Apr112013
Hearing Transcript on Examining the U.S. Department of Veterans Affairs' Claims Processing System.
|
EXAMINING THE BACKLOG AND THE U.S. DEPARTMENT OF VETERANS AFFAIRS' CLAIMS PROCESSING SYSTEM
HEARING BEFORE THE SUBCOMMITTEE ON DISABILITY ASSISTANCE AND MEMORIAL AFFAIRS OF THE COMMITTEE ON VETERANS' AFFAIRS U.S. HOUSE OF REPRESENTATIVES ONE HUNDRED TENTH CONGRESS SECOND SESSION FEBRUARY 14, 2008 SERIAL No. 110-70 Printed for the use of the Committee on Veterans' Affairs
U.S. GOVERNMENT PRINTING OFFICE For sale by the Superintendent of Documents, U.S. Government Printing Office
|
|
|
|||||
|
|
CORRINE BROWN, Florida |
STEVE BUYER, Indiana, Ranking |
|
||
|
|
|||||
|
|
Malcom A. Shorter, Staff Director SUBCOMMITTEE ON DISABILITY ASSISTANCE AND MEMORIAL AFFAIRS
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public hearing records of the Committee on Veterans' Affairs are also published in electronic form. The printed hearing record remains the official version. Because electronic submissions are used to prepare both printed and electronic versions of the hearing record, the process of converting between various electronic formats may introduce unintentional errors or omissions. Such occurrences are inherent in the current publication process and should diminish as the process is further refined. |
|
|||
C O N T E N T S
February 14, 2008
Examining the Backlog and the U.S. Department of Veterans' Affairs Claims Processing System
OPENING STATEMENTS
Chairman John J. Hall
Prepared statement of Chairman Hall
Hon. Doug Lamborn, Ranking Republican Member
Prepared statement of Congressman Lamborn
WITNESSES
U.S. Government Accountability Office, Daniel Bertoni, Director, Education, Workforce, and Income Security
Prepared statement of Mr. Bertoni
U.S. Department of Veterans Affairs, Michael Walcoff, Deputy Under Secretary for Benefits, Veterans Benefits Administration
Prepared statement of Mr. Walcoff
American Federation of Government Employees, AFL-CIO, J. David Cox, R.N., National Secretary-Treasurer
Prepared statement of Mr. Cox
American Legion, Steve Smithson, Deputy Director, Veterans Affairs and Rehabilitation Commission
Prepared statement of Mr. Smithson
Center for Naval Analyses (CNA) Corporation, Alexandria, VA, Joyce McMahon, Ph.D., Managing Director, Center for Health Research and Policy
Prepared statement of Ms. McMahon
Disabled American Veterans, Adrian Atizado, Assistant National Legislative Director
Prepared statement of Mr. Atizado
Erspamer, Gordon P., Senior Counsel, Morrison and Foerster, Walnut Creek, CA
Prepared statement of Mr. Erspamer
Institute of Medicine, The National Academies, Michael McGeary, Senior Program Officer and Study Director, Committee on Medical Evaluation of Veterans for Disability Benefits, Board on Military and Veterans Health
Prepared statement of Mr. McGeary
National Organization of Veterans' Advocates, Inc., Richard Paul Cohen, Executive Director
Prepared statement of Mr. Cohen
National Veterans Legal Services Program, Ronald B. Abrams, Joint Executive Director
Prepared statement of Mr. Abrams
Veterans for Common Sense, Paul Sullivan, Executive Director
Prepared statement of Mr. Sullivan
Veterans of Foreign Wars of the United States, Gerald T. Manar, Deputy Director, National Veterans Service
Prepared statement of Mr. Manar
Wounded Warrior Project, John Roberts, National Service Director
Prepared statement of Mr. Roberts
SUBMISSIONS FOR THE RECORD
Bilmes, Linda J., Professor, Kennedy School of Government, Harvard University, Cambridge, MA, statement
Priessman, Master Sergeant Kurt, USAF (Ret.), Vernon, TX, statement
MATERIAL SUBMITTED FOR THE RECORD
"Wounded Vets, Broken System," CQ Weekly, April 30, 2007, by Patrick Yoest and Rebecca Adams
EXAMINING THE BACKLOG AND THE U.S. DEPARTMENT OF VETERANS AFFAIRS' CLAIMS PROCESSING SYSTEM
Thursday, February 14, 2008
U. S. House of Representatives,
Subcommittee on Disability Assistance and Memorial Affairs,
Committee on Veterans' Affairs,
Washington, DC.
The Subcommittee met, pursuant to notice, at 2:15 p.m., in Room 340, Cannon House Office Building, Hon. John J. Hall [Chairman of the Subcommittee] presiding.
Present: Representatives Hall, and Lamborn.
OPENING STATEMENT OF CHAIRMAN HALL
Mr. HALL. Please forgive the delay. Once again, thank you all for being here. The Committee on Veterans' Affairs, Subcommittee on Disability Assistance and Memorial Affairs, hearing on examining the U.S. Department of Veterans Affairs' (VA's) claims processing system will come to order.
Would everyone please rise for the Pledge of Allegiance.
[Pledge of Allegiance.]
Mr. HALL. Thank you.
Today we are here to examine the VA's claims processing systems and its attendant disability claims backlog. There are many areas to explore when trying to determine why the disability claims backlog has reached the point of unmanageability and why this is the second time in a seven-year time period that we have reached this crisis point.
From 2002 to 2007, the disability claims backlog has risen from about 250,000 to nearly 650,000. During the same time period, the Veterans Benefits Administration (VBA) consistently missed its performance targets on nearly all compensation and pension (C&P) claims processing fronts.
These failures engender many questions about the complexity of the system the VA has created and the model upon which it is built.
One of my leading questions concerns the effectiveness of the claims processing improvement (CPI) model regards its suitability to establish meaningful accountability parameters to eliminate the claims backlog and accurately process claims. Thus far, none of the VA's own benchmarks have improved since the CPI implementation and I find this fact disturbing.
Moreover, it seems as if the failure is not necessarily with the system itself, but with the execution of the processes that are supposed to be reinforced with transparent and highly-visible accountability measures to make it work.
As outlined by the 2001 report of the VA Claims Processing Task Force led by Daniel L. Cooper, now VA Under Secretary for Benefits, "Accountability includes not only the proposition that a leader is responsible for the actions of the group, but also is accountable for the results of those actions or inactions. This single attribute is the most serious deficiency in the VBA organization."
At the time, Mr. Cooper was referring to VBA's then failed claims processing system, SDN. I think many of those who testify today will concur that these same observations could apply both to today's VBA organization and its claims processing system model, CPI.
One can only wonder where the accountability is in a work credit system whose only meaningful measure is productivity and where quality seems to be an afterthought.
Only about two percent of all claims are checked for quality and one in ten claims is processed incorrectly. This error rate is unacceptable and indicates that VA needs to improve its training regimens to ensure uniformity across Regional Offices (ROs) and that highly qualified individuals are processing and adjudicating claims.
Further, I ask why bonuses are consistently paid to managers at both the Regional and Central offices while claims languish. I want VA management to adopt this principle: Be accountable for the backlog, do not pay yourselves anything extra until the veterans are paid.
I know that VA contends that all of its inventory is not backlogged, but try selling these semantics to veterans waiting 183 days and longer for decisions on their claims.
From the Subcommittee's standpoint, based on the VA's current performance, most of the disability claims in its inventory are eventually going to become a part of those claims pending longer than VA's target of 145 days for claims processing. Hence, they will become part of the backlog.
Moreover, the Subcommittee does not consider as progress an increase in the time needed to process a claim from 177 days in 2006 to 183 days in 2007 accompanied by an increase in the VBA's target performance days for processing claims from 125 days up to 145 days during the same time period .
It is interesting that moving the goal from 125 days to 145 days is actually a greater increase than the increase in the backlog from 177 to 183 days.
VA should not conceive of moving its targets to compensate for its poor performance. I am confounded by these actions and would like an explanation and so would our veterans.
I am encouraged that some of the numbers from VA's fiscal year 2009 budget indicated a 19 percent increase in VBA information technology (IT) funding to support efforts to move to a paperless claims environment and increased funding for VETSNET. While technological improvements alone will not solve the backlog problem, they are clearly critical to the solution.
I am also anxious to see the results of IBM's study of the VBA's business processes involved with adjudicating a claim. This type of review is long overdue.
I am also encouraged to see that VA is requesting more money to add 703 full-time employees (FTE), yet I am aware that you have been unable to maximize the performance of the record number of 3,100 FTEs that this Congress ensured you received during the last two funding cycles.
Let us be very clear. This is not just a people problem and adding more people to a broken system cannot be the only answer to vanquishing the claims backlog and improving processing times. To date, this single-minded approach has proven unsuccessful.
I think the major faulty premise in this system is that the VA behaves as if it is only accountable to meet the numerical targets it sets and that Congress tacitly approves. But I want to reinforce to you that you are actually supposed to be accountable to the veteran who has borne the battle, to his widow, and to his orphan.
I believe we need to refocus and refine our Nation's claims processing system to make it accountable to producing better outcomes for our veterans, their families, and survivors.
I thank the witnesses on the first three panels for their thoughtful, solution-oriented testimonies. I hear the frustration in your statements and I look forward to working with you and with the Ranking Member and other Members of this Committee on ways to implement the workable solutions many of you offer.
I know that the backlog has taken on a life of its own. However, it is not bigger than the collective will we will devote to eliminating it and to honing a claims processing system that is veteran-focused, not process-focused.
Lastly, I know that VA cannot be pleased with its current disability claims processing performance and I look forward to hearing VBA's strategic plan for addressing these concerns.
Secretary Peake has highlighted this issue as one of his top priorities and I hope VA sees Congress as a friend and not a foe in helping to correct the shortfalls in the disability claims processing system.
I believe that just as the Veterans Health Administration (VHA) experienced a revolutionary transformation, it is well time to think of devoting the same type of resources into transforming the VBA. It is time for a paradigm shift.
Our veterans deserve the benefit of our collective resources to ensure that this process is a world-class, 21st century model that reflects their priceless sacrifice for our Nation.
And I would ask that the article from CQ Weekly entitled "Wounded Vets, Broken System," April 30, 2007, issue be entered into the record without objection. Without hearing any, so ordered.
[The statement of Chairman Hall, and the article referenced, "Wounded Vets, Broken System," CQ Weekly, April 30, 2007, by Patrick Yoest and Rebecca Adams, appear in the Appendix.]
Mr. HALL. Thank you very much. I would yield now to Ranking Member Lamborn for his opening statement.
OPENING STATEMENT OF HON. DOUG LAMBORN
Mr. LAMBORN. Thank you, Mr. Chairman, for yielding. I look forward to hearing our witnesses' testimony on how we might address the challenges and opportunities facing VA's compensation and pension service.
In fiscal year 2007, compensation and pension service commonly referred to as C&P performed more than 838,000 rating decisions. C&P also performed nearly 582,000 claims actions that did not require rating decisions.
Yet, despite this tremendous volume of work accomplished, C&P finds itself behind in its struggle to overcome the steady accumulation of claims awaiting action. An array of reasons contributes to this frustrating trend and our witnesses outlined a number of them in their written statements.
Foremost among them will be that VA place more emphasis on accuracy and less on speed. Rating decisions must be done right the first time. I wholeheartedly agree.
But as much as we may ponder and discuss solutions to the multitude of underlying problems, I think we all realize that the time has arrived for a reasonable, yet fundamentally different approach to the problem. If we continue to merely tread water, we are going to sink.
As my Subcommittee colleagues are aware, I have long been an advocate for major reform with regard to the use of information technology. I am heartened to know that they concur with my perspective that it is well past time for VA to embrace IT as a remedy to an outdated paper-based system. VA should be on the forefront of technology in the disability benefits arena and I believe it can be.
Not too long ago, VA's healthcare system was so poor, it was the subject of derision in movies such as Born On The Fourth Of July. Now, though, VA healthcare is the subject of emulation among a number of high-quality medical models.
I believe that VA can make a similar improvement on the benefits side of the Department. We must be open to considering new ideas, especially in the area of IT, and not be bound by narrow paradigms.
I invite the Members of the Subcommittee, the veterans groups, and others to offer suggestions that will improve the process for our future veterans.
Thank you, Mr. Chairman, and I yield back.
[The statement of Congressman Lamborn appears in the Appendix.]
Mr. HALL. Thank you, Congressman Lamborn.
I would like to welcome all of our panelists testifying before the Subcommittee today and remind our panelists that your complete written statements have been made part of the hearing record.
Please limit your remarks so that we may have sufficient time for follow-up questions once everyone has had the opportunity to testify.
Joining us on our first panel is Ms. Joyce McMahon, Managing Director, Center for Health Research and Policy, CNA Corporation; Mr. Michael McGeary, Senior Program Officer and Study Director for the Committee on Medical Evaluation of the Veterans for Disability Benefits, Board on Military and Veterans Health of the Institute of Medicine; and Mr. Daniel Bertoni, Director of Education, Workforce, and Income Security of the U.S. Government Accountability Office (GAO).
If the panelists would come to the table, please. We welcome you.
And, Ms. McMahon you are recognized for five minutes.
STATEMENTS OF JOYCE MCMAHON, PH.D., MANAGING DIRECTOR, CENTER FOR HEALTH RESEARCH AND POLICY, CENTER FOR NAVAL ANALYSES (CNA) CORPORATION, ALEXANDRIA, VA; MICHAEL MCGEARY, SENIOR PROGRAM OFFICER AND STUDY DIRECTOR, COMMITTEE ON MEDICAL EVALUATION OF VETERANS FOR DISABILITY BENEFITS, BOARD ON MILITARY AND VETERANS HEALTH, INSTITUTE OF MEDICINE, THE NATIONAL ACADEMIES; AND DANIEL BERTONI, DIRECTOR, EDUCATION, WORKFORCE, AND INCOME SECURITY, U.S. GOVERNMENT ACCOUNTABILITY OFFICE
STATEMENT OF JOYCE MCMAHON, PH.D.
Dr. MCMAHON. Thank you.
Chairman Hall, Representative Lamborn, distinguished Members, I appreciate the opportunity to testify before the House Subcommittee on Disability Assistance and Memorial Affairs today on the subject of the VA's claims processing system.
The testimony I am giving is based on findings and our final report for the Veterans' Disability Benefits Commission (VDBC), in the written testimony I have provided, there is a website link that can provide a full copy of that report.
I am going to summarize from the testimony that we have that is pertinent to the topic of examining the backlog and the VA's claims processing system.
In particular, there were two parts of our study that relate to these issues. We did an evaluation that compared the VA Disability Compensation Program to other Federal disability programs, looking at the claims process.
We also conducted surveys of both raters and Veterans Service Organizations (VSOs) to determine how they felt about the rating process and their ability to work with the claims system.
I am first going to mention briefly some of the comparisons we did across the other Federal disability programs. We looked at Social Security disability income, the supplemental security income, workers' compensation, the disability retirement under the Federal employee system, and U.S. Department of Defense's (DoD's) disability evaluation system.
Our strategy was to look at literature reviews, reports from GAO, congressional testimony, Office of Inspector General (OIG) reports, and interviews with various officials at all of these programs.
We found two difficulties in terms of making these comparisons, the first of which is there is generally a lack of formal evaluation of the effectiveness of specific practices for the non-VA programs. That limited our ability to make direct head-to-head comparisons of methods.
In addition, there are different goals and structures and procedures and claims requirements across the programs. In particular, the VA system has a great deal of complexity required for the evaluation process, more complexity than may be required for some of these other programs.
To be specific, there is a requirement that the VA disability be a service-connected disability, and multiple VA disabilities are examined. Each disability has to be assessed for a degree of disability to determine an overall disability compensation that is appropriate for the individual.
In particular, the age of claim is an important issue, because the initial disabling event may have occurred years prior to the claim being filed, meaning that the documentation that is provided is old and may have to be requested from DoD. The evidence may have to be resurrected, from old files. So the evidence that is needed to apply to the claim may not, in fact, be very current and this adds to the problem of resolving claims quickly.
We looked at several metrics including timeliness, accuracy, consistency, training issues, and staff turnover. The one that was the most striking was the timeliness issue, in that the VA claims process takes a much longer time to complete than is the case for the other programs.
In part, this may be due to the complex issues that the VA has to deal with in terms of the determination process, but we think that one suggestion that was offered by GAO has tremendous merit. GAO suggested that the VA should look at desegregating the process of the claim so that it can be determined which stages of the claims process contribute most to the total processing time.
In other words, we do not know why it takes as many days as it does. We do not know enough about where the bottlenecks occur. Is it a problem with retrieving old paperwork? Is it getting input from DoD? Is it based on the issue of trying to do medical and clinical assessments? So we think it would be very helpful to look at that process more closely.
I would like to turn now to the discussion of the rating officials, both the VBA rating officials and the accredited Veteran Service Officers in terms of the surveys that we did. These are the first-line people that deal with the claims processing, either doing the claims processing or assisting individuals with the claims processing.
We prepared surveys for each group that were related as parallel as possible so we could ask pretty much the same questions from both groups of people and get their separate opinions. We focused on the challenges in the benefits determination and claims rating process and the raters’ perspectives on their performance.
We asked raters to identify their three top challenges, for example, what kind of training they had that they thought made them very effective, what kind of resources were good to help them make the claims decisions, what types of claims were most difficult to process, and what resources would help them do a better job.
In general, the finding was that the overall determination process is difficult to use and, in particular, the VSOs reported that most veterans and survivors find it difficult to understand the determination process, difficult to navigate through the steps, and difficult to provide the needed evidence.
Both raters and VSOs agree that veterans have unrealistic expectations about the process and I think that means unrealistic in terms of what they can do to help the veterans get through the claims process more quickly. That is how the raters perceived it.
Particular things that we found from these surveys include the following: more clinical input would be helpful, especially from physicians and mental health professionals. The claims processes are viewed as being complex and getting more complex over time. And obviously, the more complex the condition that has to be considered, the more time it takes to do an accurate job on getting that done.
Some types of disabilities were identified as being more difficult to assess than others. In particular, rating mental claims is considered to be much more problematic than rating physical condition claims. Again, in particular, post traumatic stress disorder (PTSD) was singled out as requiring more judgment and subjectivity and being much more difficult and time consuming compared to physical claims. Both groups agreed.
Mr. HALL. Could you summarize, please?
Dr. MCMAHON. Yes, I can.
Among physical disabilities, neurological, musculoskeletal and sense organs were more difficult than the other physical disabilities to rate. It is not just a matter of training, but years of experience on the job that makes raters more confident. And, in particular, both the raters and VSOs believed that the claims rating process generally arrives at the fair and right decisions for veterans.
Thank you.
[The statement of Ms. McMahon appears in the Appendix.]
Mr. HALL. Thank you very much, and to remind all of our witnesses, your full statements have been entered into the record.
Mr. McGeary, you are now recognized for five minutes.
Mr. MCGEARY. Good afternoon, Mr. Chairman, Members of the Committee.
As the Chairman indicated, I was the Staff Director for the Institute of Medicine's Committee on Medical Evaluation of Veterans for Disability Benefits, which produced the report called, "A 21st Century System for Evaluating Veterans for Disability Benefits," last June. The Committee was established at the request of the Veterans' Disability Benefits Commission and it was funded by VA.
In this report, the Committee assessed the medical criteria and processes used by VA to determine the degree of disability of service-connected veterans. The Committee did not, however, assess the nonmedical aspects of the claims process. So the report does not address all the factors that might affect the timeliness of decisions on claims.
The Committee did not, for example, evaluate the adequacy of staffing nor the capacity of VA's management information systems. Rather, the main focus of the report is on the medical criteria VA uses to assess degree of disability, which are embodied in the VA's schedule for rating disability.
Dr. Lonnie Bristow, the Chairman of the Committee, is scheduled to testify before you on the rating schedule on February 26. I am here today to review the part of the report in Chapter 5 which focuses on the two steps in the claims process that are medically based, namely, the medical examination step and the rating step.
My written testimony contains statistics on timeliness, accuracy, and consistency of decisions in recent years, which I will not repeat here other than to note that, despite improvements of the time it takes to resolve claims, it is long and the number of pending claims is still large.
The Committee made several recommendations to improve the medical examination process and several more to improve the rating process. These recommendations were primarily aimed at improving the quality of the medical evidence and rating decisions rather than speeding the claims process. But two of the Committee's recommendations promise to get faster as well as better decisions.
First, VA has developed standardized on-line protocols or templates for documenting the most common disability examinations. VA has conducted studies which indicate that examinations using these templates are not only higher in quality, but reported more quickly, seven to seventeen days more quickly than traditional transcribed reports.
However, the Committee noted that the use of these templates is voluntary and the rate of use is low, although growing. And the Committee recommends, therefore, that the use of the templates be made mandatory.
Second—
Mr. HALL. Excuse me, Mr. McGeary. I am going to ask you, if you would, to pause right there and take a quick recess while we run across the street and vote and come back again.
Mr. MCGEARY. Yes, sir.
[Recess]
Mr. HALL. The hearing of the Subcommittee is back in session. Please continue Mr. McGreary.
Mr. MCGEARY. Okay. Second, the Committee found that raters should have quicker access to medical expertise. And you just heard from Ms. McMahon that the raters report the need for more medical information to use.
The raters are not medical professionals. If they have a question about the meaning of a test result or if the evidence is inconclusive, they have to refer the case back to the C&P examiners in the Veterans Health Administration, which adds time or, to save time, they can determine a rating based on incomplete information, which is obviously not desirable.
The Committee recommends, therefore, that VA have medical consultants readily available to the raters in the Regional Offices. This does not mean having a medical consultant in every Regional Office, because with modern communications technology, VBA medical consultants could be in a National or in Regional centers.
This recommendation that VBA have its own medical consultants would require congressional action because the U.S. Court of Appeals for Veterans Claims has barred the participation of physicians in adjudicating claims.
The Committee believes that the Court's decision was based on a misunderstanding of the role of physicians in adjudication, which is different from the role of a treating physician.
All other major disability programs, for example, Social Security, DoD's disability evaluation process, "The Federal Employee Compensation Act" Program, Civil Service Disability Retirement Program, either have physicians participating in the adjudication decision or have medical experts readily available to review and discuss claims with the lay disability raters.
So the Committee concluded that adoption of these recommendations, that the templates be made mandatory, and that VBA have medical consultants for raters, would, among other results, possibly improve the timeliness of the decisions.
And this concludes my remarks. Thank you for the opportunity to testify, and I would be happy to address any questions.
[The statement of Mr. McGeary appears in the Appendix.]
Mr. BERTONI. Good afternoon. I am pleased to participate in this discussion of the Department of Veterans Affairs' disability claims process.
Last year, VA provided $36 billion in benefits to nearly four million recipients. For years, VA's disability program has been plagued by untimely processes, large backlogs, and error-prone decisions. It will be further strained as more Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) veterans seek benefits in the coming years.
In 2003, we at GAO designated VA's disability program high risk because it was based on outmoded concepts and continued to experience management and operational problems. Since that time, we have issued numerous reports with recommendations for change.
Today I will briefly highlight three areas, service delivery challenges facing VA, actions taken to improve performance, and areas where fundamental reform is needed.
In summary, VA continues to experience service delivery challenges. Over the past four years, pending ratings-related claims increased over 50 percent to nearly 400,000. Claims pending longer than six months have more than doubled to over 100,000.
The time required to resolve appeals is also problematic with a current average processing time of almost 700 days. And VA also faces challenges ensuring that its decisions are accurate and consistent.
VA has taken steps to expedite and improve claims processing such as increasing staff overtime, using retired staff to provide training and claims assistance, shifting workloads to offices with excess capacity, and establishing special teams to prioritize claims for aged veterans as well as returning OIF and OEF veterans.
VA's 2009 budget funds nearly 11,000 claims processing staff, an increase of 2,600 positions, with 32 percent over fiscal year 2007.
While VA acknowledges some temporary declines in productivity until new staff are trained and gain experience, it expects productivity to ultimately increase.
Despite these assertions, we are concerned that incorporating a large number of new staff into the claims process will likely present substantial human capital challenges relative to hiring, training, and deployment of new personnel.
And even if staffing levels increase, other actions are needed to improve productivity. To that end, VA has continued to expand the number of benefits delivery at discharge (BDD) sites where servicemembers can apply for benefits prior to discharge and receive expedited claims processing.
To improve decisional accuracy and consistency, VA has begun to enhance its quality assurance processes and develop baseline data to monitor decisional variances, especially for PTSD and other brain injury claims.
Finally, to address long-standing systemic weaknesses, VA and the Department of Defense are piloting a joint disability evaluation system whereby VA performs a single medical exam, rates the disabilities of active-duty servicemembers. This pilot intends to streamline the confusing dual DoD and VA disability systems and ultimately expedite claims processing.
Despite VA's efforts, several factors may impede progress. Claims have increased steadily from about 579,000 at the start of this decade to 838,000 last year. And VA predicts that the current war will place a further strain on operations.
Court decisions are requiring VA to assist veterans in developing claims. They have also expanded workloads. Increased outreach and additional laws and regulations creating new presumptions of service-connected disabilities have added to the volume of claims. Caseload complexity has also increased as more veterans claim multiple disabilities. Thus, continuing to explore new ways to work smarter and more efficiently is essential to increasing VA's productivity.
Going forward, significant program improvements may lie in more fundamental reform. We have noted that VA's programs do not reflect the current state of science, medicine, technology, and the national economy, which has moved away from manufacturing jobs to service and knowledge-based employment. Thus, VA's rating criteria and support services have lagged behind modern concepts of disability and early intervention.
The Veterans' Disability Benefits Commission has recommended that VA's entire rating schedule be updated starting with PTSD, traumatic brain injury (TBI), and other signature disabilities of the current war.
The Dole-Shalala Commission also noted that the current schedule does not sufficiently acknowledge injuries that are new or for which diagnostic criteria are changing rapidly. This is an area of concern to us also.
Finally, we reported that VA's field structure may impede efficient operations. Despite limited ad hoc efforts to consolidate some processes and workloads at VA's 57 offices, claims processing remains unchanged and continues to experience large performance variations.
VA must take a more strategic approach to determining the appropriate structure and division of labor among its field locations.
In conclusion, reexamining claims processing challenges and implementing viable solutions for reform is difficult. However, recent studies have laid the groundwork to help VA better align its programs with modern concepts of disability.
It is imperative that VA thoughtfully assess the range of options and their potential effects and continue to look for other reforms to further improve its disability programs into the 21st century.
This concludes my statement. I am happy to answer any questions that you may have. Thank you.
[The statement of Mr. Bertoni appears in the Appendix.]
Mr. HALL. Ladies and gentlemen, thank you for your attention. We are in the middle of a stack of votes. There are five votes remaining, five-minute votes supposedly. Each one is five nominally. So you are still talking about somewhere in the neighborhood of probably 40 minutes or so.
I apologize. I cannot control the vote schedule. But I will be back and hopefully the Ranking Member will be back as well and we will proceed. Thank you for your patience. You are excused again.
I am officially putting this hearing in recess.
[Recess.]
Mr. HALL. The hearing of the Subcommittee is back in session. There is a privileged motion being discussed on the floor right now that could take anywhere from one to fifty minutes or so. I am not sure what is going to happen. We are going to try to move as much as we can through the business at hand today.
So let me ask some questions of our first panelists. And thank you for your patience.
Ms. McMahon, it seems that the bulk of the time, 111 days, according to the VDBC, is taken during the development stage of claims processing, most of which involves acquisition of medical records and a medical examination of a veteran by the VA or its contractor.
Your report to the VDBC also highlights how raters indicated that obtaining needed evidence and the insufficiency of medical examinations was a serious challenge given the time constraints.
During your analysis and comparison of disability programs, did you find that these programs allow the admission of independent outside examinations and, if not, how does it work in the other disability systems?
Dr. MCMAHON. Well, I think that it does allow an independent examination. Although when we talked to the raters, they indicated that they would appreciate more of that evidence to help them make their decisions. They did not think they received enough of that information.
So they have pointed out they wanted more information from clinicians, outside physicians, medical rehabilitation people, and material of this nature to help them with the decision process and that that was a lack in the overall process.
We are not in a position at CNA, as we are not clinicians, to make recommendations regarding the specific processes that these VA raters do or the other programs do with regard to how they take in their medical evidence. That is a little bit beyond my purview.
Mr. HALL. Okay. Thank you.
In your testimony, you mentioned that your survey results indicated that many raters and VSOs see claims with mental disorder problems or issues, especially PTSD, as requiring more judgment and subjectivity than claims of physical conditions.
We know from previous hearings before the Subcommittee that there is a tremendous variance between ROs on these claims.
Do you have recommendations for improving the consistency of the outcomes for veterans filing these types of claims and how do you think we can make these determinations less subjective?
Dr. MCMAHON. One way to make it less subjective would be to rely more on medical testimony. I would say again not as a medical person myself, this is basically what I have been told, that one way to do this would be to have an actual one-on-one assessment medically that would lay out the characteristics of the person's case and make a medical recommendation. This is time consuming but it would probably be something that would be helpful.
The issue of consistency across ROs can be dealt with, but it also takes the process further away from the individual person. For example, suppose you consolidated certain types of claims into a specified office. Perhaps it might be that all of the PTSD claims would go to a certain office with raters that were specializing in PTSD claims. You would probably get more consistency. But then you are taking the claim away from the individual Regional Office and from the individual veteran that is talking directly to a claims representative.
So you have a problem in the sense that you can try to specialize some types of claims, perhaps not just PTSD, but neurological claims also, so they are reviewed by certain types of raters, but then you may move away from the process of dealing with claims in an individual RO to some extent.
Mr. HALL. Thank you.
Mr. McGeary, would you please elaborate on your recommendation that VA should implement mandatory use of interactive on-line versions of the VA examination worksheets? How does this process work now and how could this change affect the processing times for rating claims?
Mr. MCGEARY. VA first started working on the medical exams in the mid 1990s and they developed standard worksheets. They worked up a large number, I think 50 plus worksheets for the most common conditions, for clinicians to use in conducting the C&P exams and in reporting them.
And then they went the next step, which is to develop them into an on-line interactive system. The idea here was that the template would indicate what information was needed. It would provide standardized input, structured and so forth, and would also make sure that everything that was needed would be answered.
And they have been working on developing these templates. They are, I believe at this point, rolled out nationally, but they are not mandatory yet. The Committee thought that they should make them mandatory because VA’s own studies show that it improves the quality of the exam, at least in terms of making sure that the information that is asked for is provided and that it is also faster.
I believe the average time for a Regional Office to get an examination report is about 30 to 35 days. And they found that using some of these templates would save seven to seventeen days. That was a couple of years ago. I am not sure whether they have looked at this lately.
That is why I highlighted this particular recommendation as something that would presumably result in better medical evidence and also shorten the turnaround for doing the exams.
Mr. HALL. Thank you.
Can you provide more detail on your recommendation that raters should have better access to medical expertise, such as having medical consultants in a National or Regional Office which raters would be able to confer with on the tough cases?
Currently it does not happen with most ROs, but I believe it used to be the case that doctors or medical experts were available to raters for medical advice.
Mr. MCGEARY. Yes, sir. In the 1920s, when VA started the compensation program, they had rating boards and there would be a medical person on the board. They also would have a vocational person and a legal person.
When you fast forward to when the U.S. Court of Appeals for Veterans Claims was established, the court began to issue cases in which they were putting a pretty high standard on using doctors in these decisions. So basically, VA dropped having physicians on the rating boards and at the VBA as well.
We looked at the other disability programs as CNA did and found that VA is unique in this regard, that the other programs either have medical advisors or they actually have physician adjudicators.
[Mr. McGreary subsequently provided the following information:]
The Committee’s recommendation that VBA have medical consultants for raters should reduce the number of times a case must be returned to the Veterans Health Administration and thus save time spent deciding these cases.
Mr. HALL. Thank you, Mr. McGeary.
Mr. Bertoni, in your written testimony, you note that the VA continues to fall short on its quality assurance program to assess rating accuracy. In fact, by VA's own numbers, one out of every ten cases is adjudicated incorrectly. Many of today's witnesses will testify that it may even be higher than that, closer to three in ten.
Would you please describe your observations of the VA's Systematic Technical Accuracy and Review Program (STAR) and provide any thoughts on how it might be improved?
Mr. BERTONI. Certainly. We have not done an in-depth analysis of the STAR system for some time. I guess the bottom line was that our concern with STAR was that the level and depth of their sampling perhaps at times has been insufficient to generalize and to sort of drill down into the root causes of some of the issues for the inconsistencies and inaccuracies.
To rectify that, I think you really need to look at sampling methodology, your approach, whether you are actually sampling enough cases and your methodology for doing that is going to give you a reasonable assurance that this is or is not a true soft spot or bottleneck in the system or quality assurance issue. And that has been our concern with the STAR system.
Mr. HALL. You also mentioned that VA may need to look at more fundamental reforms for improving its disability program in the long term.
Do you have any specific closing thoughts on that matter?
For instance, we will hear later today from the VA about its IT improvements and plans, something that Congressman Lamborn and I have been advocating.
Could you comment on what role you think technology might play and whether it is the panacea?
Mr. BERTONI. Absolutely. You know, technology is not the panacea, but it can make everyone's life more pleasant and result in more accurate and more consistent decisions.
I think before you talk about technology, I think you really need to, as I always say, to follow the process, to really understand the weak points, the bottlenecks, the parts of the process that really do call for reengineering.
Once you have done your due diligence and done that analysis, then you should write the system requirements that you need to write and build your systems around the new reengineered, more efficient system. And at the end of the day, you will end up with a more effective process.
I think what happens so many times at Federal programs, and we have seen it before, is agencies will take existing manual or inefficient processes and just embalm them into the new technology. And what you have is new technology that are simply built around faulty processes and techniques.
So that is the issue. You really need to look at reengineering the process, defining the system you want to use for that process, and building a system around it.
Mr. HALL. Thank you.
You highlight in your testimony how the complexity of claims is adding significantly to the challenges that the VA is facing in getting rid of its claims backlog and in decreasing processing times.
In fact, VA reported that the number of cases with eight or more disabilities increased from 21,800 to 58,500 between the years of 2000 and 2007.
Given your familiarity with the VA and its team and workflow concept instituted under CPI, would you say that its claims processing model is equipped to or flexible enough to handle this dynamic of claims complexity given that the claims processing times and the backlog have worsened?
Mr. BERTONI. I probably cannot talk specifically as to whether the current model would be sufficient or not. We have not done the drill or done the analysis on the claims processing model that we probably should do in the near future.
I was just talking to someone on your staff earlier that it is probably a good time for us to go in and do a top-to-bottom review of the claims processing structure to get a sense of where the soft spots are, where the problems are and have a better sense of that.
But in terms of the multiple impairments, I think in general, any time you have increasing complexity in a case, you want to make sure you have the most streamlined, efficient, effective process in place that is going to allow you to address that.
Complexity is not going to go away. We have an aging beneficiary cohort. We have people coming in with some very complex impairments, especially the OIF/OEF veterans coming in with some TBI and other serious brain injuries, that that and many other body systems are going to be affected.
So I think I do not know exactly whether the current system is equipped to handle those impairments. But to the extent that it is not, it could be problematic and we would need to go in and really look at that and we have not.
Mr. HALL. Thank you, Mr. Bertoni, Mr. McGeary, Dr. McMahon. Thank you for your patience. Your spoken testimony was entered into the record as well as your written testimony. Minority Counsel will enter questions for the record. With our gratitude for your patience, you are now excused.
I have votes once again on the floor, so I am going to run across the street and come back. And this hearing will be in recess until then.
[No questions were submitted.]
[Recess.]
Mr. HALL. The Subcommittee is reconvened and is called to order. Thank you again for your patience. Welcome to our second panel, Richard Cohen, Executive Director of the National Organization of Veterans' Advocates, Inc. (NOVA); Ronald Abrams, the Joint Executive Director, National Veterans Legal Services Program (NVLSP); J. David Cox, National Secretary-Treasurer, the American Federation of Government Employees (AFGE); and Gordon Erspamer; is that correct?
Mr. ERSPAMER. Erspamer.
Mr. HALL. Erspamer, thank you, Claims Attorney from California.
Your full statements, as usual, are entered in the record and you will each be recognized for five minutes starting with Mr. Cohen.
STATEMENTS OF RICHARD PAUL COHEN, EXECUTIVE DIRECTOR, NATIONAL ORGANIZATION OF VETERANS' ADVOCATES, INC.; RONALD B. ABRAMS, JOINT EXECUTIVE DIRECTOR, NATIONAL VETERANS LEGAL SERVICES PROGRAM; J. DAVID COX, R.N., NATIONAL SECRETARY-TREASURER, AMERICAN FEDERATION OF GOVERNMENT EMPLOYEES, AFL-CIO; AND GORDON P. ERSPAMER, SENIOR COUNSEL, MORRISON AND FOERSTER, WALNUT CREEK, CA
STATEMENT OF RICHARD PAUL COHEN
Mr. COHEN. Thank you, Chairman Hall and Members of the Committee.
I will not belabor what we all know about the VA's shortcomings in claims processing except to say that this Committee needs to keep in mind the devastating effects on real people because we are not really talking about inventory and we are not talking about production standards. We are talking about veterans and their families, veterans who die without their benefits or live impoverished, lose their homes or their vehicles.
Now that we are at war in two theaters, we know that there is a flood of injured veterans who are going to be turning to the VA for the benefits they deserve and now almost seven years after the Claims Processing Task Force report in October 2001, we still have an unconscionable backlog of over more than a half a million claims, with decision delays of greater than three years and in many cases greater than five years.
The main reason for this is VA funding which is too low leading to inadequate staffing and inadequate training. It is time that we, as a country, recognize that the VA's funding is a cost of war and we need to adequately fund the VA so they have adequate staff and adequate training.
We were told how complex the system is. It is a complex system, but the VA training has been less than ten or about ten hours a year. Their raters consistently demonstrate lack of knowledge and training. They have a staff of about 14,000 who are handling 1.4 million claims and these people still do not know how to apply the VA law when it applies to presumptions, and when it applies to the benefit of the doubt.
The VA is proud to tell you about an accuracy rate of over 80 percent. I am here to tell you that that is an internal number which has no reality in the real world and if you look at the numbers of the BVA decisions, the number of reversals and remands, because the case was not adequately developed or was decided wrongly, you will see that the accuracy rate is below 20 percent.
This accuracy rate is more than just an academic exercise. It directly leads to more appeals which leads to more backlogs. If the VA could decide the cases correctly the first time, it would not have the cases coming back and we would not have hamster-wheel justice that everyone is talking about.
Instead of fixating on delays and on accuracy, the VA has decided to institute their extraordinary award rule, in 2007, which puts a chilling effect upon raters who now know that, if they state that the veteran was incorrectly denied benefits for a long time, that claim will be reviewed in a Central Office in Washington, D.C.
Not only does it put a chilling effect on the raters causing them not to make the right decision, but it in effect punishes veterans who are finally able to convince raters, with further review and after further delays, that the decision was wrong initially and they are entitled to more money.
This is a big mistake by the VA. This rule has resulted in, apparently, at least 500 claims in a four-month period of 2007 being reviewed.
The production standards are improper. There is no way that someone can make three to five decisions each day. It takes longer than that to review the file and to make a proper decision. And the raters have said in a survey that they cannot keep up with those production standards.
In addition, the VA has maliciously refused to adjudicate Agent Orange claims of Blue Water vets that the Haas decision said veterans were entitled to. There is also a movement afoot, that members of NOVA have been seeing to deny PTSD benefits to combat vets.
Finally, the Veterans Claims Assistance Act (VCAA) is a mistake as applied. Congress needs to tell the VA that they should give claim-specific information to the veterans so they can know how to handle their case.
Thank you.
[The statement of Mr. Cohen appears in the Appendix.]
Mr. HALL. Thank you, Mr. Cohen.
Mr. Abrams, you are now recognized for five minutes.
Mr. ABRAMS. Thank you, Mr. Chairman, Councils.
I have several things to say and it is always enjoyable for me to talk about the VA claims process.
In 1987 as a VA employee, I was asked to testify, and I recommend to the Committee that you get a copy of serial number 100-4 where they analyzed pretty much what you are analyzing today and you will see many of the same comments talking about what is wrong with the VA system. That is about 21 years ago.
Unfortunately, not much has changed. The VA obviously needs more and better people to adjudicate claims. The system is complicated and they could use people who get paid at a higher rate if they are accountable for their work.
And, of course, unless work is measured rationally and people are evaluated based on a system that considers the needs of veterans and not the bureaucracy, things will not change. I say that again. You can go to a paperless system. You can introduce doctors to give medical opinions. But if the workers in the VA system are going to be promoted and given bonuses on productivity by moving a claims file from desk A to desk B, because that is how they internally measure, you are not going to make major changes in this system.
Please encourage the VA to measure work from the point of view of the claimant, not the bureaucracy. As part of my job in the VA, I worked in and was in charge of quality. And one of the things that we learned how to do was to look at it from the point of view of the claimant. The claimant just gets letters from the VA.
Have any of you ever looked at a statement of the case? There is usually about eight pages to fourteen pages of complete boiler-plate. Some statutes and regulations that are quoted are relevant. Others are not. Then there is a short paragraph as to why the claim was denied.
VCAA letters, as Richard said, are not claim specific. They are just generalized. They give no real help to veterans. We need to fix that.
In order to test this system, NVLSP took on a few test cases, hard cases, cases where medical opinions were necessary, where lay evidence was necessary. We made two basic assumptions, that working with the VA was not worth our time and that we knew the system as well as they did and we would go out and get all the evidence necessary. We would get the doctors to evaluate the claimants based on our knowledge of the rating schedule.
It took us about eight months to get all that evidence. It took the VA one week to grant benefits at the hundred percent rate. I say that to you because it is not important to veterans how quickly the VA makes the initial rating or decision. It is important in the overall scheme how quickly they come to a fair conclusion in the claim. That is the key measure.
The VA adjudication system is rife with premature denials based on inadequate development, and failures to recognize important issues. All of that is driven by the need for production. This is not just based on my time working for the VA, which I did for many years. It is based on over 40 recent quality reviews conducted for the American Legion. All of these reviews are available to you. I know that Mr. Smithson of the Legion is testifying in the next panel.
As far as doctors being available, it is a good thing if doctors are available to give medical advice to raters, but we certainly would not be happy if they were voting on their own medical opinions
Sign Up for Committee Updates
Stay connected with the Committee