VA Disability Benefits and Health Care: Providing Certain	 
Services to the Seriously Injured Poses Challenges (17-MAR-05,	 
GAO-05-444T).							 
                                                                 
More than 10,000 U.S. military servicemembers, including members 
of the National Guard and Reserve, have been injured in the	 
conflicts in Afghanistan and Iraq. Those with serious physical	 
and psychological injuries are initially treated at the 	 
Department of Defense's (DOD) major military treatment facilities
(MTF). The Department of Veterans Affairs (VA) has made provision
of services to these servicemembers a high priority. This	 
testimony focuses on the steps VA has taken and the challenges it
faces in providing services to the seriously injured and	 
highlights findings from three recent GAO reports that addressed 
VA's efforts to provide services to the seriously injured. These 
services include vocational rehabilitation and employment (VR&E) 
and health care for those with post-traumatic stress disorder	 
(PTSD). 							 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-05-444T					        
    ACCNO:   A19618						        
  TITLE:     VA Disability Benefits and Health Care: Providing Certain
Services to the Seriously Injured Poses Challenges		 
     DATE:   03/17/2005 
  SUBJECT:   Health care services				 
	     Military personnel 				 
	     Veterans						 
	     Veterans benefits					 
	     Veterans hospitals 				 
	     Warfare						 
	     Interagency relations				 
	     Vocational rehabilitation				 
	     Disability benefits				 
	     Military hospitals 				 
	     Afghanistan					 
	     Iraq						 
	     Post-Traumatic Stress Disorder			 

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GAO-05-444T

United States Government Accountability Office

GAO Testimony

Before the Committee on Veterans' Affairs, U.S. Senate

For Release on Delivery

Expected at 10:00 a.m. EST VA DISABILITY BENEFITS

Thursday, March 17, 2005

AND HEALTH CARE

      Providing Certain Services to the Seriously Injured Poses Challenges

Statement of Cynthia A. Bascetta Director, Health Care-Veterans' Health and
Benefits Issues

GAO-05-444T

March 17, 2005

VA DISABILITY BENEFITS AND HEALTH CARE

Providing Certain Services to the Seriously Injured Poses Challenges

                                 What GAO Found

VA has taken steps to provide services as a high priority to seriously
injured servicemembers returning from Afghanistan and Iraq. To identify
and monitor those who may require VA's services, VA and DOD are working on
a formal agreement to share data about servicemembers with serious
injuries. Meanwhile, VA has relied on its regional offices to coordinate
with staff at MTFs and VA medical centers to learn the identities, medical
conditions, and military status of seriously injured servicemembers. For
servicemembers with PTSD, VA has taken steps to improve care including
developing with DOD a clinical practice guideline for identifying and
treating individuals with PTSD. The guideline contains a four-question
screening tool, which both VA and DOD use to identify those who may be at
risk for PTSD.

VA faces significant challenges in providing services to seriously injured
servicemembers. For example, the individualized nature of recovery makes
it difficult to determine when a seriously injured servicemember will be
ready for vocational rehabilitation, and DOD has expressed concern that
VA's outreach to servicemembers could affect retention for those whose
discharge from military service is uncertain. VA is also challenged by the
lack of access to DOD data; although VA staff have developed ad hoc
arrangements, such informal agreements can break down. Regarding PTSD,
inaccurate data limit VA's ability to estimate its capacity for treating
additional veterans and to plan for an increased demand for these
services.

Seriously Injured Army Servicemembers Receive Treatment at Five Major
Military Treatment Facilities and Relocate to 1 of 57 VA Regions After
Medical Stabilization

                 United States Government Accountability Office

Mr. Chairman and Members of the Committee:

Thank you for inviting me to discuss the Department of Veterans Affairs'
(VA) efforts to provide disability benefits and health care to seriously
injured servicemembers returning from Afghanistan and Iraq.1 Since the
onset of U.S. operations in Afghanistan in October 2001 and Iraq in March
2003, more than 10,000 U.S. military servicemembers have sustained
physical and psychological injuries. It is especially fitting, with the
continuing deployment of our military forces to armed conflict, that we
reaffirm our commitment to those who serve our nation in its times of
need. Therefore, effective and efficient management of VA's disability and
health programs is of paramount importance.

You expressed concerns about servicemembers and veterans who may seek
services from VA. Today, I would like to focus on the steps VA has taken
and the challenges it faces in providing services to those who have been
seriously injured in these conflicts. Specifically I would like to
highlight the findings of our work on VA's disability program and health
care services for seriously injured servicemembers returning from
Afghanistan and Iraq. My comments are based on our reviews of VA's
programs for vocational rehabilitation and employment (VR&E)2 and health
care,3 specifically post-traumatic stress disorder (PTSD) services. This
work included visits to four Department of Defense (DOD) major military
treatment facilities (MTF), including Walter Reed Army Medical Center
where most seriously injured servicemembers are initially treated. We
interviewed officials at VA's central office and at 12 of VA's 57 regional
offices. We also interviewed officials at seven VA medical facilities
where large numbers of servicemembers were returning from Afghanistan and
Iraq to discuss the number of veterans currently receiving VA PTSD
services and the impact that an increase in demand would have on these
services. We did our work in accordance with generally accepted government
auditing standards.

1Servicemembers include active duty members of the Army, Marines, Air
Force, and Navy, and members of the Reserves and National Guard.

2GAO, More VA and DOD Collaboration Needed to Expedite Services for
Seriously Injured Servicemembers, GAO-05-167 (Washington, D.C.: Jan. 14,
2005).

3GAO, More Information Needed to Determine if VA Can Meet an Increase in
Demand for Post-Traumatic Stress Disorder Services, GAO-04-1069
(Washington, D.C.: Sept. 20, 2004). GAO, VA Should Expedite the
Implementation of Recommendations Needed to Improve Post-Traumatic Stress
Disorder Services, GAO-05-287 (Washington, D.C.: Feb. 14, 2005).

In summary, VA is taking steps to provide services to seriously injured
servicemembers as a high priority but faces significant challenges in
doing so. Specifically, VA has taken steps to expedite VR&E services to
seriously injured servicemembers, but challenges such as the inherent
differences and uncertainties in individual recovery processes make it
difficult to determine when an individual may be receptive to services. VA
has also faced difficulties in obtaining specific data from DOD about
seriously injured servicemembers; instead, VA has had to rely on ad hoc
regional office arrangements at the local level. Because such informal
data sharing relationships could break down with changes in personnel at
either the MTF or the regional office, we recommended that VA and DOD
reach an agreement for VA to have access to information that both agencies
agree is needed to promote servicemembers' recovery and return to work.
Similarly, VA requires that every returning servicemember from the
Afghanistan and Iraq conflicts who needs health care services receive
priority consideration for VA health care appointments, including PTSD
services. VA, however, faces challenges such as developing accurate data
on current workloads and estimating potential PTSD workloads. Without this
information, VA will be unable to accurately assess its capacity to serve
those servicemembers at risk for PTSD. Based on our work, we recommended
ways for VA and DOD to address these issues.

VA offers a broad array of disability benefits and health care through its
Veterans Benefits Administration (VBA) and its Veterans Health
Administration (VHA), respectively. VBA provides benefits and services
such as disability compensation and VR&E to veterans through its 57
regional offices. The VR&E program is designed to ensure that veterans
with disabilities find meaningful work and achieve maximum independence in
daily living. VR&E services include vocational counseling, evaluation, and
training that can include payment for tuition and other expenses for
education, as well as job placement assistance.

VHA manages one of the largest health care systems in the United States
and provides PTSD services in its medical facilities, community settings,
and Vet Centers.4 VA is a world leader in PTSD treatment and offers PTSD

4Vet Centers are community-based VA facilities that offer PTSD,
readjustment, and family counseling; employment services; and a range of
social services to assist veterans in readjusting from wartime military
service to civilian life. Vet Centers also function as community points of
access for many returning veterans, providing them with information and
referrals to VA medical facilities. Vet Centers were established as
entities separate from VA medical facilities to serve Vietnam veterans.

  Background

  VA Has Taken Steps to Provide Services to Seriously Injured Servicemembers as
  a High Priority

services to veterans. PTSD can result from having experienced an extremely
stressful event such as the threat of death or serious injury, as happens
in military combat, and is the most prevalent mental disorder resulting
from combat.

Servicemembers injured in Afghanistan and Iraq are surviving injuries that
would have been fatal in past conflicts, due, in part, to advanced
protective equipment and medical treatment. However, the severity of their
injuries can result in a lengthy transition involving rehabilitation and
complex assessments of their ability to function. Many also sustain
psychological injuries. Mental health experts predict that because of the
intensity of warfare in Afghanistan and Iraq 15 percent or more of the
servicemembers returning from these conflicts will develop PTSD.5

In our January 2005 report on VA's efforts to expedite VR&E services for
seriously injured servicemembers returning from Afghanistan and Iraq, we
noted that VA instructed its VBA regional offices, in a September 2003
letter, to provide priority consideration and assistance for all VA
services, including health care, to these servicemembers. VA specifically
instructed regional offices to focus on servicemembers whose disabilities
will definitely or are likely to result in military separation. Because
most seriously injured servicemembers are initially treated at major MTFs,
VA has deployed staff to the sites where the majority of the seriously
injured are treated. These staff have included VA social workers and
disability compensation benefit counselors. VA has placed social workers
and benefit counselors at Walter Reed and Brooke Army Medical Centers and
at several other MTFs. In addition to these staff, VA has provided a
vocational rehabilitation counselor to work with hospitalized patients at
Walter Reed Army Medical Center, where the largest number of seriously
injured servicemembers has been treated.

To identify and monitor those whose injuries may result in a need for VA
disability and health services, VA has asked DOD to share data about
seriously injured servicemembers. VA has been working with DOD to develop
a formal agreement on what specific information to share. VA requested
personal identifying information, medical information, and

5Based on data under the broad definition of PTSD provided in Hoge,
Charles W., MD et al., "Combat Duty in Iraq and Afghanistan, Mental Health
Problems, and Barriers to Care," The New England Journal of Medicine, 351
(2004): 13-22.

DOD's injury classification for each listed servicemember. VA also
requested monthly lists of servicemembers being evaluated for medical
separation from military service. VA officials said that systematic
information from DOD would provide them with a way to more reliably
identify and monitor seriously injured servicemembers. As of the end of
2004, a formal agreement with DOD was still pending.

In the absence of a formal arrangement for DOD data on seriously injured
servicemembers, VA has relied on its regional offices to obtain
information about them. In its September 2003 letter, VA asked the
regional offices to coordinate with staff at MTFs and VA medical centers
in their areas to ascertain the identities, medical conditions, and
military status of the seriously injured.

In regard to psychological injuries, our September 2004 report noted that
mental health experts have recognized the importance of early
identification and treatment of PTSD. VA and DOD jointly developed a
clinical practice guideline for identifying and treating individuals with
PTSD. The guideline includes a four-question screening tool to identify
servicemembers and veterans who may be at risk for PTSD. VA uses these
questions to screen all veterans who visit VA for health care, including
those previously deployed to Afghanistan and Iraq. The screening questions
are:

Have you ever had any experience that was so frightening, horrible, or
upsetting that, in the past month, you

o 	have had any nightmares about it or thought about it when you did not
want to?

o 	tried hard not to think about it or went out of your way to avoid
situations that remind you of it?

o  were constantly on guard, watchful, or easily startled?

o  felt numb or detached from others, activities, or your surroundings?

DOD is also using these four questions in its post-deployment health
assessment questionnaire (form DD 2796) to identify servicemembers at risk
for PTSD. DOD requires the questionnaire be completed by all
servicemembers, including Reserve and National Guard members, returning
from a combat theater and is planning to conduct follow-up screenings
within 6 months after return.

  VA Faces Significant Challenges in Providing Services to the Seriously Injured

VA faces significant challenges in providing services to servicemembers
who have sustained serious physical and psychological injuries. For
example, in providing VR&E services, individual differences and
uncertainties in the recovery process make it inherently difficult to
determine when a seriously injured servicemember will be most receptive to
assistance. The nature of the recovery process is highly individualized
and depends to a large extent on the individual's medical condition and
personal readiness. Consequently, VA professionals exercise judgment to
determine when to contact the seriously injured and when to begin
services.

In our January 2005 report on VA's efforts to expedite VR&E services to
seriously injured servicemembers, we noted that many need time to recover
and adjust to the prospect that they may be unable to remain in the
military and will need to prepare instead for civilian employment. Yet we
found that VA has no policy for maintaining contact with those
servicemembers who may not apply for VR&E services prior to discharge from
the hospital. As a result, several regional offices reported that they do
not stay in contact with these individuals, while others use various ways
to maintain contact.

VA is also challenged by DOD's concern that outreach about VA benefits
could work at cross purposes to military retention goals. In our January
2005 report, we stated that DOD expressed concern about the timing of VA's
outreach to servicemembers whose discharge from military service is not
yet certain. To expedite VR&E services, VA's outreach process may overlap
with the military's process for evaluating servicemembers who may be able
to return to duty. According to DOD officials, it may be premature for VA
to begin working with injured servicemembers who may eventually return to
active duty. With advances in medicine and prosthetic devices, many
serious injuries no longer result in work-related impairments. Army
officials who track injured servicemembers told us that many seriously
injured servicemembers overcome their injuries and return to active duty.

Further, VA is challenged by the lack of access to systematic data
regarding seriously injured servicemembers. In the absence of a formal
information-sharing agreement with DOD, VA does not have systematic access
to DOD data about the population who may need its services. Specifically,
VA cannot reliably identify all seriously injured servicemembers or know
with certainty when they are medically stabilized, when they are
undergoing evaluation for a medical discharge, or when they are actually
medically discharged from the military. VA has

instead had to rely on ad hoc regional office arrangements at the local
level to identify and obtain specific data about seriously injured
servicemembers. While regional office staff generally expressed confidence
that the information sources they developed enabled them to identify most
seriously injured servicemembers, they have no official data source from
DOD with which to confirm the completeness and reliability of their data
nor can they provide reasonable assurance that some seriously injured
servicemembers have not been overlooked. In addition, informal
data-sharing relationships could break down with changes in personnel at
either the MTF or the regional office.

In our review of 12 regional offices, we found that they have developed
different information sources resulting in varying levels of information.
The nature of the local relationships between VA staff and military staff
at MTFs was a key factor in the completeness and reliability of the
information the military provided. For example, the MTF staff at one
regional office provided VA staff with only the names of new patients and
no indication of the severity of their condition or the theater from which
they were returning. Another regional office reported receiving lists of
servicemembers for whom the Army had initiated a medical separation in
addition to lists of patients with information on the severity of their
injuries. Some regional offices were able to capitalize on long-standing
informal relationships. For example, the VA coordinator responsible for
identifying and monitoring the seriously injured at one regional office
had served as an Army nurse at the local MTF and was provided all
pertinent information. In contrast, staff at another regional office
reported that local military staff did not until recently provide them
with any information on seriously injured servicemembers admitted to the
MTF.

DOD officials expressed their concerns about the type of information to be
shared and when the information would be shared. DOD noted that it needed
to comply with legal privacy rules on sharing individual patient
information. DOD officials told us that information could be made
available to VA upon separation from military service, that is, when a
servicemember enters the separation process. However, prior to separation,
information can only be provided under certain circumstances, such as when
a patient's authorization is obtained.

Based on our review of VA's efforts to expedite VR&E services to seriously
injured servicemembers, we recommended that VA and DOD collaborate to
reach an agreement for VA to have access to information that both agencies
agree is needed to promote recovery and return to work for seriously
injured servicemembers. We also recommended that VA develop

policy and procedures for regional offices to maintain contact with
seriously injured servicemembers who do not initially apply for VR&E
services. VA and DOD generally concurred with our recommendations. VA also
told us that its follow-up policies and procedures include sending
veterans information on VR&E benefits upon notification of disability
compensation award and 60 days later. However, we believe a more
individualized approach, such as maintaining personal contact, could
better ensure the opportunity for veterans to participate in the program
when they are ready.

In dealing with psychological injuries such as PTSD, VA also faces
challenges in providing services. Specifically, the inherent uncertainty
of the onset of PTSD symptoms poses a challenge because symptoms may be
delayed for years after the stressful event. Symptoms include insomnia,
intense anxiety, nightmares about the event, and difficulties coping with
work, family, and social relationships. Although there is no cure for
PTSD, experts believe that early identification and treatment of PTSD
symptoms may lessen the severity of the condition and improve the overall
quality of life for servicemembers and veterans. If left untreated it can
lead to substance abuse, severe depression, and suicide.

Another challenge VA faces in dealing with veterans with PTSD is the lack
of accurate data on its workload for PTSD. Inaccurate data limit VA's
ability to estimate its capacity for treating additional veterans and to
plan for an increased demand for these services. For example, we noted in
our September 2004 report that VA publishes two reports that include
information on veterans receiving PTSD services at its medical facilities.
However, neither report includes all the veterans receiving PTSD services.
We found that veterans may be double counted in these two reports, counted
in only one report, or omitted from both reports. Moreover, the VA Office
of Inspector General found that the data in VA's annual capacity report,
which includes information on veterans receiving PTSD services, are not
accurate. Thus, VA does not have an accurate count of the number of
veterans being treated for PTSD.

In our September 2004 report, we recommended that VA determine the total
number of veterans receiving PTSD services and provide facilityspecific
information to VA medical centers. VA concurred with our recommendation
and later provided us with information on the number of Operation Enduring
Freedom and Operation Iraqi Freedom veterans that has accessed VA services
in its medical centers, as well as its Vet Centers. However, VA
acknowledged that estimating workload demand and resource readiness
remains limited. VA stated that the provision of basic

post-deployment health data from DOD to VA would better enable VA to
provide health care to individual veterans and help VA to better
understand and plan for the health problems of servicemembers returning
from Afghanistan and Iraq. In February 2005,6 we reported on
recommendations made by VA's Special Committee on PTSD; some of the
recommendations were long-standing. We recommended that VA prioritize
implementation of those recommendations that would improve PTSD services.
VA disagreed with our recommendation and stated the report failed to
address the many efforts undertaken by the agency to improve the care
delivered to veterans with PTSD. We believe our report appropriately
raised questions about VA's capacity to meet veterans' needs for PTSD
services. We noted that, given VA's outreach efforts, expanded access to
VA health care for many new combat veterans, and the large number of
servicemembers returning from Afghanistan and Iraq who may seek PTSD
services, it is critical that VA's PTSD services be available when
servicemembers return from military combat.

VA has taken steps to help the nation's newest generation of veterans who
returned from Afghanistan and Iraq seriously injured move forward with
their lives, particularly those who return from combat with disabling
physical injuries. While physical injuries may be more apparent,
psychological injuries, although not visible, are also debilitating. VA
has made seriously injured servicemembers and veterans a priority, but
faces challenges in providing services to both the physically and
psychologically injured. For example, VA must be mindful to balance
effective outreach with an approach that could be viewed as intrusive.
Moreover, overcoming these challenges requires VA and DOD to work more
closely to identify those who need services and to share data about them
so that seriously injured servicemembers and veterans receive the care
they need.

                                   Concluding

                                  Observations

Mr. Chairman, this concludes my prepared remarks. I will be happy to
answer any questions that you or Members of the Committee might have.

6GAO-05-287.

Contact and For further information, please contact Cynthia A. Bascetta at
(202) 5127101. Also contributing to this statement were Irene Chu, Linda
Diggs,

Acknowledgments Martha A. Fisher, Lori Fritz, and Janet Overton.

Related GAO Products

VA Health Care: VA Should Expedite the Implementation of Recommendations
Needed to Improve Post-Traumatic Stress Disorder Services. GAO-05-287.
Washington, D.C.: February 14, 2005.

Vocational Rehabilitation: More VA and DOD Collaboration Needed to
Expedite Services for Seriously Injured Servicemembers. GAO-05-167.
Washington, D.C.: January 14, 2005.

VA and Defense Health Care: More Information Needed to Determine if VA Can
Meet an Increase in Demand for Post-Traumatic Stress Disorder Services.
GAO-04-1069. Washington, D.C.: September 20, 2004.

VA Vocational Rehabilitation and Employment Program: GAO Comments on Key
Task Force Findings and Recommendations. GAO-04853. Washington, D.C.: June
15, 2004.

Defense Health Care: DOD Needs to Improve Force Health Protection and
Surveillance Processes. GAO-04-158T. Washington, D.C.: October 16, 2003.

Defense Health Care: Quality Assurance Process Needed to Improve Force
Health Protection and Surveillance. GAO-03-1041. Washington, D.C.:
September 19, 2003.

VA Benefits: Fundamental Changes to VA's Disability Criteria Need Careful
Consideration. GAO-03-1172T. Washington, D.C.: September 23, 2003.

High-Risk Series: An Update. GAO-03-119. Washington, D.C.: January 1,
2003.

Major Management Challenges and Program Risks: Department of Veterans
Affairs. GAO-03-110. Washington, D.C.: January 2003.

SSA and VA Disability Programs: Re-Examination of Disability Criteria
Needed to Help Ensure Program Integrity. GAO-02-597. Washington, D.C.:
August 9, 2002.

Military and Veterans' Benefits: Observations on the Transition Assistance
Program. GAO-02-914T. Washington, D.C.: July 18, 2002.

Disabled Veterans' Care: Better Data and More Accountability Needed to
Adequately Assess Care. GAO/HEHS-00-57. Washington, D.C.: April 21, 2000.

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