[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
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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
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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
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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.
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\1\ National Center for PTSD
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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
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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\.
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\3\ Military Sexual Trauma
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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\
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\4\ National Center for PTSD
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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.