Veterans' Disability Benefits: VA Could Enhance Its Progress in  
Complying with Court Decision on Disability Criteria (12-OCT-05, 
GAO-06-46).							 
                                                                 
To properly decide veterans' disability claims, the regional	 
offices of the Department of Veterans Affairs (VA) must obtain	 
all medical evidence required by law and federal regulations. To 
do so, in fiscal year 2004, the regional offices asked VA's	 
medical centers to examine about 500,000 claimants and provide	 
examination reports containing the necessary medical information.
Exams for joint and spine impairments are among the exams that	 
regional offices most frequently request, and in 2002, VA found  
that 61 percent of the exam reports for such impairments did not 
provide sufficient information for regional offices to make	 
decisions complying with disability criteria mandated by the U.S.
Court of Appeals for Veterans Claims in DeLuca v. Brown, 8 Vet.  
App. 202 (1995). In DeLuca, the court held that when federal	 
regulations define joint and spine impairment severity in terms  
of limits on range of motion, VA claims adjudicators must	 
consider whether range of motion is further limited by factors	 
such as pain and fatigue during "flare-ups" or following	 
repetitive use of the impaired joint or spine. Whenever VA	 
regional offices ask VA medical centers to conduct joint and	 
spine disability exams, the medical centers should prepare exam  
reports containing the information mandated in DeLuca. Congress  
asked that we determine VA's progress since 2002 in ensuring that
its medical centers consistently prepare joint and spine exam	 
reports containing the information required by DeLuca.		 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-06-46						        
    ACCNO:   A39357						        
  TITLE:     Veterans' Disability Benefits: VA Could Enhance Its      
Progress in Complying with Court Decision on Disability Criteria 
     DATE:   10/12/2005 
  SUBJECT:   Claims adjudicators				 
	     Claims processing					 
	     Disability benefits				 
	     Eligibility criteria				 
	     Eligibility determinations 			 
	     Medical examinations				 
	     Medical records					 
	     Performance measures				 
	     Veterans benefits					 
	     Veterans disability compensation			 
	     VA Veterans Integrated Service Network		 

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GAO-06-46

     

     * Appendix I: Briefing Section
     * Appendix II: Comments from the Department of Veterans Affairs

                 United States Government Accountability Office

Report to the Ranking Democratic

GAO

Member, Committee on Veterans' Affairs, House of Representatives

                                  October 2005

                         VETERANS' DISABILITY BENEFITS

  VA Could Enhance Its Progress in Complying with Court Decision on Disability
                                    Criteria

GAO-06-46

Contents

Letter                                                                   1 
Appendix I:      Briefing Section                                        4 
Appendix II:         Comments from the Department of Veterans Affairs   31 

This is a work of the U.S. government and is not subject to copyright
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separately.

United States Government Accountability Office Washington, DC 20548

October 12, 2005

The Honorable Lane Evans Ranking Democratic Member Committee on Veterans'
Affairs House of Representatives

Dear Mr. Evans:

To properly decide veterans' disability claims, the regional offices of
the Department of Veterans Affairs (VA) must obtain all medical evidence
required by law and federal regulations. To do so, in fiscal year 2004,
the regional offices asked VA's medical centers to examine about 500,000
claimants and provide examination reports containing the necessary medical
information. Exams for joint and spine impairments are among the exams
that regional offices most frequently request, and in 2002, VA found that
61 percent of the exam reports for such impairments did not provide
sufficient information for regional offices to make decisions complying
with disability criteria mandated by the U.S. Court of Appeals for
Veterans Claims in DeLuca v. Brown, 8 Vet. App. 202 (1995).

In DeLuca, the court held that when federal regulations define joint and
spine impairment severity in terms of limits on range of motion, VA claims
adjudicators must consider whether range of motion is further limited by
factors such as pain and fatigue during "flare-ups" or following
repetitive use of the impaired joint or spine. Whenever VA regional
offices ask VA medical centers to conduct joint and spine disability
exams, the medical centers should prepare exam reports containing the
information mandated in DeLuca. You asked that we determine VA's progress
since 2002 in ensuring that its medical centers consistently prepare joint
and spine exam reports containing the information required by DeLuca.

In conducting our research, we obtained pertinent information from and
interviewed officials of the Veterans Benefits Administration (VBA), which
manages VA's 57 regional offices; the Veterans Health Administration
(VHA), which has 21 health care networks that oversee the operations of
VA's 157 medical centers; and the Compensation and Pension Examination
Project (CPEP) Office, a national office jointly established by VHA and
VBA in 2001 to improve the disability examination process. We assessed and
determined that data from the CPEP Office's quality reviews of medical
center exam reports for the 10 most frequently requested exams were
reliable for the purposes of our work, and we attended a December 2004 VA
training conference aimed at improving the ability of medical center
clinicians to conduct and report high-quality disability examinations. In
addition, we interviewed officials of Disabled American Veterans, The
American Legion, Paralyzed Veterans of America, and National Veterans
Legal Services Program. We conducted our review from November 2004 through
September 2005 in accordance with generally accepted government auditing
standards. After discussing our initial findings on DeLuca with your
office, your office asked that we furnish briefing slides containing the
information discussed. This letter conveys the requested briefing slides.

In summary, since 2002, VA has made progress in ensuring that its medical
centers' exam reports adequately address the DeLuca criteria, but more
improvements are needed. As of May 2005, the percentage of joint and spine
exam reports not meeting the DeLuca criteria had declined substantially
from 61 percent to 22 percent. Much of this progress appears attributable
to a performance measure for exam report quality that VHA established in
fiscal year 2004. However, a 22 percent deficiency rate indicates that
many joint and spine exam reports still did not comply with DeLuca, and
moreover, the percentage of exam reports satisfying the DeLuca criteria
varied widely-from a low of 57 percent to a high of 92 percent among VHA's
21 health care networks. Further, VA's CPEP Office has found deficiencies
in a substantial portion of the requests that VBA's regional offices send
to VHA's medical centers, asking them to perform disability exams. For
example, the CPEP Office found in early 2005 that nearly one-third of the
regional office requests for spine exams contained errors such as not
identifying the pertinent medical condition or not requesting the
appropriate exam. However, VBA has not yet established a performance
measure for the quality of the exam requests that regional offices submit
to medical centers.

To help ensure continued progress in satisfying the DeLuca criteria, we
recommend that the Secretary of Veterans Affairs direct the Under
Secretary for Health to develop a strategy for improving the consistency
of VHA's networks across the nation in meeting the DeLuca criteria. We
also recommend that the Secretary direct the Under Secretary for Benefits
to develop a performance measure for the quality of the exam requests that
regional offices submit to medical centers.

In written comments on a draft of this report, VA agreed with our
conclusions and concurred with our recommendations.

As agreed with your office, unless you publicly announce its contents
earlier, we plan no further distribution of this report until 30 days
after its issue date. At that time, we will send copies of this report to
the Chairman, House Committee on Veterans' Affairs; the Chairman and
Ranking Democratic Member, Senate Committee on Veterans' Affairs; and the
Secretary of Veterans Affairs. We will also make copies available upon
request. In addition, the report will be available at no charge on GAO's
Web site at http://www.gao.gov.

If you or your staff have any questions about this report, please contact
me on (202) 512-7215 or [email protected]. Contact points for our Offices
of Congressional Relations and Public Affairs may be found on the last
page of this report. Irene Chu, Assistant Director; Ira Spears,
Analyst-In-Charge; Joseph Natalicchio; and Walter Vance also made key
contributions to this report.

Sincerely yours,

Cynthia A. Bascetta

Director, Education, Workforce, and Income Security Issues

                          Appendix I: Briefing Section

  VA Could Enhance Its Progress in Complying with Court Decision on Disability
                                    Criteria

Briefing for Staff of Representative Lane Evans Ranking Democratic Member House
                         Committee on Veterans' Affairs

     o Objective
     o Background
     o Scope and Methodology
     o Key Findings
     o Conclusions
     o Recommendations
     o In 2002, the Department of Veterans Affairs (VA) found that about 61
       percent of the joint and spine disability examination reports prepared
       by VA medical centers did not provide the information required for
       VA's joint and spine disability decisions to comply with DeLuca v.
       Brown, 8 Vet. App. 202 (1995). GAO was asked to determine the progress
       VA has made since 2002 in ensuring that joint and spine exam reports
       prepared by VA medical centers provide VA regional office claims
       adjudicators with the medical information that DeLuca requires for
       disability decisions.
     o To determine disability severity, VA claims adjudicators must use
       medical criteria published in federal regulations. For certain
       musculoskeletal disabilities, such as joint and spine impairments, the
       regulations specify range-of-motion limitations that adjudicators must
       use to determine severity.
     o However, the U.S. Court of Appeals for Veterans Claims held in DeLuca
       that, in addition to the range-of-motion limitations specified in VA's
       regulations, adjudicators also must consider any additional functional
       limitations that may occur during "flare-ups" or following "repetitive
       use" because of painful motion, weakened movement, excess fatigability
       (or lack of endurance), or incoordination.
     o Ensuring that joint and spine exam reports meet the DeLuca
       requirements is important. Otherwise, a claims adjudicator may not
       assign an appropriate severity rating for a veteran's condition.
     o Under VA's quality review standards, a joint or spine exam report
       satisfies the DeLuca "repetitive use" criteria if the exam report
       indicates the extent, if any, and the number of degrees, if possible,
       to which range of motion is additionally limited by pain, fatigue,
       weakness, or lack of endurance following repetitive use. The
       additional functional loss may be stated in terms of either degrees of
       loss of motion or the additional percentage of loss of motion.
     o Under VA's quality review standards, a joint or spine exam report
       satisfies the DeLuca "flare-up" criteria if the report either states
       the claimant does not experience any flare-ups or provides a
       description of the flare-ups.
     o The Veterans Benefits Administration (VBA) operates 57 regional
       offices whose claims adjudicators develop required evidence and decide
       disability claims.
     o The Veterans Health Administration (VHA) operates VA's 157 medical
       centers. VHA has organized these medical centers into 21 geographic
       areas known as Veterans Integrated Service Networks (VISN). Each VISN
       oversees the operations of the medical centers within its assigned
       geographic area.
     o To obtain the medical evidence required to make disability decisions,
       VBA regional offices asked VHA's medical centers to perform about
       500,000 disability examinations in fiscal year 2004.1
     o In 2001, the VA Claims Processing Task Force reported ongoing concerns
       about the quality of the VBA-VHA disability examination process.
     o In 2001, VBA and VHA jointly chartered the Compensation and Pension
       Examination Project (CPEP) Office to improve the disability
       examination process.
     o In 2002, after VA developed exam-specific quality indicators for the
       10 most frequently requested disability exams, the CPEP Office did its
       initial (baseline) review of VHA medical centers' disability
       examination reports, including joint and spine exam reports.2
     o To assess quality, the CPEP Office uses 10 exam-specific indicators to
       assess joint exam report quality and 11 indicators for spine exam
       report quality. In both cases, two of the quality indicators address
       DeLuca's repetitive use and flare-up criteria.

1Because of workload issues at certain medical centers, 10 regional
offices use the services of a contractor to obtain disability
examinations.

2The 10 exams that regional offices most frequently request are audio
(hearing), eye, feet, general medical, initial post-traumatic stress
disorder (PTSD), joints, mental disorders other than initial PTSD and
eating disorders, subsequent review of PTSD, skin (not scars), and spine.

        * We interviewed or obtained information from officials of:
             o VBA central office
             o VHA central office
             o CPEP Office, Nashville, Tenn.
             o VHA VISN offices in Duluth, Ga; and Linthicum, Md.
             o VHA medical centers in Baltimore, Md; and Birmingham, Ala.
             o VBA regional offices in Atlanta, Ga; and Baltimore, Md.
        * We also interviewed officials of:
             o Disabled American Veterans
             o The American Legion
             o Paralyzed Veterans of America
             o National Veterans Legal Services Program.
     o We attended a VA training conference for improving the ability of VHA
       clinicians to conduct and report high-quality disability examinations.
     o We assessed the CPEP Office's quality review data for the 10 most
       frequently requested exams and found these data were reliable for the
       purposes of our work.
     o We conducted our review from November 2004 through September 2005 in
       accordance with generally accepted government auditing standards.

Key Findings

     o VA has made progress since 2002 in ensuring that medical centers
       prepare joint and spine exam reports satisfying the DeLuca criteria.
       Much of this progress appears to be due to an overall performance
       measure that VHA established for exam reports for the 10 most
       frequently requested exams.
     o However, many joint and spine exam reports still do not comply with
       the DeLuca criteria, and VHA's 21 VISNs vary widely in the percentage
       of exams that satisfy the DeLuca criteria.
     o The CPEP Office has found that a substantial portion of regional
       office requests for exams are inaccurate or incomplete.
     o In its 2002 baseline review of disability exam report quality, CPEP
       found that about 61 percent of VHA's joint and spine exam reports did
       not contain the information required by DeLuca.
     o However, by May 2005, the percentage of joint and spine exam reports
       not containing the information required by DeLuca had declined
       substantially from 61 percent to 22 percent. (See table 1.)

          Table 1: VHA's Performance in Satisfying the DeLuca Criteria

                             Percentage of joint and spine exam reports
                              that did not satisfy the DeLuca criteria
Time frame of exam  Repetitive use                     Overall percentage  
reports reviewed by criteria       Flare-up criteria   of joint and spine  
          CPEP                                               reports not      
                       Joint   Spine  Joint     Spine       satisfying the    
                       exams   exams  exams     exams      DeLuca criteria    
July-September 2001                                                        
(2002 baseline                                        
study)                60      64      64        58            61.5
June-August 2004      49      52      32        26            40.0         
March-May 2005        27      27      17        17            22.0         

                                 Source: CPEP.

        * To improve disability exam report quality, including satisfying the
          DeLuca criteria, VA has done the following .
             o VHA required medical centers in 2002 to develop quality
               improvement plans for exams and exam reports for the 10 most
               requested exams, including joint and spine exams.
             o CPEP distributed musculoskeletal exam training videos and
               other resource materials in 2002 and 2004.
             o CPEP sponsored national training conferences in 2003 and 2004
               that included training on the DeLuca criteria.
             o Via satellite broadcasts, VHA conducted training on DeLuca for
               its medical centers in 2004, and VBA, for its regional offices
               in 2005.
        * VA also did the following to improve joint and spine disability
          exam report quality.
             o To focus attention on the DeLuca criteria, CPEP has published
               monthly DeLuca performance statistics for each of VHA's 21
               VISNs since October 2003.
             o VBA instructed regional offices in 2004 to send back to the
               medical centers any musculoskeletal exam reports not
               adequately addressing the DeLuca criteria.
        * In addition, CPEP and VA's Office of Information developed and
          distributed software during 2004 and 2005 that provides medical
          centers with automated templates for clinicians to use in
          conducting and reporting disability exams, including joint and
          spine exams.
             o The templates provide a guided and structured approach for
               conducting exams and entering the results at a computer
               workstation. Using the templates is optional.
             o CPEP believes the templates can help ensure that clinicians do
               not omit necessary exam information, such as for the DeLuca
               criteria.
             o CPEP is conducting a study in which medical center clinicians
               use a selected template routinely in order to gather data on
               the costs and benefits of using the templates.
     o Finally, in fiscal year 2004, VHA established a performance measure
       for the quality of exam reports for its VISN directors. This
       performance measure for exam report quality takes into account a
       VISN's combined performance on all of the 10 most frequently requested
       exams. For fiscal years 2004 and 2005, VHA defined fully successful
       performance as when 64 percent of the exam reports prepared by a
       VISN's medical centers satisfy at least 90 percent of the CPEP quality
       indicators.
     o The two VISNs we visited told us they had included this performance
       measure in the performance plans of the directors for the medical
       centers in their VISN.
     o Since VHA instituted the exam report quality performance measure, the
       combined quality of exam reports for the 10 most frequently requested
       exams has improved broadly, indicating that the performance measure
       may have been a catalyst for improvement. (See table 2.)
     o Still, it should be noted that because the performance measure applies
       to a VISN's combined performance on all 10 types of exam reports, poor
       performance on one exam type could be masked in the overall average
       performance statistic if performance on another exam type is
       sufficiently high to allow the VISN to still meet the fully successful
       definition of performance.

Table 2: Number of VISNs Meeting the Fully Successful Definition for the
Combined Exam Report Quality of the 10 Most Frequently Requested Exams

                                Number of VISNs that achieved the fully       
           Time period          successful standard                           
1st quarter-fiscal year 2004                       0                       
4th quarter-fiscal year 2004                      15                       
3rd quarter-fiscal year 2005                      21                       

                                 Source: CPEP.

     o If a joint or spine exam report fails on both of the DeLuca criteria
       (flare-ups and repetitive use), the exam report automatically fails
       the quality review-that is, it does not pass at least 90 percent of
       the exam-specific quality indicators.
     o As a result, the exam report quality performance measure provides an
       incentive for VISNs and their medical centers to focus on satisfying
       the DeLuca criteria because, to optimize the chance to be rated as
       fully successful on combined performance for all 10 of the most
       frequently requested exams, VISNs and their medical centers must pay
       attention to the quality of all 10 exam types, including the joint and
       spine exams that are subject to the DeLuca criteria.
     o As of May 2005, 22 percent of joint and spine exams still did not
       satisfy the DeLuca criteria. Also, as of May 2005, VA found a large
       degree of inconsistency in the extent that the 21 VISNs satisfied the
       DeLuca criteria. Among the 21 VISNs, the percentage of joint and spine
       exam reports satisfying the DeLuca criteria ranged from a low of 57
       percent to a high of 92 percent. (See table 3.)
     o It should be noted that within a given VISN, an individual medical
       center's performance in meeting the DeLuca criteria may be lower than
       the combined average DeLuca performance for all the medical centers in
       that VISN. Therefore, in the VISN that had 57 percent of its joint and
       spine exams meeting DeLuca criteria, an individual medical center
       within that VISN may have had less than 57 percent meeting the DeLuca
       criteria.

Table 3: Percentage of Each VISN's Joint and Spine Exams Satisfying the
DeLuca Criteria as of May 2005

                     VISN             Percentage meeting              
                    number                    DeLuca criteria         
                       1                            57                
                       2                            84                
                       3                            78                
                       4                            80                
                       5                            86                
                       6                            92                
                       7                            83                
                       8                            86                
                       9                            67                
                      10                            76                

Note: Table 3 continues on the next slide.

Source: CPEP.

Table 3: Percentage of Each VISN's Joint and Spine Exams Satisfying the
DeLuca Criteria as of May 2005, cont'd

                     VISN             Percentage meeting              
                    number                    DeLuca criteria         
                      11                            72                
                      12                            75                
                      15                            79                
                      16                            92                
                      17                            85                
                      18                            87                
                      19                            81                
                      20                            69                
                      21                            73                
                      22                            64                
                      23                            71                

Note: VA had 22 networks until January 2002, when it merged Networks 13
and 14 to form a new network, Network 23.

Source: CPEP.

        * Since early 2004, CPEP has done monthly reviews of exam requests
          that regional offices submit to medical centers, and CPEP has found
          that many requests are inaccurate or incomplete. For example, of
          the spine exams requested during the second quarter of fiscal year
          2005, 32 percent of the exam requests had at least one error such
          as:
             o not identifying the pertinent condition,
             o not requesting the appropriate exam,
             o not providing clear or useful information in the remarks
               section of the request,
             o not identifying the specific joint or part to be examined, or
             o not explaining instances in which the exam request contained
               no telephone number for the veteran who was to be examined.
     o VBA told GAO it may consider establishing a performance measure for
       the quality of exam requests after CPEP modifies its software so that
       when CPEP finds an error in an exam request, the regional office would
       be able to obtain via VA's intranet the identity of the case involved,
       study the error, and learn from the mistake.
     o In July 2005, CPEP said it would soon complete software modifications
       that will make case-specific exam request error information available
       to regional offices via VA's intranet.

Conclusions

     o Although the percentage of joint and spine exam reports that do not
       satisfy the DeLuca criteria declined substantially from 61 percent in
       2002 to 22 percent at the end of May 2005, more improvement is needed
       to further reduce the more than one-fifth of these exam reports not
       meeting the DeLuca criteria. Also, more improvement is needed to
       reduce wide variations in performance on the DeLuca criteria; among
       the 21 VISNs, the percentage of deficient exam reports ranged from a
       low of 8 percent to a high of 43 percent.
     o The ability of medical centers to provide exam reports containing the
       information that regional offices need in order to make accurate
       disability decisions is negatively affected when regional offices
       submit inaccurate or incomplete exam requests. Although CPEP has found
       that many exam requests are deficient, the lack of a performance
       measure for exam request quality means regional offices do not have
       the same incentive for improvement that medical centers have had since
       VHA instituted the performance measure for exam report quality.

Recommendations

     o To help ensure continued progress in satisfying the DeLuca criteria,
       we recommend that the Secretary of Veterans Affairs direct the Under
       Secretary for Health to develop a strategy for improving consistency
       among the VHA VISNs in meeting the DeLuca criteria. For example, if
       performance in satisfying the DeLuca criteria continues to vary widely
       among the VISNs during fiscal year 2006, VHA may want to consider
       establishing a new performance measure specifically for joint and
       spine exams. Also, if the CPEP Office's study of the costs and
       benefits of the automated exam templates supports their use, VHA could
       require that its medical centers use the automated templates for joint
       and spine exams.
     o We also recommend that the Secretary direct the Under Secretary for
       Benefits to develop a performance measure for the quality of exam
       requests that regional offices send to medical centers. This measure
       could be implemented as soon as the CPEP Office is able provide
       regional offices with case-specific exam request deficiency data via
       VA's intranet.

Appendix II: Comments from the Department of Veterans Affairs

(130483)

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