Apr112013
Hearing Transcript on The Use of Artificial Intelligence to Improve the U.S. Department of Veterans Affairs' Claims Processing System.
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THE USE OF ARTIFICIAL INTELLIGENCE TO IMPROVE 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 JANUARY 29, 2008 SERIAL No. 110-66 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
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CORRINE BROWN, Florida |
STEVE BUYER, Indiana, Ranking |
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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. |
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C O N T E N T S
January 29, 2008
The Use of Artificial Intelligence to Improve 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. Department of Veterans Affairs:
Kim A. Graves, Director, Office of Business Process Integration, Veterans Benefits Administration
Prepared statement of Ms. Graves
Stephen W. Warren, Principle Deputy Assistant Secretary for Information and Technology, Office of Information and Technology
Prepared statement of Mr. Warren
Christopherson, Gary A., University Park, MD (Former Senior Advisor to the Under Secretary for Health, and Chief Information Officer, Veterans Health Administration, U.S. Department of Veterans Affairs, Former Principal Deputy Assistant Secretary for Health Affairs, U.S. Department of Defense)
Prepared statement of Mr. Christopherson
Cleveland, Gunnery Sergeant Tai, USMC (Ret.), Dumfries, VA
Prepared statement of Gunnery Sergeant Cleveland
Miller, Randolph A., M.D., Donald A.B. and Mary M. Lindberg University Professor of Biomedical Informatics, Medicine, and Nursing, Vanderbilt University School of Medicine, Nashville, TN
Prepared statement of Dr. Miller
Mitchell, Tom M., Ph.D., E. Fredkin Professor and Chair, Machine Learning Department, School of Computer Science, Carnegie Mellon University, Pittsburgh, PA
Prepared statement of Dr. Mitchell
QTC Management, Inc., Diamond Bar, CA, Marjie Shahani, M.D, Senior Vice President, Operations
Prepared statement of Dr. Shahani
Stratizon Corporation, Atlanta, GA, Ned M. Hunter, President and Chief Executive Officer
Prepared statement of Mr. Hunter
Unum, Portland, ME, John F. McGarry, Senior Vice President of Benefits, Chief Risk Officer
Prepared statement of Mr. McGarry
Wounded Warrior Project, John Roberts, National Service Director
Prepared statement of Mr. Roberts
SUBMISSIONS FOR THE RECORD
American Veterans (AMVETS), Raymond C. Kelley, National Legislative Director, statement
American Legion, Steve Smithson, Deputy Director, Veterans Affairs and Rehabilitation Commission, statement
Disabled American Veterans, Kerry Baker, Associate National Legislative Director, statement
Paralyzed Veterans of America, statement
MATERIAL SUBMITTED FOR THE RECORD
Post Hearing Questions and Responses for the Record:
THE USE OF ARTIFICIAL INTELLIGENCE TO IMPROVE THE U.S. DEPARTMENT OF VETERANS AFFAIRS' CLAIMS PROCESSING SYSTEM
Tuesday, January 29, 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 2:06 p.m., in Room 340, Cannon House Office Building, Hon. John J. Hall [Chairman of the Subcommittee] presiding.
Present: Representatives Hall, Lamborn, Bilirakis.
OPENING STATEMENT OF CHAIRMAN HALL
Mr. HALL. Good afternoon ladies and gentlemen. The Committee on Veterans' Affairs, Subcommittee Disability Assistance and Memorial Affairs, hearing on "The use of Artificial Intelligence to Improve the U.S. Department of Veterans Affairs' (VA's) Claims Processing System" will come to order.
Before I begin with my opening statement, I would like to call attention to the fact that Raymond C. Kelley, National Legislative Director for AMVETS and Kerry Baker, Associate National Legislative Director for the Disabled American Veterans have asked to submit written statements for the hearing record.
If there is no objection, I ask unanimous consent that these statements be entered into the record.
Hearing no objection, so entered.
[The statements of Mr. Kelly and Mr. Baker appear in the Appendix.]
I would ask that we all rise for the Pledge of Allegiance. The flag is in this corner of the room.
[Pledge of Allegiance.]
I would like, first of all, to thank the witnesses for coming today to appear before the Subcommittee. I know I speak for my colleagues when I say we are all extremely frustrated and disappointed when we hear about 650,000 claims pending and another 147,000 appeals with a delay of 183 days to process those claims.
But looking at this photograph, which is up on the screen right now, of an eight-inch paper record held together with rubber bands and marked with post-it notes, it is hard to imagine that things do not get lost or missed. This has got to be cumbersome when processing our veterans' claims.
There is no doubt that we need a better system than rubber bands and post-it notes and must look beyond the current way VA is doing business. There are best practices within the scientific community and best practices in use in the private sector.
I thank you for joining me and the Subcommittee today to explore these solutions to broaden our understanding of what is possible, realistic, and achievable in this technological age.
The current VA claims process is paper intensive, complex to manage, difficult to understand, and takes years to learn. Training a rater can take two to three years and many leave within five years. Experienced raters can adjudicate about three claims a day, taking about two to three hours apiece.
This means that if there are 10 people who can rate a claim and 800 claims are ready to rate, then it will take another 80 days to process those pending claims, which have already been in the system for several months.
This is very labor intensive. And in the meantime, veterans are waiting months without compensation while their completed case sits on a shelf. I know the other Members of the Committee and most Americans find that unacceptable.
Additionally, there have been reports by the U.S. Government Accountability Office, the VA Inspector General, and the Institute for Defense Analyses that explored the variances in ratings between Regional Offices (ROs) and the lack of inter-rater reliability.
The Veterans’ Disability Benefits Commission also found a great deal of subjectivity and inconsistency in the VA's disability claims process.
So how do we solve this?
I have had a life-long interest in science, was a three-time National Science Foundation scholar, and a physics student while at Notre Dame. I learned FORTRAN when I was a kid when my father was teaching seminars when the computer would take up a room this size that now fits into a laptop.
So I find the topic of artificial intelligence, or AI, compelling since it requires the confluence of science, technology, mathematics, engineering, and physics.
In general, the purpose of AI is to make computer programs or machines that can solve problems and achieve goals. AI software increases speed, improves accuracy and reduces costs for many industries and agencies.
AI does not replace the human element, but rather facilitates its availability. There are many examples of AI in other areas, such as banking and medicine. For instance, the Veterans Health Administration (VHA) relies on VistA to help doctors with diagnosis and treatment. It sends alerts when a patient needs a flu shot, cholesterol screening, or warns of potential drug interactions.
AI can be a decision support tool for adjudicating claims too. It could be used to organize and store data. It could match key words from a veteran's record to the criteria in the Rating Schedule. It could prioritize multiple disability issues.
I envision a VA in which a veteran can apply online for benefits, upload records, exams, and other certificates, which are prioritized and classified by an expert system that can match the data to the Rating Schedule criteria and thereby shorten the time it takes to generate a claim.
The electronic template used by the examiner could be associated with the Rating Schedule, which could also help calculate ratings. Classifiers or key words could easily be matched by the computer to the Rating Schedule, such as "Arm," "Amputation," then "90 percent."
This would free up the time for the RO employers to deal with the more complicated issues, and assist veterans and their families with their problems.
This Subcommittee has often heard that veterans do not know about, or understand, their benefits and that transitioning servicemembers are not getting all of the support that they need from the Veterans Benefits Administration (VBA).
In this way, VBA staff could be providing more outreach and ensuring that veterans understand their entitlements and eligibility requirements for other programs, and benefits such as vocational rehabilitation, insurance and special monthly compensation.
I am eager to hear testimony today that will open up the discussion on information technology (IT) and share ideas that can improve rating efficiency, quality, and accuracy while reducing inconsistencies and variances in decisions for our disabled veterans who often have been waiting for a long time for a claim determination.
I look forward to working with Ranking Member Lamborn and the Members of this Subcommittee in finding real solutions that will vastly improve the VA claims process. It is unconscionable that our veterans are waiting as long as they are for their earned benefits. And this situation must end.
I now recognize the distinguished Mr. Lamborn for any opening remarks he may have.
[The statement of Chairman Hall appears in the Appendix.]
OPENING STATEMENT OF HON. DOUG LAMBORN
Mr. LAMBORN. Thank you, Mr. Chairman for yielding. I would like to welcome all of our witnesses to this Subcommittee's first hearing of the Second Session.
I want to commend you, Mr. Chairman, for your leadership and bipartisanship in the previous session. And I look forward to working with you and your staff to find meaningful solutions to improving the VBA claims processing system and reducing VBA's disability claims backlog.
I am excited that our topic of discussion today is the Use of Artificial Intelligence to Improve the Disability Claims Process.
As you know, Mr. Chairman, this is an idea that my colleagues and I on this side of the aisle have long supported.
Whether it was in our fiscal year 2008 views and estimates, or two bills that I introduced last session, H.R. 1864 and H.R. 3047, we believe that one way to truly reduce the current backlog and prevent future backlogs is to propel the VA beyond a 20th century, paper-based processing system, as you so eloquently showed us through a picture on the screen.
VA must create a system where all claims are electronically scanned and rating board members have access to computerized interactive tools to assist them in the adjudicative process.
Hopefully, the new system will lead to more accurate rating decisions that are delivered to our Nation's veterans in a timely manner.
While I envision an important role for artificial intelligence in the decision-making process, I also concur with our witnesses who will attest that this technology should not and will not ever completely replace claims adjudicators.
A few weeks ago, staff from both sides of the aisle attended a briefing where VBA laid out plans to move forward with such a system. And I am excited to learn more about those plans today.
The Subcommittee must ensure that this new initiative is fully funded and completed with the speed and attentiveness that our veterans deserve.
I am glad that we have representatives from both the private and academic sectors here with us today. It is my hope that they will be able to help VA develop some of the options that are currently available in the private sector.
While I understand that VA has a very large and unique disability claims system, there are similar systems out there. And I would hope that VA would look at these systems before they reinvent the wheel.
We must improve this system so heroes like Gunnery Sergeant Cleveland do not have to wait several years to have their claim adjudicated correctly.
Mr. Chairman, I extend my thanks to you and your staff for holding this hearing this afternoon. And I look forward to hearing the testimony of our witnesses. I yield back the balance of my time.
[The statement of Congressman Lamborn appears in the Appendix.]
Mr. HALL. Thank you, Congressman Lamborn.
Joining us on our first panel is Tai Cleveland from Dumfries, Virginia. Mr. Cleveland is a medically-retired Marine who sustained a devastating training injury in Kuwait in 2003. With him is his wife, Robin.
And they are joined by John Roberts, the National Service Director for Wounded Warrior Project (WWP), which is the veterans service organization (VSO) that represents the Clevelands. I would also like to recognize Mr. Robert's distinguished service as a Marine who was also severely injured while serving this Nation in Somalia. I thank you all for being here.
I would like to remind our panelists that your complete written statements have been made a part of the hearing record.
Therefore, if you would, try to limit your remarks to five minutes so that we have sufficient time for follow-up questions.
Mr. Cleveland, we will go ahead and begin with your testimony. You are now recognized, sir.
STATEMENTS OF GUNNERY SERGEANT TAI CLEVELAND, USMC (RET.), DUMFRIES, VA (DISABLED VETERAN); ACCOMPANIED BY ROBIN CLEVELAND, DUMFRIES, VA; AND JOHN ROBERTS, NATIONAL SERVICE DIRECTOR, WOUNDED WARRIOR PROJECT
STATEMENT OF GUNNERY SERGEANT TAI CLEVELAND, USMC (RET.)
Mr. CLEVELAND. Mr. Chairman, Ranking Member Lamborn, distinguished Members of the Committee, thank you for the opportunity to testify before you regarding my experience with the Department of Veterans Affairs' and claims process. My name is Gunnery Sergeant Tai Cleveland, United States Marine Corps Retired. With me today I have my wife, Robin. And I would like, with your permission, Mr. Chairman, for my wife, who has dealt often with the VA on our benefits claim, to discuss the issues.
Mr. HALL. Thank you, sir. And, Robin, you are now recognized for five minutes.
Mrs. CLEVELAND. Thank you, Mr. Chairman. My husband served his country proudly for 24 years as a United States Marine. And although we had many issues with the U.S. Department of Defense (DoD) following his injuries, due to the subject of this hearing, I will limit my comments to our difficulties with the VA claims processing system and its impact on our family. As I am speaking, however, please keep in mind that a severely injured servicemember must navigate multiple systems: the Department of Defense, the Social Security Administration, Medicare, and the VA. It is quite overwhelming to say the least.
Tai was injured in August 2003 during a hand-to-hand combat training accident in Kuwait, where he was flipped onto his back injuring his head and multiple vertebras. The resulting damage has left my husband a paraplegic with chronic neuropathic pain, spasticity, and what is classified as a mild-to-moderate traumatic brain injury that has its own set of challenges.
Since Tai's injury, I have had to learn the hard way how to navigate the systems. Keeping meticulous records of documents, recording dates and times of telephone calls, confirming receipt of anything sent or hand delivered to Federal agencies.
As such, I thought the best way to convey our situation was to share a timeline detailing our experiences with the VA.
In June 2005, we attended the Transition Assistance Program class provided by the Marine Corps and the VA to learn about the available options. We completed the VA's Benefits Delivery at Discharge (BDD) process, including the benefits, specially adaptive housing, and adaptive vehicle program applications, and hand delivered it with medical records, MRI compact discs, films, prescription reports, et cetera, in its totality to 1722 Eye Street, Washington, DC.
After having completed his compensation and pension exam, we called the VA Benefits number in November of 2005 where we were advised that the application was incomplete and medical records from the military treatment facility (MTF) were needed. I delivered a second copy of MTF medical records to the DC Office.
A month later, I phoned again to see if the records were received and was advised that no application was on file. I copied and redelivered the original application to the DC Office.
In January 2006, another call to VA Benefits advised me that the claim was being reviewed, but that medical records were required to make a final determination.
I again copied medical records and redelivered to the DC Office. I was later told that the housing and vehicle grant were denied.
When I called in February of 2006, I was told no determination could be made because Tai was still on active duty. Additionally, I was told that no claim was on file for the housing or vehicle. We reapplied.
In March 2006, I met with a VA employee at Walter Reed regarding benefits and our difficulty with the claims. She introduced us to a VA social worker at Walter Reed who enrolled Tai in the Adaptive Driving Program at Richmond.
We were told to reapply for benefits, because no application was found. We resubmitted the original application and completed a new application for Specially Adaptive Housing, Home Improvement and Structural Alteration (HISA), and the vehicle grant, but were informed on April 5th that the applications were denied and advised to reapply.
In June 2006, we were informed by the VA social worker that the approval for the vehicle application was in fact received. But she was "unable to locate the application, because the clerk failed to separate the application and maintain an in-house copy."
In addition, our HISA and Adaptive Housing Grants were denied. We reapplied.
Everything was quiet for the next three months until October 26, 2006, when we were readvised to reapply for vehicle and housing grants since no official notification of approval was received.
Again, in November of 2006, we received verbal notification from the VA representative at Walter Reed of the latest vehicle and housing denial. And on December 13th, 2006, we were advised to reapply for vehicle and housing grants, and were contacted by VA to verify our address.
In January of 2007, Tai was medically retired from the Marine Corps. After filing BDD, we assumed we would get his disability check within a month or so.
In February of 2007, our housing and vehicle grants were approved and supposedly had been approved since April of 2006. But the hard copy was no longer on file. To date, we still have not received the official vehicle approval.
In late May 2007, we received verbal notification from the VSO, helping us at the time, that the VA was indicating that there was not enough information on file to rate the claim. And, therefore, additional information was necessary.
In June, we received notification from the VA of an 80 percent partial rating. We were advised that the rating was temporary and additional information was necessary in order to process the claim.
As we were scheduled to be in Richmond shortly to obtain an adaptive cycle, we were advised to have Richmond perform the necessary evaluations for submittal to the Roanoke Regional Office.
While at Richmond, I also inquired about obtaining the vehicle grant hard copy and contacted the VA to inquire about Aid and Attendance. I was told that I was not eligible.
In July 2007, via express mail, Tai's medical records from Richmond to Roanoke—I delivered Tai's records from Richmond to Roanoke and sent the VA an email advising that we still had not received a disability check approximately six months post-discharge.
In August, I phoned and emailed VA Benefits again and told them that despite the temporary rating, we still had no check. I requested direct deposit information and requested to verify our address.
After having been contacted about our problems by a non-profit organization, a concerned representative from the VA's Central Office called in September about the outstanding checks. And we were told that a tracer would have to be placed on the missing checks before replacements could be mailed. I later received a call from the Roanoke office and was advised that replacement checks were going to be issued.
On October 4th, 2007, a VA representative told us that the claim was being expedited and should be completed by the 14th. We were informed on the 14th and on the 30th that the updated medical reports still had not been received. However, on the 29th we began to receive the replacement checks for the temporary rating.
At this point in the timeline, it is important to note that our family had now been without our full disability compensation and benefits for almost 11 months. Our college-aged children were forced to withdraw. The overall financial strain, and frustration level, and emotional toll, in addition to the actual injury, were crushing.
Finally, on January 7th, 2008, after the intervention of Mr. Hall's Subcommittee and the Wounded Warrior Project, we received a final rating and back payment totaling thousands of dollars.
As you can see we filed and re-filed, submitted and resubmitted medical records, claims forms, applications, and so on. But no one seemed to be able to track anything, placing additional burdens on an already overwhelmed family. In our case, after the intervention of a Congressional office and a non-profit organization, we were able to get the benefits Tai has earned. This process should not be that hard.
Today, almost four years later, while we still have a few things to resolve with our ratings and benefits, our family is trying to move on.
Many people have stepped in to help us, from government agencies, to Congressional offices, to non-profit organizations. I am planning to return to work and school. Our children are returning to school. And Tai is enrolled in a media careers program for veterans in Chairman Filner's district. He has been a noted leader in the program, and ever the Gunny, and has even spoken to the Wounded Warrior Project about being a peer mentor.
However, our purpose in coming here today is not only to tell you our story, but also to let you know that we are not alone. People we know have had similar problems. And we know there are more out there.
We are hoping that our presence here will help you understand the obstacles faced by wounded members and their families and inspire everyone involved to work together to improve the efficiency of this vital system for the benefit of those who sacrificed so much for this country.
Thank you, and I look forward to any questions you may have.
[The statement of Gunnery Sergeant Cleveland appears in the Appendix.]
Mr. HALL. Thank you, Mrs. Cleveland, and thank you so much Gunnery Sergeant Cleveland for your testimony. And—If your case was expedited, I would hate to see one that was not expedited.
Now we recognize John Roberts from the Wounded Warrior Project. Mr. Roberts, you are recognized for five minutes.
Mr. ROBERTS. Mr. Chairman, Ranking Member Lamborn, distinguished Members of the Subcommittee, thank you for the opportunity to testify before you today regarding the use of technology to improve the efficiency of the Department of Veterans Affairs' claims process.
My name is John Roberts. And I am the National Service Director for the Wounded Warrior Project, a non-profit, non-partisan organization dedicated to assisting the men and women of the United States Armed Forces who have been injured during the current conflicts around the world.
As a result of our direct, daily contact with these wounded warriors, we have a unique perspective on their needs and the obstacles they face as they attempt to transition and reintegrate into their communities.
In addition to my experience with the Wounded Warrior Project in general and the Cleveland's case specifically, I am a service-connected veteran, a former veteran service officer, and most recently a supervisor with the Houston VA Regional Office where I had the opportunity to review claims and became familiar with a number of significant deficiencies within the system.
In order to fully appreciate the problem, it is important to understand how the systems currently operate. Despite recent advances in technology common to most businesses, the Veterans Benefits Administration claims processing system is still dependent on a paper system. Although the VBA can now view electronic health records transmitted from the Veterans Health Administration, the ratings team is still required to print the records, place them in the veterans claim folder, which are then reviewed page by page by a Veteran or a Rating Veteran Service Representative (RVSR).
The current model of the VBA claims processing system has a total of six separate teams and often, but not always, include another team that is dedicated to the processing of the Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) cases.
The six main teams are, of course, triage, which handles the incoming claims, evidence, and is charged with maintaining the outdated file cabinet system, which stores the hard copy paper claims files.
Predetermination, which is charged with the initial development of all claims for Service-connected disabilities.
The rating team is responsible for reviewing all available evidence and determining if the disabilities are service related. If so, they also assign the disability percentage.
The post-determination team is responsible for inputting awards and generating notification letters to the claimants.
The appeals team maintains all pending appeals submitted by all claimants.
And the public contact team is charged with the general phone calls, questions, and conducting one-on-one interviews with the veterans, dependents, and survivors.
Files must be hand carried to each of the teams. And any member of these teams has access to the records at any given time.
Despite the number of people with access and the ease of which files may be misplaced, VBA only has one way to locate the files once it is removed from the filing cabinet.
An electronic system called COVERS. But this system is only effective if utilized by the individual employee. Rather than having access to the file through electronic means, COVERS requires manual input to identify a specific location or individual. If this is not done, it is very time consuming to locate one file among all the files that are within the processing system.
I'll give you an example. Within the Houston Regional Office, there are approximately 200 employees. And each of these employees could have up to 30 or more files at his or her desk at any time.
Another challenge is the outdated filing system, which is used to store thousands of active files warehoused either at or near Regional Offices. If a file clerk or an employee for that matter is not paying attention and misfiles a claim folder into the wrong cabinet or drawer, it then becomes a very time consuming and difficult task to check each and every drawer to locate the missing file.
The Triage Team at each RO is responsible for the intake of all new claims and evidence submitted by each and every claimant. If the file is not easily located, the mail is placed on search within the COVERS system until the file can be located.
Because there are so many teams within the claims processing system, a particular file could be located within teams at any given time. This allows for—this allows for the human error factor, which is often why the numerous pieces of vital evidence are often lost or misplaced and cannot be associated with the appropriate claim folder.
If a file cannot be located and all avenues have been exhausted to locate the file, the Regional Office will take action to rebuild the folder from scratch. This means that all prior evidence, claims, and claims which are submitted by the claimant are then lost. The responsibility to replace the missing evidence or claims is placed on the claimant. The VA will ask the claimant to submit any copies that he or she may have in their possession.
In addition, due to the current war on terrorism, VBA is faced with another challenge. The new challenge is trying to obtain records from the National Guard and Reserve units. Active duty forces obviously do not file a claim until released from service. Once demobilized, a Reserve member or National Guard component is eligible to file such a claim. If reactivated, however, the Reservist's claim is halted and he or she at that time will take their service medical records with them into theater.
There is also the large backlog of records requests to the Records Management Center, which houses not only claim folders, but now receives all servicemember records for recently discharged servicemen. Think of this as a large warehouse of nothing but paper files and an inadequate staff to locate each and every file or record that has been requested by Regional Offices across the country.
Another significant issue, which can be identified at every Regional Office around the country, is the varying levels of experience of the Rating Veterans Service Representative. In any given case, you could take five individual RVSRs and give them the same file and come up with five different opinions on how the case should be rated.
Although there have been improvements with the implementation of Rating Board Automation (RBA) 2000, the current electronic system utilized to rate compensation claims, the system is far from perfect. The overall ratings decision, including the service connection and actual percentage, is left up to the interpretation of the individual RVSR.
The gap in varying decisions nationwide can also be attributed to the local policy at each individual Regional Office. While this has been the case for many years, the issue has come to a head due to the increased frequency at which this generation of veterans speak to each other and compare their individual situations.
Mr. Chairman, unfortunately, there are—these are only a few of the issues that surround a paper-based system. And situations like the Cleveland's are not unique. Many working groups, Government Accountability Office reports, and commissions have made recommendations on this topic.
Most recently, the Veterans' Disability Benefits Commission suggested that cycle times and accuracy could be improved by "establishing a simplified and expedited process for well-documented claims, using best business practices and maximum feasible use of the information technology."
While the availability of well-trained, customer-service-minded employees cannot be overvalued, the implementation and recommendations such as these can help to greatly reduce the complexity of the claims processing system and result in a timely—result in timely results.
WWP looks forward to working with you and the VA to try to resolve these problems. Thank you again for the opportunity to testify today. And I will be happy to answer any questions you may have.
[The statement of Mr. Roberts appears in the Appendix.]
Mr. HALL. Mr. Roberts, thank you very much for your service to our country, the Marines, VA, and also now with the Wounded Warrior Project.
And, I would start, I guess by asking Sergeant and Mrs. Cleveland what would you say were the biggest missteps in where the VA communicated with you?
Mrs. CLEVELAND. That is just it—the lack of communication.
Mr. HALL. Okay. It is just a simple answer.
Mrs. CLEVELAND. Right. What happens is you just get a general form letter that says "your file is incomplete" or "medical records are necessary."
But then when you contact someone or you finally are able to get someone on the phone, they have no idea what it is that you are talking about. And it becomes submit or resubmit the entire package.
Mr. HALL. So you were initiating most of the communications?
Mrs. CLEVELAND. Exactly.
Mr. HALL. Is this your file by the way on the table?
Mrs. CLEVELAND. This is a part of it.
Mr. HALL. It is—
Mrs. CLEVELAND. This is a snapshot of it. And I was in the process. And I had it in one-inch binders is what it started out in. And it has grown quite a bit.
Mr. HALL. The average we hear today is 183 days to process a claim. And that is hard enough to imagine. But in your case, it sounds like it went closer to 365 days.
Mrs. CLEVELAND. Probably a little bit further than that, because we initially applied while he was still on active duty. July 2005 was when his application went in, the BDD.
Mr. HALL. Well, somebody from this government ought to apologize to you. So let me be the first —if nobody else has, I apologize to you both on behalf of your government that you weren't taken care of and your needs were not attended to more quickly.
Mrs. CLEVELAND. Thank you.
Mr. TAI CLEVELAND. Thank you.
Mr. HALL. I am sorry that happened. And we are going to try to make sure that it does not happen to future veterans any more. I am going to try to reduce the time and reduce the number of repetitive requests, and stop making our veterans jump through hoops and prove that something is service related when it obviously is, and try to get people like you back integrated into something approaching normalcy and going about their lives in a much quicker way.
My understanding was it took, a full year for the VA to get you a check. And that was even after you underwent the BDD process.
Mrs. CLEVELAND. Correct.
Mr. HALL. What would have helped make this a better process, other than better communication? What would you list as the things that would have made it a better process for you?
Mrs. CLEVELAND. If the process were fully automated, that would make a huge difference, because then you would not have to venture out on this paper chase.
Mr. HALL. Right.
Mrs. CLEVELAND. From my understanding, the file moves from one person to the next person in the rating process. And if one piece of paper ends up missing, the next person, it is something that they need, they don't—it is not as simple as going back and saying, excuse me, you just gave me this record. And—page 20 is missing. Can you locate it?
Mr. HALL. Yeah.
Mrs. CLEVELAND. It becomes the claimant's, the veteran's job to get that page 20 in there. Only they don't know it is page 20, so it becomes resubmit.
Mr. HALL. Thank you very much.
Mrs. CLEVELAND. The automation.
Mr. HALL. Let me just ask Mr. Roberts, as a former Regional Office supervisor, could you describe for us how you would change this system to make it more effective and efficient for veterans?
Mr. ROBERTS. Well in the Clevelands' case specifically, the VA historically, until the War on Terrorism started, they didn't—they were not used to taking active duty servicemembers, and taking claims while they were still on active duty, and establishing a claims folder.
In their case, I would imagine that because he was on active duty, a claim folder was not established. Papers that were submitted, claims that were submitted, were not tracked in any way, shape, or form, and misplaced, lost. And that is why they were resubmitting over and over.
The current claims processing system right now that—Mrs. Cleveland is absolutely right. It goes from one hand to another, from one team to another. And if the veteran has an appeal pending, then it could be in any team within the Regional Office at any given time.
Definitely having the electronic file back and forth with DoD and VA would be the most beneficial system.
Mr. HALL. Do you believe it is really necessary for six teams to handle one case?
Mr. ROBERTS. No. This is—CPI was put into place several years ago. They used to have a team concept where files were rated. Everything was done within the same team. And the file stayed within that team.
The way they have it set up now, everybody is doing part of the assembly line process. And they have their own specific part. And then it is passed onto the next person to do theirs. So it was a little bit easier years ago to do the claim, because you have RVSRs. You had decision review officers. You had veteran service representatives. You had all the components to work the claim right there on one team.
Now responsibility gets passed along to whoever takes over from after they get done with their part. And they pass it on to someone else. So it is hard to track.
Mr. HALL. Thank you, sir. My time has run out. So I just want to ask very quickly—You mentioned that you can have more than one RVSR rating a case. Five different ones that come up with five different opinions–
Mr. ROBERTS. Right.
Mr. HALL. —can VETSNET fix that problem?
Mr. ROBERTS. VETSNET has come out. And they are working in it. Before I left the VA, it was just getting rolled out and being utilized. It doesn't fix it.
And it is still the interpretation portion that the RVSR actually does on their own. They look at it. They make a judgement call based on the medical evidence. And based on their background, their experience, they make their decision. So it is still flawed in the current way it is rolled out.
Mr. HALL. Thank you, sir. Now I will turn to our Ranking Member, Mr. Lamborn, for five minutes.
Mr. LAMBORN. I thank you, Mr. Chairman. Ms. Cleveland—Mrs. Cleveland, you mentioned that there are some unresolved issues. And the Chairman may have asked you briefly about that.
Is there still anything as we sit here that needs to be resolved that we can help you with? Briefly, if not, we might have to talk separately or if you haven't already talked.
Mrs. CLEVELAND. Separately.
Mr. LAMBORN. Okay.
Mrs. CLEVELAND. Thank you.
Mr. LAMBORN. Okay, okay. Thank you.
Mr. Roberts, do you believe that several of the problems that you laid out in your testimony to date could be solved with the new and up-to-date system, electronic system, that uses some form of artificial intelligence to adjudicate the claims?
Mr. ROBERTS. Honestly, sir, I am just not that familiar with it. I wouldn't even want to get involved with that. And I will leave that up to the experts.
Mr. LAMBORN. Okay. Well, thank you for your candidness there.
Why does the VA have a policy to place the responsibility to replace a lost file on the claimant?
Mr. ROBERTS. Well, once the file is lost, they have no other option. And they are hoping that the claimant themselves have copies, like the Clevelands, in their possession. And they can resubmit and kind of rebuild the folder from the ground up again.
You have got to remember when the file is lost and they have to go through this process, they lose all service medical records, DD-214's, the initial claims, any medical evidence submitted from private physicians or medical facilities. Everything is gone. They have to start completely from scratch and rebuild the file from the ground up.
Mr. LAMBORN. Okay. And you said in your testimony that numerous pieces of vital evidence are often lost or misplaced and cannot be associated with the appropriate claim folder. Could you give us a little more specificity on how often you think this happens?
Mr. ROBERTS. Well, I imagine—and just for an example, I used to use Houston, because I worked there. If the claim file is not where it is supposed to be, if it is not in the filing cabinet, or it is not at the person's desk that says it is actually located with, the mail is just put on search. And it is put in a bin in numerical order. And it sits there until somebody COVERS in a file to themselves and sees, you know, mail search pop up. And then they physically have to go get up and go get the mail and then associate it with the file. If they don't use the system, they never know the mail is there.
I have seen files go all the way through the processing system, be adjudicated, be rated, be finalized, letter has gone out to the veteran, the file goes back, gets covered into the filing cabinet, and the little GS-4 file clerk goes, "Oh, there is mail for it." And the process starts all over again. They have to go back and re-adjudicate and re-rate that claim based on the new evidence.
The system they have now is the human error. If they don't use it, it doesn't do you any good.
Mr. LAMBORN. Now it sounds like some of the issues we are talking about right this minute, and in response to earlier questions from the Chairman, and based on the testimony from the witnesses, has to do not so much with artificial intelligence or how the claims are adjudicated, but how the records are stored, and kept, and processed, and transferred.
So at a minimum, it sounds like we should be looking at digitizing some of these records to hopefully reduce the examples where things are lost and the time is lost trying to retrieve them, if that can be done. Or multiple people can look at them at the same time, if we have these six teams, more than one of which might be looking at it at the same time.
Do you think that that is a step that the VA, at a minimum, should take?
Mr. ROBERTS. I think that is exactly what they should be doing. I have seen—this is a small example of files I have seen. I have seen two or three boxes just for one file, one veteran, in large boxes. And I have seen boxes get lost that belong with other boxes.
So I got—I have seen files from veterans file—half of the file in one side of the building and the other half of the file on another side of the building. And it takes—I have seen up to a month for them to actually connect the two of them together.
So, yeah, I have actually seen people on the appeals team working a claim with half a file. And people in predetermination working on half a file. And I am not sure how they did it. But I have seen it.
Mr. LAMBORN. I thank you for your testimony. Mr. Chairman, I yield back.
Mr. HALL. Thank you, Mr. Lamborn. It would be funny were it not so serious. The Chair will now recognize Congressman Bilirakis for five minutes of questioning.
Mr. BILIRAKIS. Thank you, Mr. Chairman. My question has already been answered.
But I appreciate you holding this hearing. And we need to solve this once and for all, because I know it has been going on a long time. And the claims—the process is too long.
Thank you very much for testifying today. And thank you for your service.
Mr. HALL. I would add my thanks to all of you, and just say that, Mr. Roberts, the help that the Wounded Warrior Project provided and you provided is very welcome I'm sure to the Clevelands but also to all of us.
And, just knowing that this is not an isolated incident, I hope that we can set up a system using as much digitizing, electronic storage, and electronic motion, and shared files, as the Ranking Member was saying, so that we can avoid this; what looks like it is well over a foot high. If you piled those on top of each other, a foot high, for what you are saying, is a relatively small case in terms of the amount of information.
But at any rate, thank you for your testimony.
And we have votes that are underway now. So we will recess the hearing for as long as it takes for us to go across the street and vote. When we come back, we will hear from our second panel.
This Committee stands at recess until then.
[Recess.]
Mr. HALL. The Subcommittee will come to order. Thank you for your patience. We now have joining us at the witness table panel two.
Dr. Tom Mitchell, Chairman of the Machine Learning Department, School of Computer Science at Carnegie Mellon University; Dr. Randolph Miller, Chairman of the Department of Biomedical Informatics at Vanderbilt University of Medicine; Dr. Marjie Shahani, Senior Vice President of Operations at QTC Management, Inc.; Mr. Ned Hunter, Chief Executive Officer from the Stratizon or is it Stratizon?
Mr. HUNTER. Stratizon.
Mr. HALL. I am thinking of that other company that ends with "izon" Corporation, to describe a pilot study in Virginia. Mr. John F. McGarry, Senior Vice President of Benefits and Chief Risk Officer at Unum; and Mr. Gary Christopherson, the former Veterans Health Administration Chief Information Officer, former Senior Advisor to the Under Secretary for Health, and former Principal Deputy Assistant Secretary for Health Affairs. A distinguished group indeed. Ladies and gentlemen, welcome to this Subcommittee. Your full written statements, have been entered into the record. And so feel free to cut corners if you wish so that we will have time for questions.
We are expecting to have Ranking Member Lamborn back here any time. But since the next round of votes is scheduled in about 40 minutes, we are going to try to move this along so we can hear from you and not interrupt the panel to have to go vote.
Dr. Mitchell, you are now recognized for five minutes.
STATEMENTS OF TOM M. MITCHELL, PH.D., E. FREDKIN PROFESSOR AND CHAIR, MACHINE LEARNING DEPARTMENT, SCHOOL OF COMPUTER SCIENCE, CARNEGIE MELLON UNIVERSITY, PITTSBURGH, PA; RANDOLPH A. MILLER, M.D., DONALD A.B. AND MARY M. LINDBERG UNIVERSITY PROFESSOR OF BIOMEDICAL INFORMATICS, MEDICINE, AND NURSING, VANDERBILT UNIVERSITY SCHOOL OF MEDICINE, NASHVILLE, TN; MARJIE SHAHANI, M.D., SENIOR VICE PRESIDENT, OPERATIONS, QTC MANAGEMENT, INC., DIAMOND BAR, CA; NED M. HUNTER, PRESIDENT AND CHIEF EXECUTIVE OFFICER, STRATIZON CORPORATION, ATLANTA, GA (VA STATE PILOT STUDY); JOHN F. MCGARRY, SENIOR VICE PRESIDENT OF BENEFITS, CHIEF RISK OFFICER, UNUM, PORTLAND, ME; AND GARY A. CHRISTOPHERSON, UNIVERSITY PARK, MD (FORMER SENIOR ADVISOR TO THE UNDER SECRETARY FOR HEALTH, AND CHIEF INFORMATION OFFICER, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS, AND FORMER PRINCIPAL DEPUTY ASSISTANT SECRETARY FOR HEALTH AFFAIRS, U.S. DEPARTMENT OF DEFENSE)
STATEMENT OF TOM M. MITCHELL, PH.D.
Dr. MITCHELL. Thank you Chairman Hall and distinguished Members of the Committee.
It is an honor for me to be asked to testify here today, and to try to help you help the members of our armed services who have served.
Clearly, we face a significant problem and backlog in the processing of benefits claims by the VA. In my opinion, we have the technology needed to address and to eliminate this problem. Think for a moment of the forms filling problem that we are all familiar with, filling out forms for income taxes.
If we can develop computer software like TurboTax, which helps us fill out very complex multiple page forms, guides us through the steps to determine what kind of information to put in which kind of field, and then can instantly apply very complex tax regulation codes to calculate to the penny the amount of income tax that we owe, then I don't see why we can't develop software that performs an analogous function for the people who have to fill out forms for VA benefits and the people who have to apply the complex regulations to those.
To take a second example that is even more similar to the problem faced by the VA, consider the current practices for processing benefits claims in the medical insurance industry.
At Highmark Inc., which is a major provider of health insurance in my home State of Pennsylvania, I am told that 90 percent, nine zero percent, of the claims that come in from physician offices and from hospitals are automatically processed without any human intervention.
How do they do this? They do it by using electronic forms instead of paper. They do it by coding the treatments that the patients have received using industry standard (International Statistical Classification of Diseases and Related Health Problems) ICD-9 codes. They do it by developing rule-based software that captures the rules and regulations by which the correct payment is calculated from the details of the treatment received by the patient.
And after the decision is made automatically by the software, the payment is issued automatically. So that process happens in 90 percent of the cases automatically. And the other cases require human intervention.
Can the VA do the same? While the type of benefits claims processed by the VA may be somewhat different from those in the medical insurance industry, it seems to me the problems are similar enough that we ought to expect that the VA can also get a great benefit out of this kind of automation.
In my opinion, it is useful to consider a three-stage introduction of computer technology for claims processing in the VA. First, we can shift from pencil and paper claims to online claims. This alone would improve the accuracy, efficiency, and as we heard in the previous panel, the ability to hold onto and not lose claims.
Second, introducing computer software to help interpret these online claims to apply the regulations about which benefits are due would be a second step. We have well understood technologies for encoding complex regulations in software such as rule-based systems.
And for steps that require some human subjective judgment along the way, we also have technologies such as case-based reasoning, which allow the computer to pull up the two or three most similar previous claims in the system for inspection by the human as they are applying their judgment to this new case.
As the third step, once these claims are online and the processing is automated, the resulting database of claims can itself serve as a resource for data mining. Data mining methods can be applied to the claims data.
For example, data mining can be used to predict and flag new claims that are outliers that might require some specialized expertise to evaluate them, or to identify soldiers, veterans, who should be taking advantage of services that they appear not to and alerting them.
So to summarize, in applications from insurance claims processing to tax filing to customer help centers, there is a growing and widespread use of computer-based tools for capturing data in forms and for applying automatic rule-based inference to those.
Much of this technology comes out of research previously sponsored by Federal agencies such as the National Science Foundation and Defense Advanced Research Projects Agency. But the core technology is by now very well understood. This is not bleeding-edge technology.
The VA should take advantage of this. And I recommend three steps that can be carried on in parallel to get started.
One, conduct a detailed three-month study of the workflow process in the benefits office to determine the different steps and to identify for each o
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