing.

                                 
                        Statement For The Record

                              JOHN TOWLES
    MR. CHAIRMAN AND MEMBERS OF THE SUBCOMMITTEE:

    On behalf of the men and women of the Veterans of Foreign Wars of 
the United States (VFW) and it's Auxiliary, thank you for the 
opportunity to offer our perspective on whether or not the Department 
of Veterans Affairs' (VA) Veterans Benefits Administration (VBA) is 
effectively processing claims for Post-Traumatic Stress Disorder 
(PTSD).
    War is as old as civilization itself, as are the stories describing 
the mental wounds incurred by men and women who fought in those wars. 
Not only do these wounds take a toll on those who served in one form or 
another, they impact those who are the closest to them - their friends 
and families.
    It goes without saying that combat changes you. Everyone is 
affected to some degree, whether they realize it or not. While some who 
serve in combat are able to return home and cope with their experiences 
with little to no assistance, there are a large number who cannot, and 
truly need access to assistance as soon as possible. With that said, it 
is important to understand that not all people or experiences are the 
same, and as such, we need an emphasis on approaches to treatment that 
are tailored for an individual's needs and what will work best for him 
or her.
    VA is the largest integrated health care system in the United 
States with specialized treatment for PTSD. The number of veterans 
seeking treatment at VA for PTSD has continued to increase as more 
veterans from the wars in Iraq and Afghanistan leave the military and 
transition to civilian life, and it is expected that these numbers will 
continue to grow.
    With 14 of the 20 veterans who die by suicide every day not seeking 
care at VA, the VFW believes VA must see to it that every one of these 
brave men and women has access the services they need to overcome these 
difficulties, easing the transition into civilian life and becoming as 
whole as possible. Sixty-five percent of veterans who die from suicide 
are 50 years old or older. No veteran should suffer untreated for what 
happened to him or her while serving this nation.

Claims Processing -

    Over the past seven years, VA has undergone sweeping reforms meant 
to ensure veterans from every generation have access to the best 
services and resources available to identify, diagnose, and treat PTSD 
for those who were deployed to combat environments. While these reforms 
were instrumental in providing help to veterans who present with 
uncomplicated cases, there are still numerous shortfalls for those who 
have other conditions as a result of their service, such as Traumatic 
Brain Injuries (TBI), which often exacerbate PTSD symptoms; and PTSD as 
a result of Military Sexual Trauma (MST).
    According to DOD's Defense and Veterans Brain Injury Center, more 
than 330,000 service members have been diagnosed with TBI between 2000 
and 2015. VA has made significant progress in diagnosing and treating 
TBI related conditions since the start of the wars in Iraq and 
Afghanistan. VA reports nearly 80,000 veterans were treated by its 
integrated Polytrauma System of Care in 2015, and estimates a more than 
30-percent increase in demand within two years. VA must continue to 
expand its services to ensure veterans who suffer from conditions 
associated with TBI are identified as soon as possible, and afforded 
the specialized care they need.
    With regards to MST, the VFW has testified before this committee 
numerous time in the past that MST claims have not been properly 
adjudicated. Despite VA relaxing the burden of proof for service 
members filing a claim for MST almost 15 years ago, there has been 
little done in the way of ensuring that those claims have been 
standardized across the administration.
    Furthermore, while there are now special considerations and relaxed 
standards regarding the burden of proof needed to substantiate sexual 
assault resulting in PTSD, there are still unique barriers or 
challenges. Female veterans of OEF/OIF are experiencing conflict and 
situations at a pace that no other previous generation of women 
veterans have faced.

Examinations -

    The VFW supports timely and accurately performed exams. VA must 
provide quality, mandatory training to contract examiners, Ratings 
Veterans Service Representatives (RVSR), and Veterans Service 
Representatives (VSR) in order to accurately rate these claims and 
Congress should continue to exercise its oversight authority in VA 
reporting completion of prescribed training.
    VA uses third party examinations in order to speed up the process 
for an initial claim, or an appeal, to ensure veterans receive timely 
decisions. While we feel as though contracted exams are a good stop gap 
for VA given the current circumstances, it should be noted that there 
is much to be desired regarding third party examinations and we would 
go so far as to caution against the full outsourcing of C&P exams.
    Like a regular VA facilities, contractors must utilize a 
standardized Disability Benefits Questionnaire (DBQ) for claims; 
however; there is little consistency from site to site with regards to 
the quality of the examination and final disposition. Examples of this 
can be seen in everything ranging from the type and nature of questions 
that are being asked during the interview, to the amount of time that 
is spent talking to veterans about the severity of their diagnoses.
    In light of this, if VA were able to ensure consistency in how it 
conducts contracted C&P examinations, we feel as though this could 
exponentially speed up the process in which claims are adjudicated.
    Mental health examinations are increasing every day, and VA 
insisting on patients seeing only VA doctors for these examinations is 
increasing the burden on its compensation and pension examinations 
system. Yet, VA does not enable veterans to seek initial C&P exams from 
contracted C&P examiners. Mental health examinations for initial and 
supplemental claims must be added to the type of services offered by 
contracted C&P examiners.
    While VA accepts private medical evidence for veterans who are 
applying for disability compensation for physical disabilities, it does 
not accept private medical evidence for mental health claims. The VFW 
urges VA to expand the use of private medical evidence to include 
mental health claims.
    Veterans should not have to see a VA doctor in order to validate 
their private sector doctors' findings. Requiring redundant 
examinations only adds to more confusion and clogs up the system. VA 
should accept evidence from competent, credible physicians and not 
force veterans to seek a second opinion from a VA physician. The VFW 
urges Congress to make VA's private medical evidence authority 
permanent.
    It is because of this that the VFW also supports the use of private 
medical evidence to review and adjudicate claims, as it significantly 
expedites the timeline for veterans with complex co-morbidities.

Conclusion -

    Overall, the biggest complaint comes from inconsistencies within 
the system as a whole. The VFW has long sought to ensure that the men 
and women who have served our country honorably receive the care and 
benefits they have earned. While we recognize that VA has taken 
significant steps in the past seven years towards fulfilling this goal, 
more must be done to standardize the processes among all who are 
responsible for conducting C&P exams and, more importantly, with those 
responsible for adjudicating claims across all VA regional offices.

                                 
                        Questions For The Record

 Letter from Chairman Mike Bost to: U.S. Department of Veterans Affairs
    The Honorable David J. Shulkin, M.D.
    Secretary
    U.S. Department of Veterans Affairs
    810 Vermont Ave, NW
    Washington, D.C. 20420

    Dear Secretary Shulkin:

    Thank you for the testimony provided by the Department of Veterans 
Affairs for the July 25, 2017, Subcommittee on Disability Assistance 
and Memorial Affairs hearing entitled ``PTSD Claims: Assessing Whether 
VBA is Effectively Serving Veterans.''
    I would appreciate receiving your answers to the hearing questions 
below by 5:00 P.M. on September 5, 2017:

    1. Is VA planning to revise its policy to allow for a veteran's 
disability rating to be lowered, at the veteran's request, if the 
veteran claims his or her condition has improved? Ifso, please describe 
the application process for such a request.

    2. Please provide a detailed description of the Department's plans, 
including training initiatives, to improve the ability for VSRs and 
RVS.Rs to identify PTSD examination results that are not adequate for 
ratings purposes?

    a. What percentage of PTSD exams conducted by VHA examiners 
requires additional clarification or supplementation because the 
initial results are not adequate for ratings purposes?

    b. What percentage of PTSD exams conducted by contract examiners 
requires additional clarification or supplementation because the 
initial results are not adequate for ratings purposes?'

    3. Please provide a detailed description of the Department's plans 
to improve the quality of disability examinations for PTSD?

    4. Please describe the measures VA has in place to verify that 
medical experts are spending sufficient time during disability 
examinations to thoroughly and accurately assess and analyze a 
veteran's claim for PTSD, including but not limited to the following 
requirements for PTSD claims:

    a. If there is credible evidence that the claimed in-service 
stressor occurred?

    b. Is there a nexus between the veteran's PTSD and service?

    c. Any other factor that would tend to support a claim for service-
connection for PTSD?.

    5. Is it mandatory for raters to use the evaluation builder tool?

    a. If yes, how does VA ensure that raters are using the evaluation 
builder?

    b. If no, why not?

    6. Please describe the general impact of the 2010 regulatory 
changes for PTSD claims?

    a. Additionally, what safeguards are in place to ensure that VA is 
devoting its resources to veterans who have earned compensation because 
they have developed service-connected PTSD?

    7. Please describe the specific steps is VA taking to encourage 
veterans who are awarded compensation benefits for PTSD to continue 
receiving medical treatment?

    8. Please describe the training provided to disability examiners on 
how to determine whether the veteran's service is consistent with the 
claimed stressor, when that information is not well-documented.

    a. How does VA ensure that the examiner takes the necessary time to 
conduct such a thorough review?

    In an effort to reduce printing costs, the Committee on Veterans' 
Affairs, in cooperation with the Joint Committee on Printing, would 
appreciate your answer provided consecutively and single- spaced. In 
addition, please restate the question in its entirety before the 
answer.
    Due to the delay in receiving mail, please provide your response to 
Maria Tripplaar, Staff Director and Counsel of the Subcommittee on 
Disability Assistance and Memorial Affairs, at Mar ia ri pp l aar@ mail 
.hou se.gov. Please also send a courtesy copy to Ms. Alissa Strawcutter 
at ali ssa [email protected] se.gov. Ifyou have any questions, 
please call Ms. Tripplaar at (202) 225-9164.

    Sincerely,

    Mike Bost
    Chairman
    Subcommittee on Disability Assistance and Memorial Affairs

    cc: The Honorable Elizabeth H. Esty, Ranking Member, Subcommittee 
on Disability Assistance and Memorial Affairs

    MB/aks

                                 
                             HVAC MINORITY
    Question 1: What community education has the Department of 
Veterans' Affairs done (including with partner organizations, the 
Department of Defense, and Veterans Service Organizations) to explain 
the new Disability Benefits Questionnaire and the examination process 
to veterans and service members?

    VA Response 1: The Veterans Benefits Administration (VBA) conducted 
community education and outreach during FY 2017, highlighting different 
parts of the Disability Benefits Questionnaire and the examination 
process. This outreach included quarterly Veterans Service Officer 
(VSO) Meetings, VSO National Conventions, quarterly community outreach 
events with VA's Center for Faith Based and Neighborhood Partnerships 
(CFBNP), partnership with the American Kidney Foundation, various 
Health Fairs, VA Resource Exhibits, Veteran Summits, VA Benefit 
Briefings for Veterans, dependents and beneficiaries. Additionally, 
during the Transition Assistance Program (TAP), briefers explain the VA 
examination process to Servicemembers.
    VBA has updated factsheets, claim, and examination letters based on 
Veteran feedback. Print information has been reformatted and includes 
easily understood language explaining the process from start-to-finish. 
Veterans may also visit the Compensation & Pension Exam Webpage - 
http://www.benefits.va.gov/compensation/claimexam.asp to review 
additional information on the examination process, informational 
videos, frequently asked questions, and fact sheets.
    Disability Benefit Questionnaires (DBQs) were created to allow 
Veterans increased control over the disability claims process and 
present the option of visiting a private health care provider or a VA 
facility. In support of VA's Fully Developed Claims (FDC) and Decision 
Ready Claims (DRC) programs, more than 70 DBQs are currently available 
on VA's external facing Disability Benefit Questionnaire Webpage - 
http://www.benefits.va.gov/COMPENSATION/dbq--disabilityexams.asp.

    Question 2: How often does VBA update its schedule for 
disabilities? When is the next update for PTSD due out?

    VA Response 2: In 2009, VBA's Under Secretary for Benefits (USB), 
on behalf of the Secretary for Veterans Affairs (VA), directed the 
revision and update of the 15 body systems that are contained in the VA 
Schedule for Rating Disabilities (VASRD).
    VBA is committed to publishing final rulemakings to update all 
VASRD body systems by the end of 2018. Thereafter, VA will place each 
VASRD body system into a 5-year cycle of staggered reviews. This 
strategy is based on recommendations from a 2007 Institute of Medicine 
(IOM) report. In that report, IOM proposes a series of corrections to 
the existing schedule for rating disabilities and guidance designed to 
improve Veterans benefits in the 21st century.
    VA is working diligently to update the mental disorders body 
system, which includes the evaluation criteria for post-traumatic 
stress disorder (PTSD). This rulemaking is a high priority for the 
Secretary and although it is a lengthy and complex process, VA will 
make every effort to get the proposed and final rules published as soon 
as possible.

    Question 3: Can you describe how a Veteran's rating due to PTSD can 
be reduced? How does this happen if the medications have not changed, 
or the symptoms being experienced by the Veteran?

    VA Response 3: If a PTSD disability evaluation is reduced, it 
generally results from either a (1) mandatory review examination 
process or (2) claim for higher evaluation.
    A review examination is typically scheduled if VA grants service 
connection for PTSD and the evidence of record shows the disability may 
improve. In such situations, a review examination will be scheduled 
three years after the date of the initial grant of service connection 
for PTSD. The evaluation may be reduced if the examination, as well as 
all other relevant evidence of record, shows material improvement. 
Also, the evaluation may be reduced if a Veteran files a claim for 
increased evaluation for PTSD, even during the initial rating period, 
if the examination and other relevant evidence shows material 
improvement. If in either case the examination findings reveal that the 
Veteran's symptoms have not changed, then the evaluation will not be 
reduced.
    VA may not reduce a disability evaluation, to include a PTSD 
evaluation, without affording the Veteran administrative due process 
under the law. VA will issue a proposed rating decision that provides 
the Veteran notice of the proposed reduction and the opportunity to 
submit additional evidence as well as request a hearing to demonstrate 
why the proposed reduction should not be effectuated. VA will only 
implement the proposed reduction if it concludes that assignment of a 
reduced evaluation is still warranted after considering all evidence 
and /or testimony presented by the Veteran.

    Question 4: In his testimony, Mr. Caraway describes an example of 
how a Veteran's claim cannot be granted service connection if a VA Form 
21-0871 is not received despite the fact that there is an apparent 
disparity between the law and VA guidance as to whether it is 
necessary. What is VA doing to clarify this discrepancy and when?

    VA Response 4: Under VA regulations, service connection for PTSD is 
established when there is a current diagnosis of PTSD, credible 
supporting evidence of the occurrence of an in-service stressor, and a 
medical association between the diagnosis and in-service stressor. As 
the occurrence of an in-service stressor must be established to support 
service connection for PTSD, VA may request information from the 
Veteran regarding his or her stressor through a VA Form 21-0871, 
Statement in Support of Claim for Service Connection for Post-Traumatic 
Stress Disorder (PTSD).
    VA often does not have to request stressor information from the 
Veteran because the record already contains sufficient evidence to 
concede that the claimed in-service stressor occurred. This is also the 
case if PTSD was initially diagnosed in service or the claimed stressor 
is related to (1) verified combat or former POW service, and consistent 
with the circumstances, condition, or hardships of such service, or (2) 
fear of hostile military or terrorist activity, or drone aircraft crew 
member duties, and consistent with the places, types, and circumstances 
of the Veteran's service.
    However, in the absence of any of the aforementioned fact patterns, 
VA will send VA Form 21-0871 to solicit specific details of the claimed 
in-service stressor, such as the date and place of the incident, 
detailed description of the incident, unit or assignment at the time of 
the incident, medals or citations received as a result of the incident, 
and names and other identifying information concerning any other 
individuals involved in the incident, if appropriate. Upon receipt of 
VA Form 21-0871, VA will further review the record and may be required 
to request additional information from the service department to 
determine if there is credible evidence that the claimed in-service 
stressor occurred.
    The above guidance has been communicated to field stations through 
training materials and in VA's Adjudication Procedures Manual.

    Question 5: What is VA's oversight over examiners contracted 
outside of VA to do disability exams? Is any oversight conducted on 
site at the physician's office? How often does VA audit the contracts?

    VA Response 5: The VBA medical disability examination contracts 
include specific training requirements for all contracted medical 
examiners. The vendors are required to provide confirmation of training 
and are regularly tasked to conduct additional training as deemed 
necessary by VA.
    VBA conducts both scheduled and surprise site visits at vendor 
locations.
    The medical disability examination contracts are audited through a 
third party vendor. The financial audit contract is expected to be re-
awarded by September 2017. The audit of each of the contract 
examination vendors is done quarterly.

    Question 6: How many VBA applicants had Other than Honorable 
discharges per year since 2001? What are the statistics per year for 
determined Honorable for VA purposes, determined dishonorable for VA 
purposes for regulatory bars, determined dishonorable for VA purposes 
for statutory bars, and no determination? How many of the claimants per 
year claimed traumatic brain injury, post-traumatic stress, military 
sexual trauma, or other mental health condition? Can you break them 
down by discharge determination? And provide the grant rates?

    VA Response 6: We are able to provide data for the number of 
character of service (COS) determinations made by VBA upon receiving an 
application for benefits or health care from 2010 through 2017 fiscal 
year to date (FYTD). We are unable to provide 2001-2009 data as we did 
not begin capturing this data element until 2010.
    VA issues character of service determinations for former 
Servicemembers with a period of service resulting in (1) an 
administrative discharge under conditions other than honorable, (2) bad 
conduct discharge, (3) an uncharacterized discharge due to void 
enlistment or dropped from the rolls, and (4) a dishonorable discharge.
    There are three potential outcomes of a character of service 
administrative decision:

      Honorable for VA Purposes: Establishes basic eligibility 
to all benefits administered by VA, provided all other requirements for 
eligibility are satisfied.

      Health Care Eligible: Establishes eligibility for 
specialized health care for service-connected disabilities, provided 
requirements for service connection are satisfied.

      Dishonorable for VA Purposes (Health Care Ineligible): 
Bars all VA benefits and services.

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


    VBA does not track whether a dishonorable determination was based 
on statutory or regulatory bar. Historically, 16 percent of VBA's 
character of discharge determinations result in a Veteran being found 
honorable for VA purposes, 53 percent result in the Veteran being found 
eligible only for VA health care, and 31 percent result in the Veteran 
being found dishonorable for VA purposes.
    VBA does not track disability data with COS determinations. 
Therefore, this data is unavailable.

    Question 7a: What is the process for receiving a discharge 
determination if a veteran presents at a VA facility to submit a claim 
with an Other than Honorable discharge on their DD214? How does a 
veteran initiate it? What is the timeline?
    VA Response 7a: In order to initiate the discharge determination 
process when a former Servicemember has an Other than Honorable 
discharge, the individual would need to seek treatment for a condition 
at a VA Medical Center or file a claim for benefits-VA Form 21-526ez, 
Application for Disability Compensation and Related Compensation 
Benefits. In both scenarios, VA sends the claimant a notice that a COS 
determination is necessary and requests all active duty and personnel 
records. After the records have been received and the time limit for 
evidence submission has elapsed, VA makes a decision on whether or not 
the individual's service is honorable or dishonorable for VA purposes.
    VBA provides oversight and prioritization of eligibility decisions, 
specifically Character of Discharge Determinations, controlled under an 
EP290 at the national level. As of April 9, 2017, all Regional Offices 
receive a daily distribution of actionable due process eligibility 
decision work that is either priority - homeless, terminally ill, etc. 
- or our oldest pending claims. Nationally, Regional Offices are held 
to a standard that appropriate action should be taken on a claim within 
five days of it being distributed to their office. Regional and 
District Office leadership, as well as the Office of Field Operations, 
routinely monitor stations' performance related to the five day Time In 
Queue (TIQ) standard. Since NWQ began managing distribution of EP290s, 
timeliness of Eligibility Determinations has improved by 81 days.
    VBA will continue to monitor the improvements in EP 290 timeliness 
and make prioritization adjustments as necessary.
    Question 7b: Does VA provide an exam for traumatic brain injury, 
military sexual trauma, post-traumatic stress disorder, or other mental 
health condition? Is there a process, training, or guidance for this 
given to the VA employees doing the determinations?
    VA Response 7b: Upon initial receipt of an eligibility 
determination request from the Veterans Health Administration (VHA), 
the Veterans Benefits Administration (VBA) will gather all relevant 
service treatment and personnel records in order to prepare an 
administrative decision as to whether the character of the former 
Servicemember's service was honorable or dishonorable for the purposes 
of establishing eligibility to disability compensation and/or health 
care benefits.
    If, upon review of facts and circumstances, the service is deemed 
honorable for VA purposes, VBA personnel will assess any claimed 
conditions by reviewing in-service and post-service medical evidence, 
as well as any available lay testimony, to determine if it demonstrates 
a(n) 1) event, injury, or disease in service, 2) current diagnosed 
disability or persistent/recurrent symptoms of disability, and 3) an 
indication of association between the current symptoms/condition and 
the in-service event. If those criteria are met, claims developers will 
request an examination (and, in most cases, medical opinion) to 
determine the condition's current degree of severity and ascertain its 
relationship to the Veteran's service, if any.
    If the service is deemed dishonorable for VA purposes, but is of a 
nature that allows eligibility to health care benefits for conditions 
determined to be related to service, VBA personnel will perform the 
same functions described in the paragraph above, but will, when 
warranted, request only a medical opinion concerning the condition's 
etiology. No examination will be requested, as a detailed account of 
the disability's symptoms does not meaningfully inform the 
establishment of eligibility to medical care in this scenario.
    If the service is deemed wholly dishonorable (i.e. eligible for 
neither disability compensation nor medical care), no examination or 
medical opinion will be requested, as no benefit entitlement, monetary 
or otherwise, may be legally established.
    Procedural guidance on this process is published in the M21-1 
Adjudication Procedures Manual; relevant provisions are found in M21-1, 
Part III, Subpart v, Chapter 7, Section A, Topic 7, Block d 
(III.v.7.A.7.d) and IX.ii.2.4, and are available to all VBA claims 
processing personnel.
    Question 7c: What training does VA provide frontline employees on 
OTH discharges? Specifically, on what benefits veterans with OTH are 
eligible for?
    VA Response 7c: Compensation Service has several courses that 
include training for Other than Honorable (OTH) discharge during 
Challenge training (all employees):

      VSR Overview-Establish Veterans Status Module TMS# 
3733279, Character of Discharge, provided via Web-Based Training
      Character of Discharge (COD) Web-Based Training (WBT) TMS 
3825367
      VSR Compensation: Initial Actions TMS 3843741

    The following courses are After Challenge Courses:

      Character of Discharge (COD) TMS 4179795
      Claims Establishment for Character of Discharge 
Determinations TMS 4300970
      TMS course 3843741 and 4179795 include training for both 
the VSRs and the RVSRs and are used as refresher training

    All of these courses cover eligibility determinations for Veterans 
with OTH discharges.

    Question 7d: DoD has issued guidance (and it was codified in the 
FY2017 NDAA) to give liberal consideration to Veterans with evidence of 
TBI or PTSD resulting from combat or MST. Does VA use the same liberal 
consideration when determining if service is honorable for VA purposes? 
If so, when was this guidance issued? And was there a change in the 
characterizations determined honorable from before the guidance to 
after? If so, was there a statistically significant change in the 
number of claims approved for PTSD for veterans with OTH discharges?

    VA Response 7d: The guidance to give liberal consideration to a 
Veteran's TBI or PTSD, as referred to in the NDAA 2017, relates to 
DoD's upgrade of characterization of discharges. As VA has a 
longstanding practice of giving similar consideration to mitigating 
factors when making a character of discharge (COD) determination for 
purposes of establishing eligibility for VA benefits, additional 
guidance was not issued.
    In cases where a former Servicemember receives an ``other-than-
honorable'' (OTH) discharge, VA considers all facts and circumstances 
surrounding the COD. This includes reviewing any lay statements from 
the former Servicemember or other individuals, service treatment 
records (for any medical conditions), personnel records, post-service 
records, etc. Once VA considers all available evidence, a formal 
determination is rendered. Any reasonable doubt is resolved in favor of 
the claimant. This longstanding practice was clarified in a March 2016 
update to the M21-1 Adjudication Manual Part III, Subpart v, Chapter 1, 
Section B.
    As there were no changes in VA's guidance, there were no 
significant changes in COD determinations.

    Question 8: Does VA do any outreach to veterans with OTH discharges 
on what services and benefits they may be eligible for? Specifically 
with respect to veterans with PTSD, TBIs, MST, or other mental health 
conditions?

    VA Response 8: VBA does not conduct outreach specifically targeted 
at reaching Veterans with OTH discharges; however, VBA does conduct 
targeted outreach in an effort to educate and provide mental health 
care access to eligible Veterans. During FY 2016, VBA completed 132,000 
hours of outreach at 69,000 events and engaged more than 1.8 million 
attendees during outreach events.
    VBA employees have provided outreach at a number of diverse events 
nationwide during FY 2017 that include: Health Fairs, VA Resource 
Exhibits, Veteran Summits, VA Benefit Briefings, and PTSD Awareness 
Programs.

      In partnership with VHA, VBA attends mental health 
summits open to Servicemembers and Veterans where benefit briefings are 
provided.
      VBA has established partnerships with the United States 
Marine Corps and the National Guard to provide military sexual trauma 
(MST) training to DoD employees. Topics include claims processing and 
eligibility for VA healthcare.
      Information about VA's MST related services is included 
as part of the course curriculum for the Transition Assistance Program 
(TAP).
      VBA created a Distressed Veteran Standard Operating 
Procedures that was introduced VBA wide in May 2017 and serves as a 
reference point for all employees encountering Veterans experiencing 
distress in the following categories: Special Emphasis (Homeless 
Veterans & Elderly Veterans), Financial Distress, Mental Distress, 
Physical Distress, & Natural Disasters.

    Question 9: Is the mitigating effect of mental health conditions 
during a period of service considered for every Other than Honorably 
discharged PTSD claimant when doing discharge characterization 
determinations?

    VA Response 9: When making a formal COD determination, VA takes 
into account all facts and circumstances surrounding the reasons for 
the OTH discharge. The specific reasons and bases for each individual 
case can be found in the formal determination located in the Veteran's 
electronic claims record. VBA is reviewing its regulation in the Code 
of Federal Regulations (38 C.F.R. Sec.  3.12) to determine if 
clarification is needed for (1) character of discharge criteria, (2) 
the circumstances in which an Other than Honorable administrative 
discharge will be found to be disqualifying for VA benefits purposes, 
and (3) mitigating circumstances, such as mental health issues.

    Question 10: Do you have data at the original claims level that 
might show how mental health is taken into account when deciding OTH 
eligibility in mental health compensation claims?

    VA Response 10: VA does not track at the corporate level all of the 
various factors considered in OTH determinations. Therefore, aggregate 
data on numbers of cases where mental health was a factor in OTH 
discharges is not obtainable.

    Question 11: Can you provide a citation to any VA Regulation, any 
section of the VBA Benefits Adjudication Manual, and any VA Fast Letter 
or Training Letter, that instructs adjudicators to consider PTSD, TBI, 
and Adjustment/Personality disorder diagnoses when considering whether 
conduct in service should be disqualifying?

    VA Response 11: Claims processors are instructed to follow guidance 
in VBA Benefits Adjudication Manual, M21-1, Part III, Subpart V, 
Chapter 1, Sections B and E. Section B provides instructions on where 
claims are to be routed, while section E contains information on the 
effect of insanity on administrative decisions. Section E states:
    If a Veteran was determined to be insane at the time of the 
commission of the act or acts that would otherwise result in an adverse 
character of discharge, line-of-duty or willful misconduct 
determination, hold that the Veteran

      was without fault, and
      is not precluded from any Department of Veterans Affairs 
(VA) benefits.

    Section B states that claims for PTSD should go to the Core Lane 
for development activity, unless they are based on military sexual 
trauma, in which case they would go to the Spec Ops Lane for 
determination.

    Question 12: With the Secretary's announcement that veterans in 
crisis will be granted emergency access on a 90 day timeline, is VA 
tracking utilization by discharge status and outcomes? Is VA tracking 
utilization of other VA and community care assets, like Vet Centers or 
the Veteran Crisis Line and emergency rooms or community providers, by 
veterans that present to the VA requesting emergency access?

    VA Response 12: VHA is establishing processes for monitoring 
emergency access services by those with Other than Honorable 
discharges. Information Technology efforts are focused on building a 
reporting mechanism within the current electronic health record (EHR), 
which will provide a local mechanism for monitoring the 90-day episode 
of care. Additionally, the Office of Mental Health and Suicide 
Prevention are coordinating efforts with the Health Eligibility Center 
(HEC) to establish the protocol for monitoring national utilization.

    Question 12a: What metrics is VA tracking and utilizing to 
determine the effectiveness of the emergency access program, 
specifically related to reducing suicidal ideations, suicide attempts, 
and deaths by suicide?

    VA Response 12a: Given complexity in measurement, initial 
effectiveness will focus on qualitative analysis of submitted Issue 
Briefs concerning adverse outcomes related to suicide ideation, 
attempts and deaths.

                                 
                             HVAC MAJORITY
    1. Is VA planning to revise its policy to allow for a veteran's 
disability rating to be lowered, at the veteran's request, if the 
veteran claims his or her condition has improved? If so, please 
describe the application process for such a request.

    VA Response: VA does not plan to revise this policy. A Veteran has 
the right to either renounce the compensation benefit in whole or 
request a reevaluation of the condition if he or she feels the 
condition has improved or worsened. The Veterans Benefits 
Administration (VBA) relies upon medical evidence to determine the 
level of severity of a service-connected condition. Therefore, it is 
not advisable to develop a policy to allow decision makers to reduce 
the percentage of disability based on a Veteran's lay statement alone.

    2. Please provide a detailed description of the Department's plans, 
including training initiatives, to improve the ability for VSRs and 
RVSRs to identify PTSD examination results that are not adequate for 
rating purposes?

    a. What percentage of PTSD exams conducted by VHA examiners 
requires additional clarification or supplementation because the 
initial results are not adequate for rating purposes?

    b. What percentage of PTSD exams conducted by contract examiners 
requires additional clarification or supplementation because the 
initial results are not adequate for rating purposes?

    VA Response: VA utilizes several avenues to ensure claim processors 
identify post-traumatic stress disorder (PTSD) examination reports that 
are not adequate for rating purposes. In a general sense, adjudicators 
are taught from the beginning that examinations must include all 
findings necessary to adequately rate the case in accordance with the 
specific regulatory criteria. VA addresses this in its centralized 
training program, Challenge, through classroom and computerized 
courses. VA has also included detailed guidance on this matter in the 
Adjudication Operations Manual. Finally, VA conducts reviews of cases 
as part of its national quality program. The results of these reviews 
are used to conduct training and further clarify examination 
procedures. During fiscal year 2016, less than 1 percent of VA 
examination reports (from both VHA and contract vendors) were returned 
as inadequate.

    3. Please provide a detailed description of the Department's plans 
to improve the quality of disability examinations for PTSD.

    VA Response: The office of Disability and Medical Assessment (DMA) 
conducts monthly ratability quality evaluations of a random sample of 
disability examinations that would include PTSD exams. These reviews 
ensure that the Disability Benefits Questionnaires (DBQ) are suitable 
for rating purposes. DMA also updates training courses to ensure the 
inclusion of the latest diagnostic criteria is used and that the 
current regulations are applied. For VHA clinicians who complete 
compensation and pension examinations, the clinical quality of their 
work is reviewed during an Ongoing Professional Practice Evaluation 
(OPPE) at the local medical center.

    4. Please describe the measures VA has in place to verify that 
medical experts are spending sufficient time during disability 
examinations to thoroughly and accurately assess and analyze a 
veteran's claim for PTSD, including but not limited to the following 
requirements for PTSD claims:

    a. If there is credible evidence that the claimed in-service 
stressor occurred?

    b. Is there a nexus between the veteran's PTSD and service?

    c. Any other factor that would tend to support a claim for service 
connection for PTSD?

    VA Response: Initial PTSD evaluations are conducted by either 
psychiatrist or psychologists who have been trained in graduate school/
medical school to conduct thorough clinical assessments for PTSD. In 
order to conduct a PTSD Compensation and Pension evaluation, an 
examiner would need to assess whether or not the Veteran reports 
experiencing a traumatic event and if so, whether the Veteran meets the 
rest of the diagnostic criteria for PTSD. The examiner would need to 
document both the traumatic event as well as all of the symptoms of 
PTSD in the DBQ. As part of the Compensation and Pension (C&P) 
evaluation, the examiner is instructed to review records provided by 
VBA within the compensation file (c-file) or the Veterans Benefit 
Management System (VBMS). These records often contain the Veteran's 
DD214 as well as other documentation that may support whether the 
claimed in-service stressor occurred. Of note, it is not the role of 
the examiner to determine whether the stressor occurred, as that is the 
role of claims adjudicators in VBA. During the evaluation, the examiner 
would need to assess and document whether there is a nexus between the 
Veteran's diagnosed condition and service. In cases of PTSD secondary 
to Military Sexual Trauma (MST), the examiner would review the c-file 
or VBMS and determine whether or not there are any ``markers'' of MST. 
Markers may include things such as: sick call visits; changes in 
performance; visits to mental health clinics; reports to police, etc. 
Without adequate time, a clinician would not be able to provide a 
quality examination. VHA C&P clinics are careful to provide mental 
health clinicians with appropriate scheduled time for both examination 
and medical records review.

    5. Is it mandatory for raters to use the evaluation builder tool?

    a. If yes, how does VA ensure that raters are using the evaluation 
builder?

    b.If no, why not?

    VA Response: Yes, it is mandatory that raters use the evaluation 
builder when determining the evaluation level of PTSD. This function is 
embedded in the rating application, Veterans Benefits Management System 
- Rating. For purposes of accountability, VA conducts local and 
national quality reviews of claims to ensure adjudicators are following 
the proper policies and procedures.

    6. Please describe the general impact of the 2010 regulatory change 
for PTSD claims?

    a. Additionally, what safeguards are in place to ensure that VA is 
devoting its resources to veterans who have earned compensation because 
they have developed service-connected PTSD?

    VA Response: The regulatory change in 2010 facilitated a more 
streamlined adjudicative process for certain PTSD claims. The change 
allowed VA to accept lay statements from claimants to verify in-service 
stressors, if such stressors are related to fear of hostile military or 
terrorist activity. This relaxed standard has contributed to the 
increased population of Veterans receiving compensation for PTSD. As 
mentioned in the hearing testimony, the number of Veterans on the 
compensation rolls for PTSD has increased from 345,000 in 2008 to over 
940,000 currently.

    Regarding measures to ensure VA allocates sufficient resources for 
PTSD claims, VA utilizes a well-established resource allocation model 
to determine the level of full time employees necessary for 
adjudicators in the regional offices. This allows VA to balance the 
hiring of claim processors (VSRs) and decision makers (RVSRs) to ensure 
claims are addressed in a timely manner.

    7. Please describe the specific steps VA is taking to encourage 
veterans who are awarded compensation benefits for PTSD to continue 
receiving medical treatment?

    VA Response: When awarding service connection, VBA notifies the 
Veteran of his or her right to free medical treatment for the service-
connected condition. VA has utilized various outreach and campaign 
efforts to raise awareness, encourage treatment, and break down the 
stigma of PTSD. Additionally, individual VHA examiners may discuss the 
benefit of seeking medical or mental health follow up when appropriate.

    8. Please describe the training provided to disability examiners on 
how to determine whether the veteran's service is consistent with the 
claimed stressor, when that information is not well-document.

    a. How does VA ensure that the examiner takes the necessary time to 
conduct such a thorough review?

    VA Response: C&P clinics are careful to provide mental health 
clinicians with appropriate scheduled time for both examination and 
medical records review. The service chiefs are responsible for 
allocating time slots for various disability exams on requests received 
from VBA to schedule exams. The C&P examiners are bound by ethics to 
conduct a thorough medical record review and the disability 
examination, and document both on the Disability Benefits 
Questionnaires.