Apr112013
Hearing Transcript on The U.S. Department of Veterans Affairs Schedule for Rating Disabilities.
|
THE U.S. DEPARTMENT OF VETERANS AFFAIRS SCHEDULE FOR RATING DISABILITIES
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 26, 2008 SERIAL No. 110-71 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 26, 2008
The U.S. Department of Veterans Affairs Schedule for Rating Disabilities
OPENING STATEMENTS
Chairman John J. Hall
Prepared statement of Chairman Hall
Hon. Doug Lamborn, Ranking Republican Member, prepared statement of
WITNESSES
U.S. Department of Veterans Affairs, Bradley G. Mayes, Director, Compensation and Pension Service, Veterans Benefits Administration
Prepared statement of Mr. Mayes
U.S. Department of Defense, Major General Joseph E. Kelley, M.D., USAF (Ret.), Deputy Assistant Secretary of Defense for Clinical and Program Policy (Health Affairs)
Prepared statement of Dr. Kelley
American Academy of Disability Evaluating Physicians, Mark H. Hyman, M.D., FAADEP, Presenter, and Mark H. Hyman, M.D., Inc., F.A.C.P., F.A.A.D.E.P., Los Angeles, CA
Prepared statement of Dr. Hyman
American Legion, Dean F. Stoline, Assistant Director, National Legislative Commission
Prepared statement of Mr. Stoline
American Psychiatric Association, Sidney Weissman, M.D., Member, Committee on Mental Healthcare for Veterans and Military Personnel and Their Families
Prepared statement of Dr. Weissman
Center for Naval Analyses (CNA) Corporation, Alexandria, VA, Joyce McMahon, Ph.D., Managing Director, Managing Director, Center for Health Research and Policy
Prepared statement of Dr. McMahon
Disabled American Veterans, Kerry Baker, Associate National Legislative Director
Prepared statement of Mr. Baker
Institute of Medicine, The National Academies:
Lonnie Bristow, M.D., Chair, Committee on Medical Evaluation of Veterans for Disability Benefits, Board on Military and Veterans Health
Prepared statement of Dr. Bristow
Dean G. Kilpatrick, Ph.D., Member, Committee on Veterans’ Compensation for Posttraumatic Stress Disorder, and Distinguished University Professor and Director, National Crime Victims Research and Treatment Center, Medical University of South Carolina, Charleston, SC
Prepared statement of Dr. Kilpatrick
Jonathan M. Samet, M.D., M.S., Chairman, Committee on Evaluation of the Presumptive Disability, Decision-Making Process for Veterans, Board on Military and Veterans Affairs, and Professor and Chairman,, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
Prepared statement of Dr. Samet
National Veterans Legal Services Program, Ronald B. Abrams, Joint Executive Director
Prepared statement of Mr. Abrams
Veterans’ Disability Benefits Commission, Vice Admiral Dennis Vincent McGinn, USN (Ret.), Member, on behalf of Lieutenant General James Terry Scott, USA (Ret.), Chairman
Prepared statement of Admiral McGinn
Veterans of Foreign Wars of the United States, Gerald T. Manar, Deputy Director, National Veterans Service
Prepared statement of Mr. Manar
SUBMISSION FOR THE RECORD
American Medical Association, statement
MATERIAL SUBMITTED FOR THE RECORD
Reports:
Post-Hearing Questions and Responses for the Record:
THE U.S. DEPARTMENT OF VETERANS AFFAIRS SCHEDULE FOR RATING DISABILITIES
Tuesday, February 26, 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 2:02 p.m., in Room 334, Cannon House Office Building, Hon. John J. Hall [Chairman of the Subcommittee] presiding.
Present: Representatives Hall, Rodriguez, Lamborn, and Bilirakis.
OPENING STATEMENT OF CHAIRMAN HALL
Mr. HALL. Good afternoon. The Committee on Veterans' Affairs, Subcommittee Disability Assistance and Memorial Affairs, hearing on the U.S. Department of Veterans Affairs (VA) Schedule for Rating Disabilities will come to order.
Before I begin my opening statement, I would like to call attention to the fact that the American Medical Association (AMA) has asked to submit a written statement for the hearing record. If there is no objection, I ask for unanimous consent that this statement be entered for the record. Hearing no objection, so entered.
[The statement of the American Medical Association appears in the Appendix.]
Mr. HALL. Could we all please rise for the Pledge of Allegiance. Flags are at both ends of the room.
[Pledge of Allegiance.]
Thank you and thank you for being here. We will be expecting Congressman Bilirakis at some point to be joining us. Minority Counsel is here and we are going to proceed with his agreement to go ahead and hope to get through as much of this hearing as possible without putting it on autopilot.
This is the third hearing of the Subcommittee regarding the VA's claims processing system. As we have discussed before, this system has not lived up to expectations and has left many disabled veterans without proper and timely compensation and other benefits.
At the heart of this system is the VA Schedule for Rating Disabilities or VASRD. The rating schedule as we know it today is divided into 14 body systems, which incorporate approximately 700 codes that describe illness or injury symptoms and levels of severity. Ratings range from zero to 100 percent and are in increments of ten. This schedule was uniquely developed for use by the VA, but the U.S. Department of Defense (DoD) has also mandated its use when the service branches conduct evaluation boards on servicemembers who are unfit for duty. Otherwise, it is not used by any other governmental agencies or private-sector disability plans.
In its study, the Veterans' Disability Benefits Commission (VDBC) concluded that the VA rating schedule had not been comprehensively updated since 1945. Although sections of it have been modified, no overall review has been satisfactorily conducted, leaving some parts of the schedule out of date, relying on arcane medical practices, and not in sync with modern disability concepts.
The notion of a rating schedule was first crafted in 1917, so that returning World War I veterans would be cared for when they could no longer function in their pre-war occupations.
At the same time, the American economy was primarily agricultural based and labor intensive. Today's economy is different and the effects of disability are understood to be greater than the average loss of earning capacity.
Many disability specialists agree that quality of life, functionality, and social adaptation are just as important.
Our Nation's disabled veterans deserve to have a system that is based on the most available and relevant medical knowledge.
There are several issues pertaining to the rating schedule I hope to have us discuss today. First would be the need to remove out-of-date and archaic criteria that are still part of the schedule for some conditions and replace them with current medical and psychiatric evaluation instruments for determining and understanding disabilities.
The medical community relies on codes from the International Classification of Disease (ICD) and the Diagnostic and Statistical Manual of Mental Disorders (DSM). Should the Veterans Benefit Administration (VBA) be relying on these and other AMA Guides as well?
Individual Unemployability, IU, as a rating gives VA an alternative means by which to compensate veterans who cannot sustain gainful occupation, but might not otherwise be rated 100 percent.
The U.S. Government Accountability Office (GAO) found that the use of IU was ineffective and inefficient since it relies on old data, outdated criteria, and lacks guidance.
[See "VA Benefits: Fundamental Changes to VA's Disability Criteria Need Careful Consideration," GAO-03-1172T, Testimony Before the Senate Committee on Veterans' Affairs, September 23, 2003, Statement of Cynthia A. Bascetta, Director, Education, Workforce, and Income Security Issues, U.S, General Accounting Office, which appears in the Appendix.]
The VDBC, Institute of Medicine (IOM), and the Center for Naval Analyses (CNA) Corporation, also studied IU and expressed their concerns over how it is utilized instead of scheduled ratings. I look forward to hearing from them today.
The criteria for psychiatric disabilities, especially for post traumatic stress disorder or PTSD, are in dire need of expansion. The current rating schedule has only one schedule for all of mental health which is based on the Global Assessment of Functioning scale, or GAF.
The IOM noted that one of the many problems with GAF is that it was developed for schizophrenia, and therefore, not as accurate for other disorders, and recommended that VA replace it as a diagnostic tool. I am especially concerned about this issue and how it pertains to PTSD and other mental disorders.
The VDBC also recommended that traumatic brain injury or TBI, in case you have not had enough initials yet, be a priority area of concentration, and for VA to improve the neurological criteria for TBI, which has become one of the signature injuries of this war.
I know there has been much discussion on how to compensate veterans for their quality of life losses. Both the VDBC and Dole-Shalala reports recommended that this be a new category added to the rating schedule in some fashion, but they did not necessarily agree or provide clear guidance on how to do this or whether the current system does so implicitly. So next steps are still needed.
Presumptions have had a major impact on VA compensation over the last few decades for conditions related to ionizing radiation, Agent Orange, and the Gulf War. The IOM, therefore, engaged in a lengthy study for the VDBC on presumptions and recommended that there be evidence-based criteria which could impact the rating schedule.
I commend Secretary Peake for changing the regulation on PTSD, but we might also want to add a presumption that combat-zone service is a stressor when evaluating PTSD.
I look forward to the testimony today on these complex rating schedule issues. I know there is a lot to be done to improve the VA claims processing system. But with the rating schedule at the core of the process, it seems that the centerpiece is in need of immediate comprehensive repair, which we intend to advocate.
I look forward to working with Ranking Member Lamborn and the Members of the Subcommittee in providing oversight for the VA's schedule for rating disabilities. The VA needs the right tools to do the right thing so our Nation's disabled veterans get the right assistance.
[The statement of Chairman Hall appears in the Appendix.]
Mr. Lamborn, our Ranking Member, was unable to be here. Will he have a statement for the record?
Mr. LAWRENCE. Yes.
[The statement of Congressman Lamborn appears in the Appendix.]
Mr. HALL. It will be made a part of the record. Whenever Mr. Bilirakis arrives, then he will be afforded the chance to make an opening statement and also to ask questions.
I would like to first of all welcome our panels, all of our panelists today, and to remind you that your complete written statements have been made part of the hearing record.
Please limit your remarks so that we can have sufficient time to follow-up with questions once everyone has had the opportunity to provide their testimony.
Joining us on our first panel is Vice Admiral Dennis Vincent McGinn, member of the Veterans' Disability Benefits Commission.
Admiral McGinn, I first want to express my deepest sympathies to you, the rest of the Commission, and its staff on the passing of Commissioner Butch Joeckel. Butch was a true American hero, a great Marine, and a veterans' advocate to the end, who understood all too well why we are here today trying to improve the qualify of life for our disabled veterans.
I understand that Butch was known for saying, "You just have to do the right thing." And I think it is apropos that we keep that spirit in mind as we move forward on improving the VA claims processing system.
We also welcome Dr. Lonnie Bristow, Chair of the Committee on Medical Evaluation of Veterans for Disability Benefits for the Institute of Medicine; Dr. Dean Kilpatrick, Member of the Committee on Veterans' Compensation for Posttraumatic Stress Disorder for the Institute of Medicine; Dr. Jonathan Samet—is that the correct pronunciation?
Dr. SAMET. Samet.
Mr. HALL. Samet. Thank you. Dr. Jonathan Samet, Chair of the Committee on Evaluation of Presumptive Disability, Decision-Making Process for Veterans for the Institute of Medicine; and Dr. Joyce McMahon from the Center for Health Research and Policy of the CNA Corporation. Thank you all for joining us.
And, Admiral McGinn, you are now recognized for five minutes.
STATEMENTS OF VICE ADMIRAL DENNIS VINCENT MCGINN, USN (RET.), MEMBER, VETERANS’ DISABILITY BENEFITS COMMISSION, ON BEHALF OF LIEUTENANT GENERAL JAMES TERRY SCOTT, USA (RET.), CHAIRMAN; LONNIE BRISTOW, M.D., CHAIR, COMMITTEE ON MEDICAL EVALUATION OF VETERANS FOR DISABILITY BENEFITS, BOARD ON MILITARY AND VETERANS HEALTH, INSTITUTE OF MEDICINE, THE NATIONAL ACADEMIES; DEAN G. KILPATRICK, PH.D., MEMBER, COMMITTEE ON VETERANS’ COMPENSATION FOR POSTTRAUMATIC STRESS DISORDER, INSTITUTE OF MEDICINE, THE NATIONAL ACADEMIES, AND DISTINGUISHED UNIVERSITY PROFESSOR AND DIRECTOR, NATIONAL CRIME VICTIMS RESEARCH AND TREATMENT CENTER, MEDICAL UNIVERSITY OF SOUTH CAROLINA, CHARLESTON, SC; JONATHAN M. SAMET, M.D., M.S., CHAIRMAN, COMMITTEE ON EVALUATION OF THE PRESUMPTIVE DISABILITY, DECISION-MAKING PROCESS FOR VETERANS, BOARD ON MILITARY AND VETERANS AFFAIRS, INSTITUTE OF MEDICINE, THE NATIONAL ACADEMIES, AND, PROFESSOR AND CHAIRMAN, DEPARTMENT OF EPIDEMIOLOGY, JOHNS HOPKINS BLOOMBERG SCHOOL OF PUBLIC HEALTH, JOHNS HOPKINS UNIVERSITY, BALTIMORE, MD; AND JOYCE MCMAHON, PH.D., MANAGING DIRECTOR, CENTER FOR HEALTH RESEARCH AND POLICY, CENTER FOR NAVAL ANALYSES (CNA) CORPORATION, ALEXANDRIA, VA
STATEMENT OF VICE ADMIRAL DENNIS VINCENT MCGINN, USN (RET.)
Admiral MCGINN. Thank you, Mr. Chairman and Members of the Committee. I am pleased to appear before you today on behalf of the Chairman of the Veterans' Disability Benefits Commission, General Terry Scott, to discuss the findings, conclusions, and recommendations of the Commission related to revising the VA rating schedule.
The Commission was tasked to examine and make recommendations concerning the appropriateness of benefits, the appropriateness of the level of benefits, and appropriate standards for determining whether a disability or death of a veteran should be compensated. We completed our work and submitted our report on the 3rd of October 2007.
Mr. Chairman, I appreciate your comments concerning Commissioner Joeckel. You may note that we dedicated our report to him and he was the conscience of our Commission and a continuous reminder of the tremendous debt our Nation owes to disabled veterans.
For almost two and a half years, the Commission conducted an extensive and comprehensive examination of issues related to veterans' disability benefits. This was the first time that the subject had been studied in depth by an independent body since the Bradley Commission in 1956.
We identified 31 key issues for study and made every effort to ensure that our analysis was evidence based and data driven. And we engaged two well-known organizations to provide medical expertise and analysis. First the Institute of Medicine of the National Academies and the CNA Corporation. Both of those organizations are represented today in this panel.
Of the many issues the Commission examined, one of the most important was determining the effectiveness of the VA rating schedule.
You will be hearing from four panels today, including to my left Drs. Bristow, Kilpatrick, Samet representing their IOM Committees, and Dr. McMahon from CNA, independent experts, Veteran Service Organizations, and later Admiral Dan Cooper and Mr. Mayes representing the Department of Veterans Affairs.
I will keep my remarks brief and focus on the conclusions and recommendations of our Commission related to the rating schedule.
Our Commission is most appreciative of the outstanding work of the IOM Committees and CNA. We believe that their efforts were exceptionally complementary of each other and that the results were remarkably consistent.
The Commission's report summarizes the analysis and recommendations of CNA and the IOM Committees in some detail. However, the reports to the Commission are rich in detail with extensive analysis and each should be carefully reviewed by the Committee.
I would like to highlight a few of their key findings that our Commission found especially helpful. For example, Dr. Bristow's Committee emphasized that the rating schedule should achieve horizontal and vertical equity.
Vertical equity means that the VA ratings of severity of disability assigned in ten percent increments from zero to 100 percent should be accurately assigned so that those assigned more severe ratings should be those veterans whose disabilities impact their earnings more than those assigned less severe ratings.
CNA's comparison of the earnings of veterans who are not service disabled with service-disabled veterans demonstrated that disability causes lower earnings in employment at all levels of severity and types of disabilities and that the earnings loss of the disabled veteran increases as the percent rating increases. Thus, VA ratings using the rating schedule are generally achieving vertical equity.
Horizontal equity means that assigning ratings of severity should reflect average loss of earnings among the nearly 800 diagnostic codes and across the 16 body systems. CNA's analysis generally confirmed horizontal equity as well. Overall, their analysis confirmed that the VA rating schedule and VA's assignment of ratings using the rating schedule results in compensation paid to veterans that is generally adequate to offset average impairment of earnings.
Taken as a whole, the rating schedule is doing its job reasonably well. The detailed and comprehensive analysis demonstrated that even veterans with less severe ratings do, in fact, have loss of earnings.
However, the key word in the aforementioned paragraph is generally. The CNA analysis also identified very pronounced disparities for some veteran cohorts in which vertical and horizontal equity are not being achieved.
The amount of compensation is not sufficient to offset loss of earnings for three specific groups of veterans, those whose primary disability is post traumatic stress disorder, PTSD, or other mental disorders, those who are severely disabled at a young age, and those who are granted maximum benefits because their disabilities make them unemployable.
For these veteran groups, horizontal and vertical equity is not being achieved. Those severely disabled at a young age have greater loss of earning, especially over their remaining lives since they did not have established civilian careers or transferable job skills and have more of the normal working years ahead of them.
The analysis also clearly demonstrates that veterans with PTSD and other mental disorders experience much greater loss of employment and earnings than those with physical disabilities, particularly those more severely disabled.
These disparities should be addressed by a careful but prompt revision to the rating schedule leading to a more equitable level of payment to disabled veterans in the severely disabled category.
Concerning PTSD and mental disorders, the reasons for insufficient compensation may lie partly in the criteria in the rating schedule itself and partly in how the VA raters interpret or apply the criteria.
The rating schedule was revised a few years ago to eliminate separate criteria for diagnoses such as PTSD and in order to have a single set of criteria for all 67 diagnoses contained in the body system known as mental disorders.
The Commission asked the IOM to provide advice as to whether a single set of criteria is effective. IOM recommended that separate criteria should be established for PTSD and CNA's survey of VA raters and VSO service officers found agreement with that advice.
Concerning the interpretation of the criteria by raters, the Commission learned that almost one-half of 223,000 veterans granted individual unemployability or IU as being unable to work due to their service-connected disabilities had a primary diagnosis of PTSD, that would constitute 31 percent, or other mental disorders, 16 percent.
To be granted IU, the veteran must be rated at 60 to 90 percent disabled and also be found unable to work due to the service-connected disability.
Mr. HALL. Excuse me, Admiral.
Admiral MCGINN. Yes.
Mr. HALL. I am sorry. Could you summarize, please?
Admiral MCGINN. I certainly will. Yes, sir.
Our Commission concluded that there has been an implied but unstated congressional intent to compensate disabled veterans for impairment to quality to life due to their service-connected disabilities. And this is a key area that the Committee can make a real difference.
I would also like to point out before I make my concluding remarks that since the reports of the IOM that indicated the need to update the rating schedule, there has been very, very limited progress by the VA. And this should be looked at both in terms of what is the sense of urgency and other adequate resources available to do this rating schedule update as a matter of priority.
As I reflected in my written statement and partially in the oral statement I have just made, only by keeping the rating schedule current with the best up-to-date medical knowledge and by adjusting the payment levels to offset both loss of earnings and quality of life can we be assured that disabled veterans and their families are adequately compensated.
This was the clear consensus of our Commission. The specific recommendations in our report should be used to guide needed legislative actions by Congress as well as the policy and resource allocations by the departments and agencies needed to update and improve disabled veterans' benefits.
Mr. Chairman, I would be glad to answer any questions the Committee may have.
[The statement of Admiral McGinn appears in the Appendix.]
Mr. HALL. Thank you, Admiral.
And next, Dr. Bristow, you are recognized for five minutes.
STATEMENT OF LONNIE BRISTOW, M.D.
Dr. BRISTOW. Thank you. Good afternoon, Chairman Hall and Ranking Member Lamborn and Members of the Committee.
My name is Lonnie Bristow. I am a physician and I have served as the President of the American Medical Association. And I am joined this day on this panel by Drs. Dean Kilpatrick and Jonathan Samet who will introduce themselves shortly.
But on their behalf, we want to thank you for the opportunity to testify about the work of our Institute of Medicine Committees, our three Committees from the IOM.
My task today is to present to you the recommendations of the IOM Committee, which I chair, which was asked to evaluate the VA's schedule for rating disabilities and related matters.
Dr. Kilpatrick will follow me to speak about his Committee's work which focused on post traumatic stress disorder, a particular challenge for the VA to evaluate. And Dr. Samet will conclude our panel's presentation from the IOM by briefing you on the findings of his Committee which was asked to offer its perspective on the scientific considerations underlying the question of whether a health outcome should be presumed to be connected to military service.
We submitted testimony, written testimony for the record and we will summarize our presentations here. I only have a few minutes, so let me quickly list our key findings and recommendations concerning the VA rating schedule. And I will be glad to go into more detail about any of them during the question period.
Our Committee found that the statutory purpose of disability compensation which is to compensate for an average loss of earning capacity is, in fact, an unduly restrictive rationale for the program and it is inconsistent with the current modern models of disability.
The Committee recommends that the VA compensate for three consequences of service-connected injuries and diseases. First, for work disability which it currently does. And, second, however, for loss of ability to engage in usual life activities other than work, what disability experts today call functional limitations. And, third, for loss in quality of life.
Concerning the rating schedule, the Committee found that the schedule is not as current medically as it could be or should be. The relationship of the rating levels to average loss of earning capacity is not known at the time of our evaluation. The schedule does not evaluate impact on a veteran's ability to function in every-day life and the schedule does not evaluate for loss in quality of life.
The Committee, therefore, recommends that VA immediately update the current rating schedule medically beginning with those body systems that have gone the longest without a comprehensive update and adopt a system for keeping that schedule up to date medically.
Second, establish an external Disability Advisory Committee to provide advice during the updating process.
And, third, as a part of updating the schedule, we recommend moving to the ICD and DSM diagnostic classification systems.
Fourth, we recommend investigating the relationship between the ratings and actual earnings to see the extent to which the rating schedule is compensating for loss of earnings on average and make adjustments in the rating criteria to reduce any disparities that are found.
Fifth, compensate for functional limitations on usual life activities to the extent that the rating schedule does not.
And, sixth, develop a method of measuring loss of quality of life and where the schedule does not adequately compensate for it, VA should adopt a method for doing so.
The Committee also reviewed individual unemployability or IU and our main finding concerning IU is that it is not something that can be determined on medical grounds alone. Therefore, the Committee recommends that the VA conduct vocational assessments as well as medical evaluations whenever they are determining IU eligibility.
This concludes my remarks. And I want to thank you again for the opportunity to testify, and I will be happy to address any questions you might have about our report.
[The statement of Dr. Bristow appears in the Appendix.]
Mr. HALL. Thank you, Doctor.
And as you heard, the bell buzzer was sounding indicating that votes have been called. So I am going to have to ask you to be patient once again, and this Subcommittee will be in recess until this stack of votes are over.
[Recess.]
Mr. HALL. The Subcommittee is called back to order. And we apologize for the delay. You will be happy to know our legislative business is over for this afternoon, so we will be able to continue uninterrupted.
Dr. Kilpatrick, your written statement is in the record. You are now recognized for five minutes, please.
STATEMENT OF DEAN G. KILPATRICK, PH.D.
Dr. KILPATRICK. Thank you very much, and I appreciate the opportunity to testify on behalf of the Committee on Veterans’ Compensation for PTSD.
Last June, our Committee completed its report entitled “PTSD Compensation and Military Service,” which addresses several potential revisions to the schedule for rating disabilities in the context of a larger review of how the VA administers its PTSD compensation program. Our Committee's review of the scientific literature led it to draw the following conclusions:
First, there are two primary steps in the VA's disability compensation process. The first of these is a compensation and pension or C&P exam.
Testimony presented to our Committee indicated that clinicians often feel pressured to limit the time they devote to conducting a PTSD C&P exam, sometimes to as little as 20 minutes, even though the protocol suggested in a best practice manual developed by the VA National Center for PTSD can take three hours or more to complete.
Our Committee felt very strongly that the key to a proper administration of the VA's PTSD compensation program is a thorough C&P clinical examination conducted by experienced mental health professionals. Many of the issues that arise could be dealt with nicely if the resources needed for a thorough examination were provided.
The Committee also recommended that a system-wide training program be implemented for the clinicians who conduct these exams in order to promote uniformity and consistent evaluations.
The second step in the VA compensation process is rating the level of disability associated with service-connected disorders. This rating is performed by a VA employee using information gathered in the C&P exam and the criteria set forth in the schedule for rating disabilities.
Currently the same set of criteria are used for rating all mental disorders and they primarily focus on symptoms from schizophrenia, mood and anxiety disorders.
The Committee found that these criteria are, at very best, a crude and it is an overly-general instrument for the assessment of PTSD disability. We recommend that the new criteria be developed and applied that specifically address PTSD symptoms and that are firmly grounded in the standards set out in the DSM used by mental health professionals.
A third point is that our Committee suggested that the VA take a broader and more comprehensive view of what constitutes disability for PTSD. There is a special emphasis and some might say a total emphasis on occupational impairment in the current criteria that unduly penalizes veterans who may be capable of working but who are significantly symptomatic or impaired in other dimensions and, thus, the current system may serve as a disincentive to both work and recovery.
Under this framework, the psychosocial and occupational aspects of functional impairment would be separately evaluated and the claimant would be rated on the dimension upon which he or she is more affected.
In order to promote more accurate, consistent, and uniform PTSD disability ratings, the Committee recommended that the VA establish a specific certification program for raters who deal with PTSD claims and to have training along with that as well.
Finally, at the VA's request, the Committee addressed whether it would be advisable to establish a set schedule for reexamining veterans receiving compensation for PTSD. The Committee concluded that this was not appropriate to require across-the-board, periodic reexaminations and instead recommended that it be done on a case-by-case basis when there is some reason to believe that maybe the disability status had changed.
Our reasoning for that was that the resources that the VA has are finite and they would be better spent focusing on doing a really first-class and timely initial evaluation than diverting the resources to do periodic rereviews.
The second point about that is that if only PTSD is singled out, it says to the veteran that there is something suspect about this so that we have to reexamine you over and over again. And we did not find any data that suggests that there was a need for that.
I realize that there has been some differences of opinion between various committees about the extent to which reexamination should happen and I think honest people could disagree on that. And we would just urge that, you know, the Congress as well as that the VA, consider carefully the merits of each of those approaches.
And, finally, I really would say, and this is my opinion, but I think it is consistent with what our Committee thought, that if we are going to do periodic PTSD reexaminations and we are going to implement that, we should not do so until there are adequate resources to ensure that every veteran gets a first-rate initial C&P exam that is done in a timely fashion.
We have several other recommendations in our report. I understand that each of you have that, and so I would be happy to answer any questions when the time comes.
[The statement of Dr. Kilpatrick appears in the Appendix.]
Mr. HALL. Thank you, Doctor.
Dr. Samet, you are now recognized for five minutes.
STATEMENT OF JONATHAN M. SAMET, M.D., M.S.
Dr. SAMET. Thank you. Good afternoon. I am pleased to speak with you today on behalf of our 16-member Committee about the report, improving the presumptive disability, decision-making process for veterans. You have the report and we have also made the executive summary available.
We were charged with describing the current process for how presumptive decisions are made for veterans and with proposing the scientific framework for making such presumptive decisions in the future.
As you know, presumptions are made in order to reach decisions in the face of unavailable or incomplete information. And presumptions have been made since 1921 around matters of exposure and causation.
To address our charge, we met with the full range of involved stakeholders. We completed a series of ten in-depth case studies to look at lessons learned from past presumptions. We also looked at how information is obtained on the health of the veterans and how exposures during military service are evaluated and potentially linkable to health events in the future. We also looked at how scientists synthesize information to judge what is known about association and causation.
To the first part of our charge, the present approach to presumptive disability, decision making largely flows from the "Agent Orange Act of 1991." In that law, Congress asked the VA to contract with an independent organization to review scientific evidence for Agent Orange, that organization being the Institute of Medicine.
The Institute of Medicine provides its reports to the VA which then acts with its own internal decision-making process to determine if a presumption is to be made.
Our case studies pointed to a number of difficulties in this current approach that need to be addressed in any future approach, lack of information on exposures received by military personnel, insufficient surveillance of veterans for service-related illness, gaps in information because of secrecy, varying approaches to bringing information together, and variation in classification of evidence in different presumptions sometimes around association and sometimes around causation, and a general lack of transparency of aspects of the process.
We proposed a new approach that we feel will address these deficiencies when implemented. We call for an approach that is outlined in the figure attached to my testimony. Elements of this approach include an open process for nominating exposures and health conditions for review involving all stakeholders who are interested in the outcome of the presumptive disability, decision-making process.
We recommend a revised process for evaluating scientific information on whether a given exposure causes a health condition in veterans. We offer a new set of categories to assess the strength of evidence for causation and propose that in a second step of the scientific evaluation of the evidence, an estimate be made of the numbers of exposed veterans who are at risk from the exposure.
We call for a consistent and transparent decision-making process by the VA and a system for tracking the exposures of military personnel and for monitoring health conditions while in service and after separation and an organizational structure to support this process.
Two elements of the organizational process include creating two panels. One we called the Advisory Committee would be advisory to the VA. This Committee would monitor information as it comes in on the exposures and health of veterans. It would assess nominations made for consideration for presumptions and give recommendations to the VA.
The second panel would be a Science Review Board, an independent body that would evaluate the evidence, the strength of the evidence, and do the quantitative estimations if appropriate. The recommendations of this group would go to the VA as well.
We propose a set of principles, including stakeholder inclusiveness, evidence-based decisions, a transparent process, flexibility and consistency, and, finally, use of causation and not just association as the target for decision making.
We offer a set of categories around how certain the evidence is for causation and suggest that for the purpose of causation that the benefit always goes to the veterans and that the evidence should be at least 50 percent or more pointing towards causation for making presumptive decision making.
This implementation of this approach will call for action by Congress. Legislation would be needed to create the two panels and the resources would be needed to create and sustain exposure and health tracking for service personnel and veterans.
Elements of this system we recommend could be implemented at present even as steps are taken to move the DoD and VA towards implementing the full model.
Thank you.
[The statement of Dr. Samet appears in the Appendix.]
Mr. HALL. Thank you, Doctor.
Dr. McMahon, you are now recognized.
STATEMENT OF JOYCE MCMAHON, PH.D.
Dr. MCMAHON. Thank you. Chairman Hall, Representative Lamborn, and distinguished Members, I appreciate the opportunity to testify before the House Subcommittee on Disability Assistance and Memorial Affairs of the House Committee on Veterans' Affairs today on the subject of revising the VA schedule for rating disabilities.
This testimony is based on the findings reported in the CNA final report for the Veterans' Disability Benefits Commission.
We were asked to provide analysis to the Commission regarding the appropriateness of the current benefits program for compensating for loss of average earnings and degradation of quality of life resulting from service-connected disabilities for veterans.
Pertinent to today's topic is that we were asked to examine the evidence regarding the individual unemployability rating, to evaluate the quality of life findings for disabled veterans, and to conduct surveys of raters and Veterans Service Officers with regard to how they perceive the process of rating claims and assisting applicants.
Our primary task was to focus on how well the VA compensation benefits served to replace the average loss in earnings capacity for service-disabled veterans. We defined subgroups of disabled veterans by body system of the primary disability and on the total combined disability rating in four groups, 10 percent, 20 to 40 percent, 50 to 90 percent, and 100 percent disabled.
Within this, we further stratified the 50- to 90-percent disabled group into those with and without individual unemployability status.
Our overall finding is that for male veterans, there is general parity overall at the average age of entry. When we looked at various subgroups, we found some differences as has been mentioned before. In particular, those with a primary mental disability have lower earnings ratios than those with a primary physical disability and many of the rating subgroups for those with a primary mental disability had earnings rates below parity. In addition, entry at a young age with severe disability is associated with below parity earnings ratios.
We were asked to look at veterans' quality of life degradation, and we did this by conducting a survey using health-related questions taken from a standardized bank of questions used to survey the general population. This allowed us to compare results for service-disabled veterans to widely-used population norms.
We found that as the degree of disability increased, generally overall health declined, and that there were differences between those with physical and mental primary disabilities. Physical disability led to lower physical health, but in general did not lead to lowered mental health except for the most severely disabled.
On the other hand, mental disability led not only to lower mental health scores but was also associated with lower physical health in general. For those with a primary mental disability, physical scores were well below the population norms for all rating groups and lowest for those with PTSD.
In general, we did not find that there were any implicit quality of life payments being made to the disabled veteran population since most veterans were at parity with the exception of the subgroups we have mentioned. Overall, there is no quality of life payment implicitly being provided by the current compensation schedule.
There are groups that are below parity and these would include those entering as severely-disabled veterans at a young age and, in particular, those with a mental primary disability. Since these people are below parity, that implies a negative implicit quality of life payment for these groups. However, it is worth noting that in general the loss of quality of life appears to be the greatest for those with a mental primary disability.
Turning to the survey of raters and Veterans Service Officers that we conducted, I will make a few points quickly. Many raters indicated that the criteria for IU are too broad and that more specific decision criteria or evidence regarding IU would be helpful in deciding IU claims.
They reported that claims are becoming more complex, that mental claims are harder to evaluate than physical claims, and that they would appreciate more specific criteria to help them resolve mental health issues, especially PTSD.
Turning to IU, we were asked specifically to look at this in the context of the system and how it works. We have a figure that eight percent of those receiving VA disability compensation have IU, but 31 percent of those with PTSD as their primary diagnosis have IU status. This may indicate that the rating schedule does not work well for PTSD.
We were asked to comment on the rapid growth in the number of disabled veterans categorized as IU from 2000 to 2005. The data suggests that the vast majority of the increase in the IU population is explained by demographic changes, specifically the aging of the Vietnam cohort.
We also looked at mortality rates to determine if there were clinical differences for those with IU, and we found that those with IU status have higher mortality rates than those who were rated 50 to 90 percent disabled without IU. IU mortality rates were, however, less than was observed for those who are 100 percent disabled.
Finally, we would make a couple of comments about rating system implications. If the purpose of the IU designation is primarily related to employment, there could be a maximum eligibility age reflecting typical retirement patterns. But if it is to correct for rating schedule deficiencies, an option might be to simply correct the rating schedule so that fewer disabled veterans would need to be classified as IU.
In particular, I do not think you will ever find that you can get away from the rating system using an IU designation completely, but you might well be able to limit the number of veterans who receive this designation each year by changing the schedule or considering other options such as a greater use of retraining programs.
Thank you.
[The statement of Dr. McMahon appears in the Appendix.]
Mr. HALL. Thank you, Doctor.
Thank you to all of our panelists.
At this time, I want to acknowledge Congressman Rodriguez and Congressman Bilirakis who have joined us.
I will ask a few questions first. Admiral McGinn, as a member of the Commission and participant in its deliberations, what is your sense of the priority of revising the rating schedule from the perspective of the veteran? In other words, what do veterans need most?
Admiral MCGINN. I think the comments by some of my colleagues at the panel here reflected the priority that should be placed on PTSD, TBI or traumatic brain injury, and other mental conditions as areas in which the VA should start their review of the rating schedule. Those are all very, very compelling in terms of numbers and the effects it has on veterans and their families. And from a veteran's perspective, that is a good place to start.
That said, the entire rating schedule should be approached, and updated with a much greater sense of urgency. And if that requires more resources, those should be applied.
Thank you, sir.
Mr. HALL. In your testimony, you called for VA's response to be urgent and expedient, but then pointed out that this has never been the case with the VA's reaction to recommendations such as those made by Omar Bradley's Commission in 1956.
So if we want this done now, what is the best way for Congress to ensure your call to action?
Admiral MCGINN. I know we made a recommendation in our report on establishing an oversight group comprised of DoD and the VA to track the progress of the various recommendations that we made.
I will say that given the fact that we are at war, we are seeing terribly injured veterans come back and into the system, tremendous effect on their families, and various spotlights have been put on how we treat those veterans.
The VA and DoD, for example, have made tremendous progress, more in the past couple of months, six months say, than in the previous ten years on addressing the so-called seamless transition from uniform member to disabled veteran.
I think that same type of focus needs to be applied in updating the rating schedule and we will see the results that we need.
Mr. HALL. And would you consider the 25-percent quality of life payment as recommended by the Commission sufficient to correct the horizontal and vertical equity issues described by CNA? Should the maximum payment of 25 percent only pertain to the most severely disabled or for the three groups you described as below parity?
Admiral MCGINN. I think that horizontal and vertical equity issues should be dealt with separately than quality of life. And quality of life should be applied as we are developing standards for measuring quality of life or decrement to quality of life and what appropriate compensation should be.
I think that immediately those veterans who are most severely disabled should benefit first from a quality of life increase.
Mr. HALL. Thank you.
Dr. Bristow, could the rating schedule be simplified and still be an effective tool for VA to use in compensating veterans?
Dr. BRISTOW. That is a very difficult question, Mr. Chairman. I believe the rating system needs to be clarified. I am not sure if simplified is the term that I would use. But I think it certainly needs to be clarified so that it has logic.
It currently fails to have the sort of logic, at least from the point of view or from the perspective of medicine or science, that it should have and can have. It has a lack of logic because it has not progressed during the last five decades at the rate that it should have.
In some areas, it has been abysmally behind the times. Others, there have been fitful starts in an effort to become more modernized. But its problem is a lack of being up to date rather than being too complex.
Mr. HALL. Do you agree with the Commission's recommendation to begin with mental health, specifically PTSD and TBI?
Dr. BRISTOW. Yes, sir, although my Committee recommended that the updating take place approaching those particular systems that have had the longest lag of inattention.
This actually dovetails with the Commission's recommendation, particularly if you look at traumatic brain injury, which is a part of the neurological system, which would be one of the first systems that needs to be upgraded.
The addition of PTSD that the Commission is recommending for early and urgent attention, I think, is based on pragmatism and it makes eminently good sense. And I am quite certain that no one on my Committee would disagree or dispute or find fault with that.
Mr. HALL. Thank you.
In a hearing last month, Dr. Randy Miller from Vanderbilt University testified that the rating schedule was too vague and ambiguous. He suggested that if it had better definitions and clear-cut key words, it could be automated.
What is your opinion on these observations and would you advocate for the automating of the rating schedule using software, artificial intelligence, et cetera?
Dr. BRISTOW. I think it is key that the rating system begin to use as rapidly as can be accomplished DSM and ICD codes. The reason is because that would bring the greatest clarity to what the medical condition or surgical condition is of a particular individual. And clarity is essential if you are going to do any sort of epidemiologic approach to a given population.
The rating system currently has been using only 700 plus codes and whenever a condition does not fit a particular code, the raters are encouraged or advised that they should use an analogous code. That is a matter of administrative convenience. But when one attempts to look back and decide what is going on with a given population of diseases or injuries, there is a mishmash that has been created in that fashion.
And so it is important that although the ICD codes are far more numerous, parenthetically, we are talking about an alternative with the potential use, the use of potentially anywhere from 14 to 17,000 different codes as opposed to 700 plus, they would bring a great deal more clarity and make the information that the VA is collecting much more useful in terms of how to allocate resources, in terms of how to develop programs, and provide the sort of the services that the entire Nation wishes our veterans to have.
Mr. HALL. Thank you.
And my seven minutes have just gone flying by.
Congressman Rodriguez?
Mr. BILIRAKIS. I have one question.
Mr. HALL. Mr. Bilirakis?
Mr. BILIRAKIS. One question. Thank you.
Dr. McMahon, how might the VA adjust the rating schedule so that it more accurately reflects the consequences of PTSD?
Dr. MCMAHON. Well, I am not a clinical expert. We approach this at CNA from a point of analysis of what the rating schedule showed. I would say that the information with regard to individual unemployability suggested that there was an inability to rate the person in terms of the fullness of the disability. In other words, many people were unable to work and were granted individual unemployability who did have PTSD.
One way to address that would be to r
Sign Up for Committee Updates
Stay connected with the Committee