DOD and VA: Preliminary Observations on Efforts to Improve Care  
Management and Disability Evaluations for Servicemembers	 
(27-FEB-08, GAO-08-514T).					 
                                                                 
In February 2007, a series of Washington Post articles about	 
conditions at Walter Reed Army Medical Center highlighted	 
problems in the Army's case management of injured servicemembers 
and in the military's disability evaluation system. These	 
deficiencies included a confusing disability evaluation process  
and servicemembers in outpatient status for months and sometimes 
years without a clear understanding about their plan of care.	 
These reported problems prompted various reviews and commissions 
to examine the care and services to servicemembers. In response  
to problems at Walter Reed and subsequent recommendations, the	 
Army took a number of actions and DOD formed a joint DOD-VA	 
Senior Oversight Committee. This statement updates GAO's	 
September 2007 testimony and is based on ongoing work to (1)	 
assess actions taken by the Army to help ill and injured soldiers
obtain health care and navigate its disability evaluation	 
process; and to (2) describe the status, plans, and challenges of
DOD and VA efforts to implement a joint disability evaluation	 
system. GAO's observations are based largely on documents	 
obtained from and interviews with Army, DOD, and VA officials.	 
The facts contained in this statement were discussed with	 
representatives from the Army, DOD, and VA.			 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-08-514T					        
    ACCNO:   A81091						        
  TITLE:     DOD and VA: Preliminary Observations on Efforts to       
Improve Care Management and Disability Evaluations for		 
Servicemembers							 
     DATE:   02/27/2008 
  SUBJECT:   Aid for the disabled				 
	     Disability benefits				 
	     Health care facilities				 
	     Health care programs				 
	     Health care services				 
	     Health centers					 
	     Interagency relations				 
	     Military hospitals 				 
	     Military personnel 				 
	     Oversight committees				 
	     Persons with disabilities				 
	     Post-traumatic stress disorders			 
	     Program evaluation 				 
	     Program management 				 
	     Strategic planning 				 
	     Veterans benefits					 
	     Veterans disability compensation			 
	     Beneficiaries					 

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GAO-08-514T

   

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Testimony: 

Before the Subcommittee on National Security and Foreign Affairs, Committee 
on Oversight and Government Reform, House of Representatives: 

United States Government Accountability Office: 
GAO: 

For Release on Delivery: 
Expected 2:00 p.m. EST: 
Wednesday, February 27, 2008: 

DOD and VA: 

Preliminary Observations on Efforts to Improve Care Management and 
Disability Evaluations for Servicemembers: 

Statement of Daniel Bertoni, Director:
Education, Workforce, and Income Security: 

Statement of John H. Pendleton, Acting Director: Health Care: 

GAO-08-514T: 

GAO Highlights: 

Highlights of GAO-08-514T, a testimony before the Subcommittee on 
National Security and Foreign Affairs, Committee on Oversight and 
Government Reform, House of Representatives. 

Why GAO Did This Study: 

In February 2007, a series of Washington Post articles about conditions 
at Walter Reed Army Medical Center highlighted problems in the Armyï¿½s 
case management of injured servicemembers and in the militaryï¿½s 
disability evaluation system. These deficiencies included a confusing 
disability evaluation process and servicemembers in outpatient status 
for months and sometimes years without a clear understanding about 
their plan of care. These reported problems prompted various reviews 
and commissions to examine the care and services to servicemembers. In 
response to problems at Walter Reed and subsequent recommendations, the 
Army took a number of actions and DOD formed a joint DOD-VA Senior 
Oversight Committee. 

This statement updates GAOï¿½s September 2007 testimony and is based on 
ongoing work to (1) assess actions taken by the Army to help ill and 
injured soldiers obtain health care and navigate its disability 
evaluation process; and to (2) describe the status, plans, and 
challenges of DOD and VA efforts to implement a joint disability 
evaluation system. GAOï¿½s observations are based largely on documents 
obtained from and interviews with Army, DOD, and VA officials. The 
facts contained in this statement were discussed with representatives 
from the Army, DOD, and VA. 

What GAO Found: 

Over the past year, the Army significantly increased support for 
servicemembers undergoing medical treatment and disability evaluations, 
but challenges remain. To provide a more integrated continuum of care 
for servicemembers, the Army created a new organizational structureï¿½the 
Warrior Transition Unitï¿½in which servicemembers are assigned key staff 
to help manage their recovery. Although the Army has made significant 
progress in staffing these units, several challenges remain, including 
hiring medical staff in a competitive market, replacing temporarily 
borrowed personnel with permanent staff, and getting eligible 
servicemembers into the units. To help servicemembers navigate the 
disability evaluation process, the Army is increasing staff in several 
areas, but gaps and challenges remain. For example, the Army expanded 
hiring of board liaisons to meet its goal of 30 servicemembers per 
liaison, but as of February 2008, the Army did not meet this goal at 11 
locations that support about half of servicemembers in the process. The 
Army faces challenges hiring enough liaisons to meet its goals and 
enough legal personnel to help servicemembers earlier in the process. 

To address more systemic issues, DOD and VA promptly designed and are 
now piloting a streamlined disability evaluation process. In August 
2007, DOD and VA conducted an intensive 5-day exercise that simulated 
alternative pilot approaches using previously-decided cases. This 
exercise yielded data quickly, but there were trade-offs in the nature 
and extent of data that could be obtained in that time frame. The pilot 
began with ï¿½liveï¿½ cases at three treatment facilities in the 
Washington, D.C. area in November 2007, and DOD and VA may consider 
expanding the pilot to additional sites around July 2008. However, DOD 
and VA have not finalized their criteria for expanding the pilot beyond 
the original sites and may have limited pilot results at that time. 
Significantly, current evaluation plans lack key elements, such as an 
approach for measuring the performance of the pilotï¿½in terms of 
timeliness and accuracy of decisionsï¿½against the current process, which 
would help planners manage for success of further expansion. 

Figure: Major Differences between Current and Pilot Military Disability 
Evaluation Processes: 

[See PDF for image] 

Current process: 
Servicemember: 
Board liaison provides support; 
Medical Evaluation Board (MEB): Physical performed by military 
department; Physical Evaluation Board (PEB): Military department 
determines disability rating for computing DOD disability benefits. 

Current process, after separation: 
Veteran: 
Receives DOD disability benefits and develops claim for VA disability 
benefits; 
* Comprehensive physical performed to VA standards; 
* VA determines disability rating. 

Pilot process: 
Servicemember: 
Board liaison and VA staff provide support; Medical Evaluation Board 
(MEB): Comprehensive physical performed to VA standards; Physical 
Evaluation Board (PEB): VA determines disability rating sued for 
computing DOD disability benefits. 

Pilot process, after separation: 
Receives DOD disability benefits and received VA disability benefits 
shortly after leaving military. 

Source: GAO analysis of DOD documents. 

[End of figure] 

To view the full product, including the scope and methodology, click on 
[hyperlink, http://www.GAO-08-514T]. For more information, contact 
Daniel Bertoni at (202) 512-7215 or [email protected]; or John H. 
Pendleton at (202) 512-7114 or [email protected]. 

[End of section] 

Mr. Chairman and Members of the Subcommittee: 

We are pleased to be here today as you examine issues related to 
meeting the critical needs of returning wounded warriors. At present, 
over 30,000 servicemembers have been wounded in Operations Enduring 
Freedom and Iraqi Freedom.[Footnote 1] Due to improved battlefield 
medicine, those who might have died in past conflicts are now 
surviving, many with multiple serious injuries such as amputations, 
traumatic brain injury (TBI), and post-traumatic stress disorder 
(PTSD). Beyond adjusting to their injuries, returning servicemembers 
can face additional challenges within the military. In February 2007, a 
series of Washington Post articles about conditions at Walter Reed Army 
Medical Center highlighted problems in the Army's management of care 
for injured servicemembers and in the military's disability evaluation 
system. 

Since that time, various reviews and high-level commissions have 
identified substantial weaknesses in the care that servicemembers 
receive and the disability evaluation systems that they must navigate. 
For example, in March 2007, the Army Inspector General identified 
numerous issues with the Army's disability evaluation system and 
related care,[Footnote 2] including a failure to meet timeliness 
standards for determinations, inadequate training of staff, and the 
lack of standardized operations and structure to care for returning 
servicemembers. Similarly, reports from several commissions highlighted 
long delays and confusion that ill or injured servicemembers experience 
as they navigate the military disability evaluation system, and their 
distrust of a process perceived to be adversarial.[Footnote 3] The 
commissions referred to prior GAO work, including a March 2006 report 
in which GAO found that the services were not meeting Department of 
Defense (DOD) timeliness goals for processing disability cases and that 
neither DOD nor the services systematically evaluated the consistency 
of disability decisions.[Footnote 4] In October 2007, the Veterans' 
Disability Benefits Commission reported significant differences in 
disability ratings between DOD and the Department of Veterans Affairs 
(VA)--with VA often assigning higher ratings than DOD.[Footnote 5] 

In response to the deficiencies reported by the media, the Army took 
several actions including, most notably, initiating the development of 
the Army Medical Action Plan in March 2007. The plan, designed to help 
the Army become more patient-focused, includes tasks for establishing a 
continuum of care and service, automating portions of the disability 
evaluation system, and maximizing coordination of efforts with VA. 

In May 2007, DOD established the Wounded, Ill, and Injured Senior 
Oversight Committee (Senior Oversight Committee) to bring high-level 
attention to addressing the problems associated with the care and 
treatment of returning servicemembers. The committee is co-chaired by 
the Deputy Secretaries of Defense and Veterans Affairs and also 
includes the military service secretaries and other high-ranking 
officials within DOD and VA. To conduct its work, the Senior Oversight 
Committee established workgroups that have focused on specific areas 
including the disability evaluation system. In particular, under the 
direction of the Senior Oversight Committee, DOD and VA are piloting a 
joint disability evaluation system. 

In September 2007, we testified before this subcommittee on our 
preliminary observations with respect to Army, DOD, and VA efforts to 
improve health care and disability evaluations for servicemembers. 
[Footnote 6] Our testimony today provides an update on these efforts 
and focuses on our ongoing work to (1) assess actions taken by the Army 
to help ill and injured soldiers obtain health care and navigate its 
disability evaluation process, and (2) describe the status, plans, and 
challenges of DOD's and VA's efforts to implement a joint disability 
evaluation system. Our testimony is based on documents obtained from 
and interviews with Army, DOD, and VA officials. Specifically, we 
reviewed staffing data related to case management and disability 
evaluation initiatives established in the Army Medical Action Plan. We 
did not verify the accuracy of these data; however, we interviewed 
agency officials knowledgeable about the data, and we determined that 
they were sufficiently reliable for the purposes of this statement. We 
visited several Army sites--Walter Reed Army Medical Center 
(Washington, D.C.), Forts Sam Houston and Hood (Texas), Fort Lewis 
(Washington), and Forts Benning and Gordon (Georgia)--to talk with Army 
officials about efforts to improve the health care and the disability 
evaluation system for servicemembers and obtain views from 
servicemembers about how these efforts are affecting them. In addition, 
we reviewed the results of Army efforts to obtain servicemembers' 
opinions about the Warrior Transition Unit and the disability 
evaluation process. We also spoke with officials from DOD and VA to 
learn about their plans for implementing and evaluating the disability 
evaluation pilot. Our findings are preliminary. It was beyond the scope 
of our work for this statement to review the efforts underway in other 
military services. We discussed the facts contained in this statement 
with Army officials, and we incorporated their comments where 
appropriate. Our work, which began in July 2007, is being conducted in 
accordance with generally accepted government auditing standards. Those 
standards require that we plan and perform the audit to obtain 
sufficient, appropriate evidence to provide a reasonable basis for our 
findings and conclusions based on our audit objectives. We believe that 
the evidence obtained provides a reasonable basis for our findings and 
conclusions based on our audit objectives. 

In summary, the Army continues to increase support to servicemembers 
undergoing medical treatment and disability evaluations, but faces 
challenges reaching or maintaining its goals. To provide a more 
integrated continuum of care for servicemembers, the Army has developed 
a new organizational structure called Warrior Transition Units. Within 
each unit, a servicemember is assigned to a team of three key staff--a 
primary care manager, a nurse case manager, and a squad leader--who 
manage the servicemember's care. Since September 2007, the Army has 
made considerable progress in staffing this structure, increasing the 
number of staff assigned to key positions by almost 75 percent. 
However, shortfalls continue to exist in some areas--11 of the 32 U.S. 
Warrior Transition Units had less than 90 percent of needed staff for 
one or more key positions. In addition, the Army is facing other 
challenges, which include replacing borrowed staff in key positions 
with permanently assigned staff without disrupting the continuity of 
care for servicemembers and moving additional eligible servicemembers 
into the units without exacerbating existing staff shortfalls in some 
locations. Furthermore, another emerging challenge is the Army's 
ability to gather reliable and objective data on how well the units are 
meeting servicemembers' needs. 

Some servicemembers may not recover sufficiently to return to duty. To 
support servicemembers who must undergo a fitness for duty assessment 
and disability evaluation, the Army is reducing caseloads and expanding 
hiring of key staff responsible for helping servicemembers navigate the 
process. For example, for evaluation board liaisons who help 
servicemembers track the process, the Army established an average 
caseload goal of 30 servicemembers per board liaison and hired more 
board liaisons to help meet this goal. However, almost one-third of 
treatment locations--which support about half of servicemembers in the 
disability evaluation process--have not met this goal. In addition, the 
Army assigned 18 additional legal staff to support the disability 
evaluation process in June 2007; however, current staffing levels are 
still insufficient for widespread legal support early in the process. 
The Army has other efforts underway to improve servicemembers' ability 
to navigate the disability process, such as conducting standardized 
briefings about the evaluation process, but reliable data on the 
effectiveness of these and other efforts are not yet available. 

To address issues with both DOD and VA disability evaluations, 
including untimely and inconsistent decisions and servicemember 
frustration, the agencies have designed, and are piloting, a 
streamlined disability evaluation process. DOD and VA moved quickly to 
design and implement the pilot for eventual expansion to all 
servicemembers. To obtain the data for determining the pilot design and 
supporting the implementation decision, DOD and VA conducted an 
intensive 5-day exercise that simulated four alternative pilot 
approaches using previously-decided cases. While the simulation was a 
formal exercise and yielded useful information, the short time frames 
necessitated trade-offs between moving quickly and doing a more 
thorough evaluation, such as using a small number of cases instead of a 
larger number that better represented the relative workloads of the 
military services. DOD and VA began "live" implementation of the pilot-
-using actual cases--at three treatment facilities in the Washington, 
D.C. area in November 2007. DOD and VA may consider expanding the pilot 
to a few sites outside the Washington, D.C. area around July 2008, but 
have yet to finalize their criteria for expanding implementation beyond 
the original sites. Further, some key metrics, such as the timeliness 
and accuracy of final DOD and VA decisions, might lag behind expansion 
time frames and dates for reporting on pilot progress to Congress. To 
date, DOD's and VA's pilot evaluation plan lacks key elements, such as 
an approach for measuring the performance of the pilot--for example, in 
terms of timeliness, accuracy, and consistency of decisions--against 
the current process, and for surveying and measuring satisfaction of 
pilot participants. 

Background: 

DOD and VA offer health care benefits to active duty servicemembers and 
veterans, among others. Under DOD's health care system, eligible 
beneficiaries may receive care from military treatment facilities or 
from civilian providers. Military treatment facilities are individually 
managed by each of the military services--the Army, the Navy,[Footnote 
7] and the Air Force. Under VA, eligible beneficiaries may obtain care 
through VA's integrated health care system of hospitals, ambulatory 
clinics, nursing homes, residential rehabilitation treatment programs, 
and readjustment counseling centers. VA has organized its health care 
facilities into a polytrauma system of care[Footnote 8] that helps 
address the medical needs of returning servicemembers and veterans, in 
particular those who have an injury to more than one part of the body 
or organ system that results in functional disability and physical, 
cognitive, psychosocial, or psychological impairment. Persons with 
polytraumatic injuries may have injuries or conditions such as TBI, 
amputations, fractures, and burns. 

Over the past 6 years, DOD has designated over 30,000 servicemembers 
involved in Operations Iraqi Freedom and Enduring Freedom as wounded in 
action. Servicemembers injured in these conflicts are surviving 
injuries that would have been fatal in past conflicts, due, in part, to 
advanced protective equipment and medical treatment. The severity of 
their injuries can result in a lengthy transition from patient back to 
duty, or to veteran status. Initially, most seriously injured 
servicemembers from these conflicts, including activated National Guard 
and Reserve members, are evacuated to Landstuhl Regional Medical Center 
in Germany for treatment. From there, they are usually transported to 
military treatment facilities in the United States, with most of the 
seriously injured admitted to Walter Reed Army Medical Center or the 
National Naval Medical Center. According to DOD officials, once they 
are stabilized and discharged from the hospital, servicemembers may 
relocate closer to their homes or military bases and are treated as 
outpatients by the closest military or VA facility. 

As part of the Army's Medical Action Plan, the Army has developed a new 
organizational structure--Warrior Transition Units--for providing an 
integrated continuum of care for servicemembers who generally require 
at least 6 months of treatment, among other factors. Within each unit, 
the servicemember is assigned to a team of three key staff and this 
team is responsible for overseeing the continuum of care for the 
servicemember.[Footnote 9] The Army refers to this team as a "Triad," 
which consists of a (1) primary care manager--usually a physician who 
provides primary oversight and continuity of health care and ensures 
the quality of the servicemember's care; (2) nurse case manager-- 
usually a registered nurse who plans, implements, coordinates, 
monitors, and evaluates options and services to meet the 
servicemember's needs; and (3) squad leader--a noncommissioned officer 
who links the servicemember to the chain of command, builds a 
relationship with the servicemember, and works along side the other 
parts of the Triad to ensure the needs of the servicemember and his or 
her family are met. The Army established 32 Warrior Transition Units, 
to provide a unit in every medical treatment facility that has 35 or 
more eligible servicemembers.[Footnote 10] The Army's goal is to fill 
the Triad positions according to the following ratios: 1:200 for 
primary care managers; 1:18 for nurse case managers at Army medical 
centers that normally see servicemembers with more acute conditions and 
1:36 for other types of Army medical treatment facilities; and 1:12 for 
squad leaders. 

Returning injured servicemembers must potentially navigate two 
different disability evaluation systems that generally rely on the same 
criteria but for different purposes. DOD's system serves a personnel 
management purpose by identifying servicemembers who are no longer 
medically fit for duty. The military's process starts with 
identification of a medical condition that could render the 
servicemember unfit for duty, a process that could take months to 
complete. The servicemember is evaluated by a medical evaluation board 
(MEB) to identify any medical conditions that may render the 
servicemember unfit. The member is then evaluated by a physical 
evaluation board (PEB) to make a determination of fitness or unfitness 
for duty. If found unfit, and the unfit conditions were incurred in the 
line of duty, the PEB assigns the servicemember a combined percentage 
rating for those unfit conditions using VA's rating system as a 
guideline, and the servicemember is discharged from duty. This 
disability rating, along with years of service and other factors, 
determines subsequent disability and health care benefits from 
DOD.[Footnote 11] For servicemembers meeting the minimum rating and 
years of duty thresholds, monthly disability retirement payments are 
provided; for those not meeting these thresholds, a lump-sum severance 
payment is provided. 

As servicemembers in the Army navigate DOD's disability evaluation 
system, they interface with staff who play a key role in supporting 
them through the process. MEB physicians play a fundamental role as 
they are responsible for documenting the medical conditions of 
servicemembers for the disability evaluation case file. In addition, 
MEB physicians may require that servicemembers obtain additional 
medical evidence from specialty physicians such as a psychiatrist. 
Throughout the MEB and PEB process, a physical evaluation board liaison 
officer serves a key role by explaining the process to servicemembers, 
and ensuring that the servicemembers' case files are complete before 
they are forwarded for adjudication. The board liaison officer informs 
servicemembers of board results and of deadlines at key decision points 
in the process. The military also provides legal counsel to 
servicemembers in the disability evaluation process. The Army, for 
example, provides them with legal representation at formal board 
hearings. The Army will provide military counsel, or servicemembers may 
retain their own representative at their own expense. 

In addition to receiving benefits from DOD, veterans may receive 
compensation from VA for lost earning capacity due to service-connected 
disabilities. Although a servicemember may file a VA claim while still 
in the military, he or she can only obtain disability compensation from 
VA as a veteran. VA will evaluate all claimed conditions, whether they 
were evaluated previously by the military service's evaluation process 
or not. If the VA finds that a veteran has one or more service- 
connected disabilities with a combined rating of at least 10 
percent,[Footnote 12] VA will pay monthly compensation. The veteran can 
claim additional benefits over time, for example, if a service- 
connected disability worsens. 

To improve the timeliness and resource utilization of DOD's and VA's 
separate disability evaluation systems, the agencies embarked on a 
planning effort of a joint disability evaluation system that would 
enable servicemembers to receive VA disability benefits shortly after 
leaving the military without going through both DOD's and VA's 
processes. A key part of this planning effort included a "table top" 
exercise whereby the planners simulated the outcomes of cases using 
four potential options that incorporated variations of following three 
elements: (1) a single, comprehensive medical examination to be used by 
both DOD and VA in their disability evaluations; (2) a single 
disability rating performed by VA; and (3) incorporating a DOD-level 
evaluation board for adjudicating servicemembers' fitness for duty. 
Based on the results of this exercise, DOD and VA implemented the 
selected pilot design using live cases at three Washington, D.C.-area 
military treatment facilities including Walter Reed Army Medical Center 
in November 2007.[Footnote 13] Key features of the pilot include (see 
fig. 1): 

* a single physical examination conducted to VA standards as part of 
the medical evaluation board;[Footnote 14] 

* disability ratings prepared by VA, for use by both DOD and VA in 
determining disability benefits; and: 

* additional outreach and non-clinical case management provided by VA 
staff at the DOD pilot locations to explain VA results and processes to 
servicemembers. 

Figure 1: Major Differences between Current and Pilot Military 
Disability Evaluation Processes: 

[See PDF for image] 

Current process: 
Servicemember: 
Board liaison provides support; 
Medical Evaluation Board (MEB): Physical performed by military 
department; Physical Evaluation Board (PEB): Military department 
determines disability rating for computing DOD disability benefits. 

Current process, after separation: 
Veteran: 
Receives DOD disability benefits and develops claim for VA disability 
benefits; 
* Comprehensive physical performed to VA standards; 
* VA determines disability rating. 

Pilot process: 
Servicemember: 
Board liaison and VA staff provide support; Medical Evaluation Board 
(MEB): Comprehensive physical performed to VA standards; Physical 
Evaluation Board (PEB): VA determines disability rating sued for 
computing DOD disability benefits. 

Pilot process, after separation: 
Receives DOD disability benefits and received VA disability benefits 
shortly after leaving military. 

Source: GAO analysis of DOD documents. 

[End of figure] 

The Army Continues to Increase Support to Servicemembers Undergoing 
Medical Treatment and Disability Evaluation, but Faces Challenges 
Reaching Stated Goals: 

The Army has made strides increasing key staff positions in support of 
servicemembers undergoing medical treatment as well as disability 
evaluation, but faces a number of challenges to achieving or 
maintaining stated goals. Although the Army has made significant 
progress in staffing its Warrior Transition Units, several challenges 
remain, including hiring medical staff in a competitive market, 
replacing temporarily borrowed personnel with permanent staff, and 
getting eligible servicemembers into the units. With respect to 
supporting servicemembers as they navigate the disability evaluation 
process, the Army has reduced caseloads of key support staff, but has 
not yet reached its goals and faces challenges with both hiring and 
meeting current demands of servicemembers in the process. 

Army Has Made Considerable Progress in Staffing Its Warrior Transition 
Units, but Faces Shortfalls and Other Challenges: 

Since September 2007, the Army has made considerable progress in 
staffing its Warrior Transition Units, increasing the number of staff 
assigned to Triad positions by almost 75 percent. As of February 6, 
2008, the Army had about 2,300 personnel staffing its Warrior 
Transition Units. In February 2008, the Army reported that its Warrior 
Transition Units had achieved "full operational capability," which was 
the goal established in the Army's Medical Action Plan. The Warrior 
Transition Units reported that they had met this goal even though some 
units had staffing shortages or faced other challenges.[Footnote 15] 

Although encouraging, the Army is facing several challenges in fully 
staffing the Warrior Transition Units and ensuring all eligible 
servicemembers can benefit from the care provided in these units. For 
example, the Army established a goal of having at least 90 percent of 
Triad staff positions filled to meet the staff-to-servicemember ratios 
that the Army had established for its Warrior Transition 
Units.[Footnote 16] As of February 6, 2008, the Army had surpassed this 
goal for 21 of the 32 units. However, the remaining 11 Warrior 
Transition Units had less than 90 percent of needed staff for one or 
more Triad positions--representing a total shortfall of 10 primary care 
managers, 44 nurse case managers, and 10 squad leaders. (See table 1.) 
Although most of these locations were missing only 1 or 2 staff, a few 
locations had more significant shortfalls. For example, Fort Hood 
needed almost 30 nurse case managers to meet the Army's 90 percent 
goal. Army officials cited challenges in staffing Triad positions, 
including difficulties in hiring physicians and other medical personnel 
at certain locations because salary levels do not provide the necessary 
incentives in a competitive market: 

Table 1: Locations Where Warrior Transition Units Had Less Than 90 
Percent of Staff in Place in One or More Triad Positions, as of 
February 6, 2008. 

Location (size of Warrior Transition Unit population): Fort Hood, Texas 
(957); 
Additional Triad staff needed[A]: Primary care managers: 2; 
Additional Triad staff needed[A]: Nurse case managers: 28; 
Additional Triad staff needed[A]: Squad leaders: 2. 

Location (size of Warrior Transition Unit population): Walter Reed Army 
Medical Center, Washington, D.C. (674); 
Additional Triad staff needed[A]: Primary care managers: 1; 
Additional Triad staff needed[A]: Nurse case managers: [Empty]; 
Additional Triad staff needed[A]: Squad leaders: [Empty]. 

Location (size of Warrior Transition Unit population): Fort Lewis, 
Washington (613); 
Additional Triad staff needed[A]: Primary care managers: 3; 
Additional Triad staff needed[A]: Nurse case managers: 10; 
Additional Triad staff needed[A]: Squad leaders: [Empty]. 

Location (size of Warrior Transition Unit population): Fort Campbell, 
Kentucky (596); 
Additional Triad staff needed[A]: Primary care managers: 1; 
Additional Triad staff needed[A]: Nurse case managers: 1; 
Additional Triad staff needed[A]: Squad leaders: [Empty]. 

Location (size of Warrior Transition Unit population): Fort Drum, New 
York (395); 
Additional Triad staff needed[A]: Primary care managers: 1; 
Additional Triad staff needed[A]: Nurse case managers: 1; 
Additional Triad staff needed[A]: Squad leaders: 5. 

Location (size of Warrior Transition Unit population): Fort Polk, 
Louisiana (248); 
Additional Triad staff needed[A]: Primary care managers: 1; 
Additional Triad staff needed[A]: Nurse case managers: [Empty]; 
Additional Triad staff needed[A]: Squad leaders: [Empty]. 

Location (size of Warrior Transition Unit population): Fort Knox, 
Kentucky (243); 
Additional Triad staff needed[A]: Primary care managers: 1; 
Additional Triad staff needed[A]: Nurse case managers: [Empty]; 
Additional Triad staff needed[A]: Squad leaders: [Empty]. 

Location (size of Warrior Transition Unit population): Fort Irwin & 
Balboa, California (89); 
Additional Triad staff needed[A]: Primary care managers: [Empty]; 
Additional Triad staff needed[A]: Nurse case managers: 2; 
Additional Triad staff needed[A]: Squad leaders: 1. 

Location (size of Warrior Transition Unit population): Fort Belvoir, 
Virginia (43); 
Additional Triad staff needed[A]: Primary care managers: [Empty]; 
Additional Triad staff needed[A]: Nurse case managers: 1; 
Additional Triad staff needed[A]: Squad leaders: 1. 

Location (size of Warrior Transition Unit population): Fort Huachuca, 
Arizona (41); 
Additional Triad staff needed[A]: Primary care managers: [Empty]; 
Additional Triad staff needed[A]: Nurse case managers: 1; 
Additional Triad staff needed[A]: Squad leaders: [Empty]. 

Location (size of Warrior Transition Unit population): Redstone 
Arsenal, Alabama (17); 
Additional Triad staff needed[A]: Primary care managers: [Empty]; 
Additional Triad staff needed[A]: Nurse case managers: [Empty]; 
Additional Triad staff needed[A]: Squad leaders: 1. 

Total Staff Needed: 
Additional Triad staff needed[A]: Primary care managers: 10; 
Additional Triad staff needed[A]: Nurse case managers: 44; 
Additional Triad staff needed[A]: Squad leaders: 10. 

Source: GAO analysis of Army data. 

Note: The staffing needed is based on the number of servicemembers in 
each Warrior Transition Unit, as of February 6, 2008. 

[A] The number of additional staff needed to achieve the Army's goal of 
filling 90 percent of Triad positions at each location. 

[End of table] 

The Army is confronting other challenges, as well, including replacing 
borrowed staff in Triad positions with permanently assigned staff 
without disrupting the continuity of care for servicemembers. We 
previously reported in September 2007 that many units were relying on 
borrowed staff to fill positions--about 20 percent overall. This 
practice has continued; in February 2008, about 20 percent of Warrior 
Transition Unit staff continued to be borrowed from other 
positions.[Footnote 17] Army officials told us that using borrowed 
staff was necessary to get the Warrior Transition Units implemented 
quickly and has been essential in staffing units that have experienced 
sudden increases in servicemembers needing care. Army officials told us 
that using borrowed staff is a temporary solution for staffing the 
units, and these staff will be transitioned out of the positions when 
permanent staff are available. Replacing the temporary staff will 
result in turnover among Warrior Transition Unit staff, which can 
disrupt the continuity of care provided to servicemembers. 

Another lingering challenge facing the Army is getting eligible 
servicemembers into the Warrior Transition Units. In developing its 
approach, the Army envisioned that servicemembers meeting specific 
criteria, such as requiring more than 6 months of treatment or having a 
condition that requires going through the Medical Evaluation Board 
process, would be assigned to the Warrior Transition Units. Since 
September 2007, the Warrior Transition Unit population has increased by 
about 80 percent--from about 4,350 to about 7,900 servicemembers. 
However, although the percentage of eligible servicemembers going 
through the Medical Evaluation Board process who were not in a Warrior 
Transition Unit has been cut almost in half since September 2007, more 
than 2,500 eligible servicemembers were not in units, as of February 6, 
2008. About 1,700 of these servicemembers (about 70 percent) are 
concentrated in ten locations. (See table 2.) 

Table 2: Locations with 100 or More Eligible Servicemembers Not in a 
Warrior Transition Unit, as of February 6, 2008: 

Location: Fort Hood, Texas; 
Total number of servicemembers eligible for a Warrior Transition Unit: 
1,331; 
Number of eligible servicemembers not in a Warrior Transition Unit: 
374; 
Percentage of total eligible servicemembers not in a Warrior Transition 
Unit: 28. 

Location: Fort Carson, Colorado; 
Total number of servicemembers eligible for a Warrior Transition Unit: 
603; 
Number of eligible servicemembers not in a Warrior Transition Unit: 
240; 
Percentage of total eligible servicemembers not in a Warrior Transition 
Unit: 40. 

Location: Fort Bragg, North Carolina; 
Total number of servicemembers eligible for a Warrior Transition Unit: 
666; 
Number of eligible servicemembers not in a Warrior Transition Unit: 
199; 
Percentage of total eligible servicemembers not in a Warrior Transition 
Unit: 30. 

Location: Fort Gordon, Georgia; 
Total number of servicemembers eligible for a Warrior Transition Unit: 
437; 
Number of eligible servicemembers not in a Warrior Transition Unit: 
183; 
Percentage of total eligible servicemembers not in a Warrior Transition 
Unit: 42. 

Location: Fort Lewis, Washington; 
Total number of servicemembers eligible for a Warrior Transition Unit: 
783; 
Number of eligible servicemembers not in a Warrior Transition Unit: 
170; 
Percentage of total eligible servicemembers not in a Warrior Transition 
Unit: 22. 

Location: Fort Knox, Kentucky; 
Total number of servicemembers eligible for a Warrior Transition Unit: 
359; 
Number of eligible servicemembers not in a Warrior Transition Unit: 
116; 
Percentage of total eligible servicemembers not in a Warrior Transition 
Unit: 32. 

Location: Fort Campbell, Kentucky; 
Total number of servicemembers eligible for a Warrior Transition Unit: 
711; 
Number of eligible servicemembers not in a Warrior Transition Unit: 
115; 
Percentage of total eligible servicemembers not in a Warrior Transition 
Unit: 16. 

Location: Fort Drum, New York; 
Total number of servicemembers eligible for a Warrior Transition Unit: 
500; 
Number of eligible servicemembers not in a Warrior Transition Unit: 
105; 
Percentage of total eligible servicemembers not in a Warrior Transition 
Unit: 21. 

Location: West Point, New York; 
Total number of servicemembers eligible for a Warrior Transition Unit: 
164; 
Number of eligible servicemembers not in a Warrior Transition Unit: 
105; 
Percentage of total eligible servicemembers not in a Warrior Transition 
Unit: 64. 

Location: Tripler Army Medical Center, Hawaii; Total number of 
servicemembers eligible for a Warrior Transition Unit: 283; Number of 
eligible servicemembers not in a Warrior Transition Unit: 101; 
Percentage of total eligible servicemembers not in a Warrior Transition 
Unit: 36. 

Location: Total; 
Total number of servicemembers eligible for a Warrior Transition Unit: 
5,837; 
Number of eligible servicemembers not in a Warrior Transition Unit: 
1,708; 
Percentage of total eligible servicemembers not in a Warrior Transition 
Unit: 29. 

Source: GAO analysis of Army data. 

[End of table] 

Warrior Transition Unit commanders conduct risk assessments of eligible 
servicemembers to determine if their care can be appropriately managed 
outside of the Warrior Transition Unit. These assessments are to be 
conducted within 30 days of determining that the servicemember meets 
eligibility criteria. For example, a servicemember's knee injury may 
require a Medical Evaluation Board review--a criterion for being placed 
in a Warrior Transition Unit--but the person's unit commander can 
determine that the person can perform a desk job while undergoing the 
medical evaluation process. According to Army guidance, servicemembers 
eligible for the Warrior Transition Unit will generally be moved into 
the units, that it will be the exception, not the rule, for a 
servicemember to not be transferred to a Warrior Transition Unit. Army 
officials told us that the population of 2,500 servicemembers who had 
not been moved into a Warrior Transition Unit consisted of both 
servicemembers who had just recently been identified as eligible for a 
unit but had not yet been evaluated and servicemembers whose risk 
assessment determined that their care could be managed outside of a 
unit. Officials told us that servicemembers who needed their care 
managed more intensively through Warrior Transition Units had been 
identified through the risk assessment process and had been moved into 
such units. As eligible personnel are brought into the Warrior 
Transition Units, however, it could exacerbate staffing shortfalls in 
some units. To minimize future staffing shortfalls, Army officials told 
us that they are identifying areas where they anticipate future 
increases in the number of servicemembers needing care in a Warrior 
Transition Unit and would use this information to determine appropriate 
future staffing needs of the units. 

Another emerging challenge is gathering reliable and objective data to 
measure progress. A central goal of the Army's efforts is to make the 
system more servicemember-and family-focused and the Army has initiated 
efforts to determine how well the units are meeting servicemembers' 
needs. To its credit, the Army has developed a wide range of methods to 
monitor its units, among them a program to place independent ombudsmen 
throughout the system as well as town hall meetings and a telephone 
hotline for servicemembers to convey concerns about the Warrior 
Transition Units. Additionally, through its Warrior Transition Program 
Satisfaction Survey, the Army has been gathering and analyzing 
information on servicemembers' opinions about their nurse case manager 
and the overall Warrior Transition Unit. However, initial response 
rates have been low, which has limited the Army's ability to reliably 
assess satisfaction. In February 2008, the Army started following up 
with nonrespondents, and officials told us that these efforts have 
begun to improve response rates. To obtain feedback from a larger 
percentage of servicemembers in the Warrior Transition Units, the Army 
administered another satisfaction survey in January 2008. This survey, 
which also solicited servicemembers' opinions about components of the 
Triad and overall satisfaction with the Warrior Transition Units, 
garnered a more than 90 percent response rate from the population 
surveyed.[Footnote 18] While responses to the survey were largely 
positive, the survey is limited in its ability to accurately gauge the 
Army's progress in improving servicemember satisfaction with the 
Warrior Transition Unit, because it was not intended to be a 
methodologically rigorous evaluation. For example, the units were not 
given specific instructions on how to administer the survey, and as a 
result, it is not clear the extent to which servicemembers were 
provided anonymity in responding to the survey. Units were instructed 
to reach as many servicemembers as possible within a 24-hour period in 
order to provide the Army with immediate feedback on servicemembers' 
overall impressions of the care they were receiving. 

Despite Hiring Efforts, Army Faces Challenges Providing Sufficient 
Staff to Help Servicemembers Navigate the Disability Evaluation 
Process: 

Injured and ill servicemembers who must undergo a fitness for duty 
assessment and disability evaluation rely on the expertise and support 
of several key staff--board liaisons, legal personnel, and board 
physicians--to help them navigate the process. Board liaisons explain 
the disability process to servicemembers and are responsible for 
ensuring that their disability case files are complete. Legal staff and 
medical evaluation board physicians can substantially influence the 
outcome of servicemembers' disability evaluations because legal 
personnel provide important counsel to servicemembers during the 
disability evaluation process, and evaluation board physicians evaluate 
and document servicemembers' medical conditions for the disability 
evaluation case file.[Footnote 19] 

With respect to board liaisons, the Army has expanded hiring efforts 
and met its goals for reducing caseloads at most treatment facilities, 
but not at some of the facilities with the most servicemembers in the 
process. In August 2007, the Army established an average caseload 
target of 30 servicemembers per board liaison. As of February 2008, the 
Army had expanded the number of board liaisons by about 22 percent. 
According to the Army, average caseloads per liaison have declined from 
54 servicemembers at the end of June 2007 to 46 at the end of December 
2007. However, 11 of 35 treatment facilities continue to have shortages 
of board liaisons and about half of all servicemembers in the 
disability evaluation process are located at these 11 treatment 
facilities. (See fig. 2.) Due to their caseloads, liaisons we spoke 
with at one location had difficulty making appointments with 
servicemembers, which has challenged their ability to provide timely 
and comprehensive support. 

Figure 2: Average Number of Servicemembers per Board Liaison at 
Treatment Facilities, February 6, 2008: 

[See PDF for image] 

This figure contains both a pie-chart and a vertical bar graph. The pie-
chart depicts the following data: 

Percentage of servicemembers represented by facilities that are meeting 
and not meeting the Army's goal: 
11 facilities not meeting Army's goal: 52%; 
24 facilities meeting Army's goal: 48%. 

The bar graph depicts the average number of service members per board 
liaison at various treatment facilities. The Army's goal is to have 30 
servicemembers per board liaison. The following approximated data is 
depicted in the graph: 

Treatment facility: Fort Wainwright, Alaska; 
Average number of service members per board liaison: 80. 

Treatment facility: Bavaria, Germany; 
Average number of service members per board liaison: 78. 
Treatment facility: Fort Hood, Texas; 
Average number of service members per board liaison: 74. 

Treatment facility: Fort Jackson, South Carolina; 
Average number of service members per board liaison: 46. 

Treatment facility: Fort Leonard Wood, Missouri; 
Average number of service members per board liaison: 42. 

Treatment facility: Fort Gordon, Georgia; 
Average number of service members per board liaison: 41. 

Treatment facility: Fort Drum, New York; 
Average number of service members per board liaison: 34. 

Treatment facility: Landstuhl, Germany; 
Average number of service members per board liaison: 33; 

Treatment facility: Fort Polk, Louisiana; 
Average number of service members per board liaison: 33. 

Treatment facility: Fort Campbell, Kentucky; 
Average number of service members per board liaison: 32. 

Treatment facility: Fort Lewis, Washington; 
Average number of service members per board liaison: 29. 

Treatment facility: Fort Bragg, North Carolina; 
Average number of service members per board liaison: 28. 

Treatment facility: Fort Richardson, Alaska; 
Average number of service members per board liaison: 27. 

Treatment facility: Fort Irwin and Balboa, California; 
Average number of service members per board liaison: 27. 

Treatment facility: Fort Huachuca, Arizona; 
Average number of service members per board liaison: 26. 

Treatment facility: Fort Sam Houston, Texas; 
Average number of service members per board liaison: 25. 

Treatment facility: Fort Eustis, Virginia; 
Average number of service members per board liaison: 23. 

Treatment facility: Tripler, Hawaii; 
Average number of service members per board liaison: 20. 

Treatment facility: Fort Sill, Oklahoma; 
Average number of service members per board liaison: 17; 

Treatment facility: Fort Belvoir; Virginia; 
Average number of service members per board liaison: 17. 

Treatment facility: Fort Benning, Georgia; 
Average number of service members per board liaison: 16. 

Treatment facility: Fort Stewart, Georgia; 
Average number of service members per board liaison: 16. 

Treatment facility: Fort Know, Kentucky; 
Average number of service members per board liaison: 16. 

Treatment facility: Fort Bliss, Texas; 
Average number of service members per board liaison: 16. 

Treatment facility: West Point, New York; 
Average number of service members per board liaison: 15. 

Treatment facility: Fort Lee, Virginia; 
Average number of service members per board liaison: 15. 

Treatment facility: Heidelberg, Germany; 
Average number of service members per board liaison: 12. 

Treatment facility: Walter Reed, Washington, DC; 
Average number of service members per board liaison: 10. 

Treatment facility: Fort Meade, Maryland; 
Average number of service members per board liaison: 7. 

Treatment facility: Fort Rucker, Alabama; 
Average number of service members per board liaison: 7. 

Treatment facility: Fort Leavenworth, Kansas; 
Average number of service members per board liaison: 5. 

Treatment facility: Fort Dix, New Jersey; 
Average number of service members per board liaison: 3. 

Treatment facility: Redstone Arsenal, Alabama; 
Average number of service members per board liaison: 3. 

Source: GAO analysis based on Army data. 

[End of figure] 

The Army plans to hire additional board liaisons, but faces challenges 
in keeping up with increased demand. According to an Army official 
responsible for staff planning, the Army reviews the number of liaisons 
at each treatment facility weekly and reviews Army policy for the 
target number of servicemembers per liaison every 90 days. The official 
also identified several challenges in keeping up with increased demand 
for board liaisons, including the increase in the number of injured and 
ill servicemembers in the medical evaluation board process overall, and 
the difficulty of attracting and retaining liaisons at some locations. 
According to Army data, the total number of servicemembers completing 
the medical evaluation board process increased about 19 percent from 
the end of 2006 to the end of 2007. 

In addition to gaps in board liaisons, according to Army documents, 
staffing of dedicated legal personnel who provide counsel to injured 
and ill servicemembers throughout the disability evaluation processes 
is currently insufficient. Ideally, according to the Army, 
servicemembers should receive legal assistance during both the medical 
and physical evaluation board processes. While servicemembers may seek 
legal assistance at any time, the Office of the Judge Advocate 
General's policy is to assign dedicated legal staff to servicemembers 
when their case goes before a formal physical evaluation board. In June 
2007, the Army assigned 18 additional legal staff--12 Reserve attorneys 
and 6 Reserve paralegals--to help meet increasing demands for legal 
support throughout the process. As of January 2008, the Army had 27 
legal personnel--20 attorneys and 7 paralegals--located at 5 of 35 Army 
treatment facilities who were dedicated to supporting servicemembers 
primarily with the physical evaluation board process.[Footnote 20] 
However, the Office of the Judge Advocate General has acknowledged that 
these current levels are insufficient for providing support during the 
medical evaluation board process, and proposed hiring an additional 57 
attorneys and paralegals to provide legal support to servicemembers 
during the medical evaluation board process. The proposed 57 attorneys 
and paralegals include 19 active-duty military attorneys, 19 civilian 
attorneys, and 19 civilian paralegals. On February 21, 2008, Army 
officials told us that 30 civilian positions were approved, consisting 
of 15 attorneys and 15 paralegals. 

While the Army has plans to address gaps in legal support for 
servicemembers, challenges with hiring and staff turnover could limit 
their efforts. According to Army officials, even if the plan to hire 
additional personnel is approved soon, hiring of civilian attorneys and 
paralegals may be slow due to the time it takes to hire qualified 
individuals under government policies. Additionally, 19 of the 57 Army 
attorneys who would be staffed under the plan would likely only serve 
in their positions for a period of 12 to 18 months.[Footnote 21] 
According to a Disabled American Veterans representative with extensive 
experience counseling servicemembers during the evaluation process, 
frequent rotations and turnover of Army attorneys working on disability 
cases limits their effectiveness in representing servicemembers due to 
the complexity of disability evaluation regulations. 

With respect to medical evaluation board physicians, who are 
responsible for documenting servicemembers medical conditions, the Army 
has mostly met its goal for the average number of servicemembers per 
physician at each treatment facility. In August 2007, the Army 
established a goal of one medical evaluation board physician for every 
200 servicemembers.[Footnote 22] As with the staffing ratio for board 
liaisons, the ratio for physicians is reviewed every 90 days by the 
Army and the ratio at each treatment facility is reviewed weekly, 
according to an Army official. As of February 2008, the Army had met 
the goal of 200 servicemembers per physician at 29 of 35 treatment 
facilities and almost met the goal at two others.[Footnote 23] 

Despite having mostly met its goal for medical evaluation board 
physicians, according to Army officials, the Army continues to face 
challenges in this area. For example, according to an Army official, 
physicians are having difficulty managing their caseload even at 
locations where they have met or are close to the Army's goal of 1 
physician for 200 servicemembers due not only to the volume of cases 
but also their complexity. According to Army officials, disability 
cases often involve multiple conditions and may include complex 
conditions such as TBI and PTSD. Some Army physicians told us that the 
ratio of servicemembers per physician allows little buffer when there 
is a surge in caseloads at a treatment facility. For this reason, some 
physicians told us that the Army could provide better service to 
servicemembers if the number of servicemembers per physician was 
reduced from 200 to 100 or 150. 

In addition to increasing the number of staff who support this process, 
the Army has reported other progress and efforts underway that could 
further ease the disability evaluation process. For example, the Army 
has reported improving outreach to servicemembers by establishing and 
conducting standardized briefings about the process. The Army has also 
improved guidance to servicemembers by developing and issuing a 
handbook on the disability evaluation process, and creating a web site 
for each servicemember to track his or her progress through the medical 
evaluation board. Finally, the Army told us that efforts are underway 
to further streamline the process for servicemembers and improve 
supporting information technology. For example, the Army established a 
goal to eliminate 50 percent of the forms required by the current 
process. While we are still assessing the scope, status, and potential 
impact of these efforts, a few questions have been raised about some of 
them. For example, according to Army officials, servicemembers' usage 
of the medical evaluation board web site has been low. In addition, 
some servicemembers with whom we spoke believe the information 
presented on the web site was not helpful in meeting their needs. 

One measure of how well the disability evaluation system is working 
does not indicate that improvements have occurred. The Army collects 
data and regularly reports on the timeliness of the medical evaluation 
board process. While we have previously reported that the Army has few 
internal controls to ensure that these data were complete and accurate, 
the Army recently told us that they are taking steps to improve the 
reliability of these data.[Footnote 24] We have not yet substantiated 
these assertions. Assuming current data are reliable, the Army has 
reported not meeting a key target for medical evaluation board 
timeliness and has even reported a negative trend in the last year. 
Specifically, the Army's target is for 80 percent of the medical 
evaluation board cases to be completed in 90 days or less, but the 
percent that met the standard declined from 70 percent in October 
through December 2006, to 63 percent in October through December 2007. 

Another potential indicator of how well the disability evaluation 
process is working is under development. Since June 2007, the Army has 
used the Warrior Transition Program Satisfaction Survey to ask 
servicemembers about their experience with the disability evaluation 
process and board liaisons. However, according to Army officials in 
charge of the survey, response rates to survey questions related to the 
disability process were particularly low because most surveyed 
servicemembers had not yet begun the disability evaluation process. The 
Army is in the process of developing satisfaction surveys that are 
separate from the Warrior Transition Unit survey to gauge 
servicemembers' perceptions of the medical and physical evaluation 
board processes. 

DOD-VA Joint Disability Evaluation Process Pilot Geared Toward Quick 
Implementation, but Pilot Evaluation Plans Lack Key Elements: 

DOD and VA have joined together to quickly pilot a streamlined 
disability evaluation process, but evaluation plans currently lack key 
elements. In August 2007, DOD and VA conducted an intensive 5-day 
"table top" exercise to evaluate the relative merits of four potential 
pilot alternatives. Though the exercise yielded data quickly, there 
were trade-offs in the nature and extent of data that could be obtained 
in that time frame. In November 2007, DOD and VA jointly initiated a 1- 
year pilot in the Washington, D.C. area using live cases, although DOD 
and VA officials told us they may consider expanding the pilot to other 
locations beyond the current sites around July 2008. However, pilot 
results may be limited at that and other critical junctures, and pilot 
evaluation plans currently lack key elements, such as criteria for 
expanding the pilot. 

Selection of Pilot Design Based on Formal but Quick 5-day Exercise: 

Prior to implementing the pilot in November 2007, the agencies 
conducted a 5-day "table top" exercise that involved a simulation of 
cases intended to test the relative merits of 4 pilot options. All the 
alternatives included a single VA rating to be used by both agencies. 
However, the exercise was designed to evaluate the relative merits of 
certain other key features, such as whether DOD or VA should conduct a 
single physical examination, and whether there should be a DOD-wide 
disability evaluation board, and if so, what its role would be. 
Ultimately, the exercise included four pilot alternatives involving 
different combinations of these features. Table 3 summarizes the pilot 
alternatives. 

Table 3: Summary of Pilot Alternatives Considered by DOD and VA During 
August 2007 "Table Top" Exercise: 

Alternative 1: 
Comprehensive medical examination: None. Separate DOD and VA 
examinations; 
Single disability rating done by VA: Yes; 
DOD-level evaluation board: Makes fitness determinations. 

Alternative 2[A]: 
Comprehensive medical examination: Done by VA; 
Single disability rating done by VA: Yes; 
DOD-level evaluation board: None. Services make fitness determinations. 

Alternative 3: 
Comprehensive medical examination: None. Separate DOD and VA 
examinations; 
Single disability rating done by VA: Yes; 
DOD-level evaluation board: Adjudicates appeals of services' fitness 
determinations. 

Alternative 4: 
Comprehensive medical examination: None. Separate DOD and VA 
examinations; 
Single disability rating done by VA: Yes; 
DOD-level evaluation board: Conducts quality assurance reviews of 
services' fitness determinations. 

Source: GAO analysis of information provided by DOD. 

[A] Based on the table top exercise, alternative 2 was selected for 
implementation. 

[End of table] 

The simulation exercise was formal in that it followed a pre-determined 
methodology and comprehensive in that it involved a number of 
stakeholders and captured a broad range of metrics. DOD and VA were 
assisted by consultants who provided data collection, analysis, and 
methodological support. The pre-determined methodology involved 
examining previously decided cases, to see how they would have been 
processed through each of the four pilot alternatives. The 33 selected 
cases intentionally reflected decisions originating from each of the 
military services and a broad range and number of medical conditions. 
Participants in the simulation exercise included officials from DOD, 
each military service, and VA who are involved in all aspects of the 
disability evaluation processes at both agencies. Metrics collected 
included case outcomes including the fitness decision, the DOD and VA 
ratings, and the median expected days to process cases. These outcomes 
were compared for each pilot alternative with actual outcomes. In 
addition, participants rank ordered their preference for each pilot 
alternative, and provided feedback on expected servicemember 
satisfaction as well as service and organization acceptance. They also 
provided their views on legislative and regulatory changes and resource 
requirements to implement alternative processes, and identified 
advantages and disadvantages of each alternative. 

This table top exercise enabled DOD and VA to obtain sufficient 
information to support a near-term decision to implement the pilot, but 
it also required some trade-offs. For example, the intensity of the 
exercise--simulating four pilot alternatives, involving more than 40 
participants over a 5-day period--resulted in an examination of only a 
manageable number of cases. To ensure that the cases represented each 
military service and different numbers and types of potential medical 
conditions, a total of 33 cases were judgmentally selected by service: 
8 Army, 9 Navy, 8 Marine, and 8 Air Force. However, the sample used in 
the simulation exercise was not statistically representative of each 
military service's workload; as such it is possible that a larger and 
more representative sample could have yielded different outcomes. Also, 
expected servicemember satisfaction was based on the input of the DOD 
and VA officials participating in the pilot rather than actual input 
from the servicemembers themselves. 

Based on the data from this exercise, the Senior Oversight Committee 
gave approval in October 2007 to proceed with piloting an alternative 
process with features that scored the highest in terms of participants' 
preferential voting and projected servicemember satisfaction. These 
elements included a single VA rating (as provided in all the 
alternatives tested) and a comprehensive medical examination conducted 
by VA. The selected pilot design did not include a DOD-wide disability 
evaluation board.[Footnote 25] Rather, the services' physical 
evaluation boards would continue to determine fitness for duty, as 
called for under Alternative 2. 

The Pilot Is Geared toward Quick Expansion, but Evaluation Plans Lack 
Key Elements: 

DOD and VA officials have described to us a plan for expanding the 
pilot that is geared toward quick implementation, but may have limited 
pilot results available to them at a key juncture. With respect to time 
frames, the pilot, which began in November 2007, is scheduled to last 1 
year, through November 2008. However, prior to that date, planners have 
expressed interest in expanding the pilot outside the Washington 
metropolitan area. Pilot planners have told us that around July 2008-- 
which is not long after the first report on the pilot is due to 
Congress [Footnote 26]--they may ask the Senior Oversight Committee to 
decide on expansion to more locations based on data available at that 
time. They suggested that a few additional locations would allow them 
to collect additional experience and data outside the Washington, D.C. 
area before decisions on broader expansion are made. According to DOD 
and VA officials, time frames for national expansion have not yet been 
decided. However, DOD also faces deadlines for providing Congress an 
interim report on the pilot's status as early as October 2008, and for 
issuing a final report.[Footnote 27] 

While expanding the pilot outside the Washington, D.C. area will likely 
yield useful information to pilot planners, due to the time needed to 
fully process cases, planners may have limited pilot results available 
to guide their decision making. As of February 17, 2008, 181 cases were 
currently in the pilot process, but none had completed the process. 
After conducting the simulation exercise, pilot planners set a goal of 
275 days (about 9 months) for a case to go through the entire joint 
disability evaluation process. If the goal is an accurate predictor of 
time frames, potentially very few cases will have made it through the 
entire pilot process by the time planners seek to expand the pilot 
beyond the Washington area. As a result, DOD and VA are accepting some 
level of risk by expanding the pilot solely on the basis of early pilot 
results. 

In addition to having limited information at this key juncture, pilot 
planners have yet to designate criteria for moving forward with pilot 
expansion and have not yet selected a comparison group to identify 
differences between pilot cases and cases processed under the current 
system, to allow for assessment of pilot performance. DOD and VA are 
collecting data on decision times and rating percentages, but have not 
identified how much improvement in timeliness or consistency would 
justify expanding the pilot process. Further, pilot planners have not 
laid out an approach for measuring the pilot's performance on key 
metrics--including timeliness and accuracy of decisions--against the 
current process. Selection of the comparison group cases is a 
significant decision, because it will help DOD and VA determine the 
pilot's impact, compared with the current process, and help planners 
identify needed corrections and manage for success. An appropriate 
comparison group might include servicemembers with a similar 
demographic and disability profile. Not having an appropriate 
comparison group increases the risk that DOD and VA will not identify 
problem areas or issues that could limit the effectiveness of any 
redesigned disability process. Pilot officials stated that they intend 
to identify a comparison group of non-pilot disability evaluation 
cases, but have not yet done so. 

Another key element lacking from current evaluation plans is an 
approach for surveying and measuring satisfaction of servicemembers and 
veterans with the pilot process. As noted previously, several high- 
level commissions identified servicemember confusion over the current 
disability evaluation system as a significant problem. Pilot planners 
told us that they intend to develop a customer satisfaction survey and 
use customer satisfaction data as part of their evaluation of pilot 
performance but, as of February 2008, the survey was still under 
development. Even after the survey has been developed, results will 
take some time to collect and may be limited at key junctures because 
the survey needs to be administered after servicemembers and veterans 
have completed the pilot process. Without data on servicemember 
satisfaction, the agencies cannot know whether or the extent to which 
the pilot they are implementing has been successful at reducing 
servicemember confusion and distrust over the current process. 

Concluding Observations: 

Over the past year, the Army has made substantial progress toward 
improving care for its servicemembers. After problems were disclosed at 
Walter Reed in early 2007, senior Army officials assessed the situation 
and have since dedicated significant resources--including more than 
2,000 personnel--and attention to improve this important mission. 
Today, the Army has established Warrior Transition Units at its major 
medical facilities and doctors, nurses, and fellow servicemembers at 
these units are at work helping wounded, injured, and ill 
servicemembers through what is often a difficult healing process. Some 
challenges remain, such as filling all the Warrior Transition Unit 
personnel slots in a competitive market for medical personnel, 
lessening reliance on borrowed personnel to fill slots temporarily, and 
getting servicemembers eligible for Warrior Transition Unit services 
into those units. Overall, the Army is to be commended for its efforts 
thus far; however, sustained attention to remaining challenges and 
reliable data to track progress will be important to sustaining gains 
over time. 

For those servicemembers whose military service was cut short due to 
illness or injury, the disability evaluation is an extremely important 
issue because it affects their service retention or discharge and 
whether they receive DOD benefits such as retirement pay and health 
care coverage. Once they become veterans, it affects the cash 
compensation and other disability benefits they may receive from VA. 
Going through two complex disability evaluation processes can be 
difficult and frustrating for servicemembers and veterans. Delayed 
decisions, confusing policies, and the perception that DOD and VA 
disability ratings result in inequitable outcomes have eroded the 
credibility of the system. The Army has taken steps to increase the 
number of staff that can help servicemembers navigate its process, but 
is challenged to meet stated goals. Moreover, even if the Army is able 
to overcome challenges and sufficiently ramp up staff levels, these 
efforts will not address the systemic problem of having two consecutive 
evaluation systems that can lead to different outcomes. 

Considering the significance of the problems identified, DOD and VA are 
moving forward quickly to implement a streamlined disability evaluation 
that has potential for reducing the time it takes to receive a decision 
from both agencies, improving consistency of evaluations for individual 
conditions, and simplifying the overall process for servicemembers and 
veterans. At the same time, DOD and VA are incurring some risk with 
this approach because the cases used were not necessarily 
representative of actual workloads. Incurring some level of risk is 
appropriate and perhaps prudent in this current environment; however, 
planners should be transparent about that risk. For example, to date, 
planners have not yet articulated in their planning documents the 
extent of data that will be available at key junctures, and the 
criteria they will use in deciding to expand the pilot beyond the 
Washington, D.C. area. More importantly, decisions to expand beyond the 
few sites currently contemplated should occur in conjunction with an 
evaluation plan that includes, at minimum, a sound approach for 
measuring the pilot's performance against the current process and for 
measuring servicemembers' and veterans' satisfaction with the piloted 
process. Failure to properly assess the pilot before significant 
expansion could potentially jeopardize the systems' successful 
transformation. 

Mr. Chairman, this completes our prepared remarks. We would be happy to 
respond to any questions you or other Members of the Subcommittee may 
have at this time. 

For further information about this testimony, please contact Daniel 
Bertoni at (202) 512-7215 or [email protected], or John H. Pendleton at 
(202) 512-7114 or [email protected]. Contact points for our Offices of 
Congressional Relations and Public Affairs may be found on the last 
page of this statement. GAO staff who made major contributions to this 
testimony are listed in appendix I. 

[End of section] 

Appendix I: GAO Contacts and Staff Acknowledgments: 

GAO Contacts: 

Daniel Bertoni at (202) 512-7215 or [email protected]: 

John H. Pendleton at (202) 512-7114 or [email protected]: 

Acknowledgments: 

In addition to the contacts named above, Bonnie Anderson, Assistant 
Director; Michele Grgich, Assistant Director; Janina Austin; Susannah 
Compton; Cindy Gilbert; Joel Green; Christopher Langford; Bryan 
Rogowski; Chan My Sondhelm; Walter Vance; and Greg Whitney, made key 
contributions to this statement. 

[End of section] 

Footnotes: 

[1] The data include Active, Reserve, and National Guard servicemembers 
wounded in action from October 7, 2001, to February 2, 2008. Over two- 
thirds of these servicemembers are in the Army. 

[2] Office of the Inspector General, Department of the Army, Report on 
the Army Physical Disability Evaluation System (Washington, D.C.: Mar. 
6, 2007). 

[3] Independent Review Group, Rebuilding the Trust: Report on 
Rehabilitative Care and Administrative Processes at Walter Reed Army 
Medical Center and National Naval Medical Center (Arlington, Va.: Apr. 
2007); Task Force on Returning Global War on Terror Heroes, Report to 
the President (April 2007); President's Commission on Care for 
America's Returning Wounded Warriors, Serve, Support, Simplify (July 
2007). 

[4] GAO, Military Disability System: Improved Oversight Needed to 
Ensure Consistent and Timely Outcomes for Reserve and Active Duty 
Service Members, GAO-06-362 (Washington, D.C.: Mar. 31, 2006). 

[5] Veterans' Disability Benefits Commission, Honoring the Call to 
Duty: Veterans' Disability Benefits in the 21st Century (October 2007). 

[6] GAO, DOD and VA: Preliminary Observations on Efforts to Improve 
Health Care and Disability Evaluations for Returning Servicemembers, 
GAO-07-1256T (Washington, D.C.: Sept. 26, 2007). 

[7] The Navy is responsible for the medical care of servicemembers in 
the Marine Corps. 

[8] The system is composed of categories of medical facilities that 
offer varying levels of services. 

[9] The Warrior Transition Unit also includes other staff, such as 
human resources and financial management specialists. 

[10] The Army also established three Warrior Transition Units in 
Germany. 

[11] Servicemembers who separate from the military with a DOD 
disability rating of 30 percent or higher receive health care benefits 
for life regardless of years of service. 

[12] VA determines the degree to which veterans are disabled in 10 
percent increments on a scale of 0 to 100 percent. 

[13] The three pilot locations are Walter Reed Army Medical Center, 
Washington, D.C.; National Naval Medical Center, Bethesda, Maryland; 
and Malcolm Grow Air Force Medical Center, Andrews Air Force Base, 
Maryland. 

[14] For the current pilot locations, examinations are conducted at the 
Washington, D.C., VA Medical Center. 

[15] The Army's January 2008 assessment defined full operational 
capability across a wide variety of areas identified in the Army's 
Medical Action Plan, not just personnel fill. For example, the 
assessment included whether facilities and barracks were suitable and 
whether a Soldier and Family Assistance Center was in place and 
providing essential services. In addition, the commander assessed 
whether the unit could conduct the mission-essential tasks assigned to 
it. As a result, such ratings have both objective and subjective 
elements, and the Army allows commanders to change the ratings based on 
their judgment. 

[16] The ratios are 1:200 for primary care managers; 1:18 for nurse 
case managers at Army medical centers that normally see servicemembers 
with more acute conditions and 1:36 for other types of Army medical 
treatment facilities; and 1:12 for squad leaders. 

[17] These staff include the Triad--primary care managers, nurse case 
managers, and squad leaders--as well as other Warrior Transition staff 
such as platoon sergeants, behavioral health specialists, social 
workers, and administrative personnel. 

[18] The survey was distributed to 4,430 servicemembers, which 
represented about 60 percent of the total Warrior Transition Unit 
population at the time of the survey. Some servicemembers may not have 
received a survey because, according to an Army official, they were 
receiving care through a Community Based Health Care Organization, were 
on leave, or were undergoing treatment. Additionally, three units' 
survey responses were received too late to incorporate into the Army's 
analyses. 

[19] Board physicians, unlike board liaisons and legal staff who are 
dedicated to serving servicemembers in the disability evaluation 
process, are part of the Warrior Transition Units. 

[20] According to Army officials, the Judge Advocates General's Corps 
has approximately 4,200 military and civilian attorneys and a 
significant portion of these can provide legal assistance to 
servicemembers. However, these officials also noted that these 
attorneys are not dedicated exclusively to the disability evaluation 
process and the extent to which these attorneys actually provide legal 
support to servicemembers during the disability evaluation process is 
unknown. 

[21] These 19 are intended to be active duty attorneys. The Army 
intends to assign active duty attorneys to the disability evaluation 
process for a limited time period out of concern for the attorney to 
gain experience in other legal practice areas. 

[22] Although board physicians are part of the Warrior Transition 
Units, staffing targets for board physicians are based on the number of 
servicemembers in the disability evaluation process as opposed to the 
number of servicemembers in the Warrior Transition Units. 

[23] Two of the Army treatment facilities not meeting the 200 to 1 
servicemember to physician ratio--Fort Riley, Kansas, and Fort Knox, 
Kentucky--each had a ratio of 201 to 1. 

[24] GAO-06-362, p. 26. 

[25] The DOD Disability Advisory Council will conduct a quality control 
review of some service physical evaluation board decisions. 

[26] Pursuant to the National Defense Authorization Act for Fiscal Year 
2008, enacted January 28, 2008, the Secretary of Defense must submit an 
initial report on the pilot within 90 days after enactment. The report 
is to include a description of the pilot program's scope and objectives 
and the methodology to be used to achieve the objectives. Pub. L. No. 
110-181, ï¿½1644(g). 

[27] Under section 1644(g), the interim report must be submitted no 
later than 180 days after the date of the submittal of the initial 
report. Not later than 90 days after the completion of all of the pilot 
programs carried out under the act, the Secretary of Defense must 
submit a report setting out a final evaluation and assessment of the 
pilot programs. The final report is to include any recommendations for 
legislative or administrative action that the Secretary considers 
appropriate in light of the pilot programs. 

[End of section] 

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