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Submission For The Record of Robert J. Epley, Member of the Advisory Committee on Disability Compensation

This statement is provided in response to your staff E-mail request of May 14, 2013,  asking me to provide a statement on the VA’s initiative to expedite processing of rating claims pending over two years.

Your request indicated you are interested in hearing views of organizations which may provide different perspectives on the implications of the VA initiative.  I serve as a member of the Advisory Committee on Disability Compensation.  This committee reviews matters relating to the VA Disability Compensation program and provides periodic reports to the Secretary and to your Committee.

The history of the Advisory Committee on Disability Compensation is that its charter and initial instructions from the Secretary suggested focus on the adequacy of the VA Schedule of Rating Disabilities (VASRD), as well as matters relating to veteran’s Quality of Life and transition from service to civilian life.  The Committee has devoted the majority of its time to these issues, although the VA has recently asked that we review matters related to the claims backlog.

The Committee has provided one interim report and two formal reports since its inception.  Our most recent report, dated October 31, 2012, discussed the need for timely and accurate claims resolution and offered six recommendations to improve workflow and processing time.  These recommendations did not specifically address claims over two years old.  The recommendations could, however, facilitate processing of aging claims.  They are listed below:
•    Set time expectations for each major step in the claims process to include: establishment of the claim; development of evidence; rating, and award authorization.  These expectations should be consistent with the overall goal of 125 days.
•    Require early and continuous claims management from filing to disposition.  
•    In addition to assigning claims to express, special operations or core lanes, triage all claims within 20 days of filing to award any part of the claim supported by the record; identify gaps in development and the records/exams needed to remedy the gaps; notify veterans and/or their representatives of information needed via a standard form.  
•    Seek out best practices in work flow management for claims and case management from subject matter experts with experience inside and outside VA.  
•    Standardize hearings by video conferencing to the maximum extent possible at the regional offices and exclusively at the BVA level.  
•    Establish centers of excellence for the processing of complex claims, e.g., PTSD and TBI.  

Our Advisory Committee has heard presentations from VA representatives, including the Under Secretary for Benefits, about the several ongoing initiatives to address the claims backlog and improve processing.

The volume of VBA Compensation claims pending for lengthy periods of time is an extremely important issue and it has vexed the organization for some time.

The VA has asked for, and received, authority to hire more claims examiners to work disability claims.  They have solicited management ideas from outside and inside the organization; they are evaluating several suggestions to improve processing.  They are actively working to improve the working relationship with DOD and other stakeholders.  They are looking at technology to facilitate improvements.  But for now at least, the backlog persists and grows.

Examples of key management initiatives to improve processing and address the backlog are the Veterans Benefits Management System (VBMS), eBenefits, Disability Benefits Questionnaires (DBQs), and sorting Compensation claims into “segmented lanes” for more efficient processing.  VBMS is intended to streamline the claims process primarily through a conversion to paperless processing.  eBenefits will provide a portal for veterans and claimants to access their records and to submit evidence electronically.  DBQs provide an electronic protocol that allows private physicians to conduct medical exams that will meet the VA’s evidentiary needs.  Segmented Lanes sorts the claims by type and complexity so they can receive more efficient handling.

The initiative to expedite claims over two years old appears to be an overarching one.  It will be intense and it is intended to be executed in the very near term.  The VA directive on this initiative (referred to as a Special Initiative) is VBA Letter 20-13-05, dated April 19, 2013.

In offering views on the VA Special Initiative, it is important to start by acknowledging that the goal to immediately review, decide, and complete all claims pending over two years is a laudable one.   Certainly, those veterans who have been waiting for decisions for two years or more deserve immediate attention.

The key components of the Special Initiative are:
•    All Rating Veterans Service Representatives (RVSRs) and as many Veterans Service Representatives (VSRs) will be devoted to the project;
•    All two year old cases are to be completed within 60 days (approximately June 18);
•    Complete final rating decision if all necessary and pertinent evidence is on hand and the claim is considered “ready to rate”;
•    Issue a “provisional” rating decision where VA is still waiting for certain evidence – for these claims, Service Treatment Records, VA medical records, any evidence needed to establish Veteran status and/or pertinent service dates, and appropriate VA medical exams;
•    No issues will be deferred;
•    For provisional decisions, one year from the date of the decision, ROs will assess all claims and provide notice of a final decision to include appeal rights;
•    For provisional decisions, no appeal rights will be provided to the claimant.

The VA Special Initiative addresses a very important issue.  It is also complicated.  It has significant positive aspects, and it will have ramifications that may seem negative.  I have listed some positive components, and some concerns about possible challenges and negative impacts below.
Positives –
•    The veterans whose claims have been pending so long can begin to receive their entitled benefits.  They certainly have medical and financial needs that have been challenged while they await claims decisions.
•    Claims can become more complicated as they age; deciding these claims will have a positive effect on the overall workload.
•    Addressing these critical claims on a priority basis demonstrates the VA’s concern for those with potentially the greatest need, as well as the VA’s commitment to reduce the overall backlog.

Possible Concerns –
•    If all RVSRs are devoted to the Special Initiative, then other claims will lay dormant for 60 days or more.  It is likely that this additional aging will result in additional questions and concerns from the veterans who have filed these “other” claims.  Responding to those questions will result in additional resource utilization being diverted from direct decision-making.
•    The concept of a provisional rating decision may be confusing to veteran-recipients.  Receipt of such a decision may trigger new, additional questions and concerns from the veteran-recipients.  Issuance of final decisions wherever possible will be preferable.  
•    Since the Special Initiative involves some procedural changes from normal processing flow, there may be confusion among VSRs and RVSRs which results in processing variances.
•    Provisional decisions executed under the Special Initiative will require a second review and promulgation of a final decision after one year has elapsed.  This second review and decision constitutes “new work”.  It represents work and resource expenditure that would not be necessary without the Special Initiative.  This could result in an overall reduction in claim decision output over the life of the initiative.  
•    Any special project involves adaptation of standard procedures.  Execution of the Special Initiative needs to remain cognizant of the statutory and regulatory framework that guides the Compensation program.  The Special Initiative must be executed within the existing statutory/regulatory framework so that decisions are not remanded or reversed through the appellate process.  

The concerns suggested above highlight how important it is that this Special Initiative be managed closely and vigorously.  Clearly, it has been undertaken with the best of intentions, but good intentions are often subverted by poor execution.  The Special Initiative will require close, constant communications within VBA and with the veteran community to avoid missteps.  There should be a formal communications protocol developed to assure that all employees and stakeholders are kept up to date on Special Initiative developments.  
This special initiative responds to a situation similar to one VBA faced a decade ago when the repercussions of the Veterans Claims Assistance Act (VCAA) resulted in a large backlog.  To address the oldest pending claims at that time, VBA created a special team called the “Tiger Team” in Cleveland to handle them. Rather than task all employees at each regional office to be involved, the aging claims were temporarily transferred to the Tiger Team for special handling.  This approach could be resurrected to assist with today’s generation of aging claims.  
As I mentioned above, VA is already working on several key management initiatives to help alleviate the backlog.  
All of these ongoing initiatives have merit and will add improvements to the Compensation claim process.  Clearly, VA needs to extract itself from the current limitations that result from reliance on paper.  An electronic process will bring many improvements.  Also, providing an electronic portal for submission of claims, evidence, and tracking claim progress will be very beneficial.  These enhancements will not, however, “fix the backlog”.  The Special Initiative on two year old claims will not either.  Additional measures need to be implemented to strengthen the initiatives listed above, and to maximize their impact.  

I have outlined several areas below where additional measures should be taken to strengthen Compensation program management.  The Advisory Committee on Disability Compensation has not discussed these areas in depth or agreed upon recommendations.  The views below represent my thoughts.  

VBA needs to undertake additional measures that relate to more basic management functions that will provide the foundation for improved technology and improved communications with the veterans.  These additional required improvement measures – Organizational Alignment, Ownership, Processing Team Improvements, and Accountability – will provide the foundation necessary to allow for reduction and control of the backlog.  

Organizational Alignment.  
Clearly, the VA strives to provide veterans with high quality, equitable decisions on a timely basis.  The likelihood of achieving these outcomes is greatly enhanced if everyone in the claims process understands how their role contributes to a successful outcome.  
Each position in the claims process (e.g., Development technician, VSR, RVSR, supervisor) needs to be structured to clearly focus on the core activity or activities that contribute directly to accurate, timely, professional decisions on disability compensation.  The core activities need to be measured.  The employees need to understand, and be regularly reminded, how their efforts fit into program outcomes.  Positive achievements in their core activities need to be rewarded – regularly and publicly (conversely, poor performance must be identified and addressed quickly).  
It is important for each employee to understand how his work feeds into the overall process. No single individual guarantees a positive outcome; all employees are contributing; helping each other move toward a positive outcome.  This implies that there should be regular communication among the different technical positions.  A given function needs to know if they are providing the claims package to the next phase in a manner that optimizes that next step.   

Ownership.
VBA needs to build in “ownership” of the process.  Historically, this has been a problem for VA.  There has not been clear ownership of the entire process.  But this process ownership must be established and it must resonate from well below the division level in the organization.  VBA needs to ensure that processing teams  own a claim from start to finish. These teams should include staff to do all phases of a claim: initial intake, triage, evidentiary development, rating evaluation, award authorization, and customer service.  Each team should have direct links to VHA and DOD, as well as NSOs.  These groups need to be vested in the success of the process.  
The role of management is critical to the success of the operations.  Supervisory and managerial responsibilities need to be clearly defined; at the core of their work is managing the workflow, analyzing and correcting bottlenecks, and most importantly, managing the people.  They are responsible for conveying the organizational message, recognizing quality performers and developing improvement plans for poor performers.
At the same time, VBA needs to build in clear responsibility for monitoring the claims flow.  This includes monitoring incoming work, and the number and age of claims pending in each step of the process.  By doing this, the responsible manager (the traffic cop) can adjust work assignments, move work around, etc., to minimize any bottlenecks.  This function requires a solid, sophisticated cycle time management system.  
The Segmented Lanes initiative seems to endorse this process ownership concept, and to the extent it does, that initiative deserves full support.  

Processing Team Improvements, Priorities, Flexibility.
There should be clear structure to the process, but there should also be flexibility built in to avoid unnecessary delays, and to properly handle unusual, problematic claims.  
The initial phase of the claim process must be strengthened.  It is critical that claims receive an initial review quickly, that the review correctly identifies all claimed and inferred issues and evidence needed for an informed, equitable decision.  The evidence gathering must start almost immediately.  It currently takes about seven months on average to collect identified evidence.  Within the existing regulatory and administrative constraints, this timeframe should be closer to three months with the introduction of improved efficiency and accountability measures.  
Claim flow needs to be revised to get the claims into the hands of senior technicians early in the process. The purpose of their review would be twofold: determine if ANY claimed conditions could be found service-connected, and clearly direct the action needed in order to make an informed decision.  For conditions clearly related to service they would either rate the condition(s) or immediately schedule an exam to determine current disabling effects.  
Exam scheduling should be changed.  If, at initial review, the senior technician finds that a VA exam is likely going to be needed, then the exam should be scheduled 45 – 60 days in the future.  In that way, the evidence development can be completed coincident with the exam.  
Specialization should be considered (selectively) for types of claims that are difficult, complex, or time-consuming.  (This is similar to VA’s Segmented Lanes concept.)  These difficult claims (for example, PTSD, Traumatic Brain Injury, or sexual trauma) should be handled exclusively by a special unit.  That unit could develop close relations to stakeholder groups (medical providers, DOD, CURR, etc.)  The special unit would own the claim for the veteran’s lifetime.  This would facilitate improved communications with the veteran.  It would also help build in accountability that is lost when a special unit handles a claim on a “one-time” basis, then sends it back to a “home” office.  
After VA converts fully to electronic records, they could consider using specialized offices for “referrals” and expert analysis of esoteric issues.  Such specialized offices would operate under unique accountability measures.  
Case management should be incorporated into the claims process. Just as specialization can help with complex categories of claims, case management can be an effective tool for individual claims that show difficulties or complexities.  Sometimes, these claims need special handling and/or more personal communications with the claimant.  Trust can be built, and roadblocks can be averted by more personal case handling. When individual claims are identified as unusual, difficult, or problematic, they would be assigned to a case manager.  As with specialization, case management should be used selectively.  It should not interrupt or overwhelm the basic team processing – it should complement that process.  Case management activities should be incorporated into the standard processing teams to assure clear accountability.  
Accountability.  
The Disability program’s quality assurance process should be dramatically strengthened.  The Compensation program has a national quality assurance program.  It is useful for that purpose – Quality Assurance.  Additionally, data from that process should be analyzed regularly to determine most persistent quality problems; root causes for those trends should be identified, and systemic corrections should be implemented to reduce the errors. In-process quality control reviews should be institutionalized.  (VBA has instituted a process called Quality Review Teams – QRT – but these do not constitute in-process quality control; they are currently designed to sample and quantify individual employee performance).  Data from these reviews could identify systemic and individual deficiencies, and lead to corrections that expedite the process.  
The Performance Management process needs to support and reinforce organizational alignment.  VBA uses an extensive Performance Management System, but the system should undergo thorough review and revision to assure that performance measures reflect the core activities of each position in the process. If the positions have been constructed properly to focus on activities that build toward successful outcomes, then reward of positive completion of those core activities will incentivize actions which lead to successful outcomes.  Each position should have performance measures focused around their core actions.  The structure of each position, and its performance measures, should also relate clearly to the performance measures of the whole claims process, so they are clearly linked to their colleagues’ performance in the process.  By constructing performance measures this way, each employee will be rewarded for focusing on their core activities; completing those activities productively, accurately, timely, and professionally.     
The concepts I have outlined above are probably not comprehensive.  Additional enhancements may be necessary to build an optimum claims process.  But I believe each of these ideas can help improve the current process.  
Thank you for the opportunity to address these very important issues before your Committee.  I greatly appreciate any opportunity to contribute to improved service to our veterans.