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Witness Testimony of Lieutenant General James Terry Scott, USA (Ret.), Chairman, Advisory Committee on Disability Compensation

Chairman Miller, Ranking Member Filner, and Members of the Committee: It is my pleasure to appear before you today representing the Advisory Committee on Disability Compensation. The Committee is chartered by the Secretary of Veterans Affairs under the provisions of38 U.S.C. in compliance with P.L. 110-389 to advise the Secretary with respect to the maintenance and periodic readjustment of the VA Schedule for Rating Disabilities. Our charter is to "(A)ssemble and review relevant information relating to the needs of veterans with disabilities; provide information relating to the character of disabilities arising from service in the Armed Forces; provide and on-going assessment of the effectiveness of the VA's Schedule for Rating Disabilities; and provide on-going advice on the most appropriate means of responding to the needs of veterans relating to disability compensation in the future".

The Committee has met twenty nine times and has forwarded two reports to the Secretary that addressed our efforts as of September 30, 2010 and fulfilled the statutory requirement to submit a report by October 31,2010. (Copies of these reports were furnished to majority and minority staff in both Houses of Congress.) The Secretary of Veterans Affairs responded to the interim report on February 23,2010. (Copies provided for the Record).

Our focus has been in three areas of disability compensation: Requirements and methodology for reviewing and updating the VASRD; adequacy and sequencing of transition compensation and procedures for service members transitioning to veteran status with special emphasis on seriously ill or wounded service members; and disability compensation for non-economic loss (often referred to as quality of life).

After coordination with the Secretary's office and senior VA staff, we have added review of individual unemployment and the review of the methodology for determining presumptions to our agenda. Recently, we were asked to review the appeals process as it pertains to the timely and accurate award of disability compensation.

Your letter of invitation asked me to "(P)resent the views of the Department on the serious questions that have been raised about the VA mental health care system and the Department's ability to provide timely, effective and accessible care and benefits to veterans struggling with mental illness". I believe that the representatives of the Department are more current and better qualified to present the view of the Department. I am offering my views based on the analysis, findings, and recommendations of the Veterans Disability Benefits Commission (VDBC) that I had the privilege of chairing from 2004-2007.

Discussions with the Committee staff included a request that I review the pertinent findings and recommendations of the Veterans Disability Benefits Commission (VDBC) that met from 2004-2007 and made 113 recommendations covering a wide range of Veterans disability issues. Specifically, I was asked to discuss the VDBC work on the topic of integration among compensation, treatment, vocational assessment and training, and follow up examination for Veterans suffering from mental disability, to include PTSD.

It is important to acknowledge the significant progress that VA has made in adopting and implementing many of the VDBC recommendations and many of the recommendations of the Advisory Committee.

A master plan for reviewing and updating the entire VASRD body system by body system is published. A dedicated staff is working on this important project and making significant progress. A draft of the revised mental health body system is prepared and under review. Significant progress is underway on four other body systems with initial conferences set for October 2011 to begin review of three more body systems.

Disability Benefits Questionnaires are being developed and tested that simplify the process of evaluating conditions.

Additional adjudicators are being hired and trained.

VA and DoD have established working groups at all levels of the organizations to insure improved transition from soldier to veteran.

Pertinent to today's hearing, the VDBC invested significant time and effort analyzing the then current methods of diagnosing, evaluating, and adjudicating the claims of veterans suffering from mental illness including PTSD. Principal source documents used in the analysis were a 2005 report by the VA Office of the Inspector General that summarized the trends in PTSD claims and compensation from FY 1999-2004 and an Institute of Medicine study competed in 2006 titled "Posttraumatic Stress Disorder: Diagnosis and Assessment". These studies and the testimony of veterans, family members, medical professionals, and VA subject experts provided the basis for the six recommendations the VDBC offered. They are;

Recommendation 5.28

VA should develop and implement new criteria specific to posttraumatic stress disorder in the VA Schedule for Rating Disabilities. Base those criteria on the Diagnostic and Statistical Manual of Mental Disorders and consider a multidimensional framework for characterizing disability caused by posttraumatic stress disorder. (This recommendation is addressed by the revision of the pertinent VASRD section).

Recommendation 5.29

VA should consider a baseline level of benefits described by the Institute of Medicine to include health care as an incentive for recovery for posttraumatic stress disorder as it relapses and remits. (This recommendation is yet to be addressed and will likely be addressed as part of the comprehensive approach described in Recommendation 5.30)

Recommendation 5.30

VA should establish a holistic approach that couples posttraumatic stress disorder treatment, compensation, and vocational assessment. Reevaluation should occur every 2-3 years to gauge treatment effectiveness and encourage wellness. (This recommendation is the central issue in recasting V A approach to all mental illness including PTSD)

Recommendation 5.31 The posttraumatic stress disorder examination process: Psychological testing should be conducted at the discretion of the examining clinician. VA should identify and implement an appropriate replacement for the Global Assessment of Functioning. Post traumatic stress disorder data collection and research:

V A should conduct more detailed research on military sexual assault and posttraumatic stress disorder and develop and disseminate reference materials for raters.

Recommendation 5.32

A national standardized training program should be developed for VA and VA-contracted clinicians who conduct compensation and pension psychiatric evaluations. This training program should emphasize diagnostic criteria for posttraumatic stress disorder and comorbid conditions with overlapping symptoms, as set for the Diagnostic and Statistical Manual of Mental Disorders. (Implementing this recommendation will address the reported inconsistencies in diagnosis and evaluation of veterans claiming mental illness).

Recommendation 5.33

VA should establish a certification program for raters who deal with claims for posttraumatic stress disorder (PTSD), as well as provide training to support the certification program and periodic recertification. PTSD certification requirements should be regularly reviewed and updated to include medical advances and to reflect lessons learned. The program should provide specialized training on the psychological and medical issues (including comorbidities) that characterize the claimant population, and give guidance on how to appropriately manage commonly encountered rating problems. (Implementing this recommendation will also help address the reported inconsistencies in diagnosis and evaluation of veteran claiming mental illness. Consolidating the adjudicating of mental illness claims in a few centers of excellence may also assist in the timely, accurate and consistent award of mental disabilities).

The key recommendation of the VDBC regarding significant change to the VA approach to diagnosing, evaluating, adjudicating and treating mental disability is to create a linkage among compensation, treatment, vocational assessment/rehabilitation, and follow up examinations to determine efficacy of treatment. The benefits of linking treatment, compensation, vocational assessment, and periodic reevaluation include the potential to reduce homelessness and suicide as well as evaluate the effectiveness of treatment programs. Most importantly, it greatly improves the opportunity for a veteran suffering from mental disability to maximize his/her future contributions to society.

This is a controversial recommendation in the sense that it dramatically changes the role of the Department in evaluating and treating mental disability. The principal arguments against the linkage are that it will be viewed by some stakeholders as a mechanism to reduce disability payments and that it differs from how the Department addresses physical disabilities. Both of these arguments can be addressed with carefully written and explained regulation and/or policy directives. Recommendation 5.29 offers an approach to compensation that recognizes the relapsing and remitting nature of mental illness. Regarding the differences in approach to physical versus mental disabilities, there is significant evidence that individuals with mental disabilities are less likely to seek and maintain a treatment regimen than those with physical disabilities.

The VDBC recommendation to link compensation, treatment, vocational assessment/training, and periodic reevaluations offers an opportunity to reduce homelessness, suicide and substance abuse among veterans suffering from mental disabilities, particularly PTSD. Such an approach should offer long term help for mentally disabled veterans and improve their chances for maximum integration into society.

Thank you for the opportunity to present this recommendation to you and for your consideration and attention.