Witness Testimony of Dr. Gail Wilensky, Senior Fellow, Project HOPE
Before the introduction of the Integrated Disability Evaluation System (IDES), service members first needed to separate from his or her service and then to enter the VA process, requiring two different exams. The process and criteria for determining fitness differed across services and the process for determining disability differed between the services and the VA. The result was real and perceived differences in equity of treatment across services and between the services as well as a lengthy and frequently contentious process.
The IDES produces a single exam, done by a VA certified physician that serves both as the basis for determining fitness to serve and to establish a level of disability. The services continue to determine fitness to serve; the VA determines the disability level.
The result has been to cut the time from about 540 days to less than 295 days. It is a substantial reduction but far from the stated goal of 100 days. In addition, occasional lengthy and inexplicable delays are still reported. Several issues remain. First, why did it take so long to have the IDES fully rolled-out—from its development in 2007 until the fall of 2011? Second, shortening the time is important but clear agreement on the functions and goals of the disability evaluation program is equally important. Some questions remain here as well. The need also remains for ongoing, periodic medical evaluations to determine whether initial levels of disability continue in the future.
The Dole/Shalala Commission, where I was a commissioner, also recommended the complete restructuring of the disability and compensation system. Like the IDES, the goal was to simplify the disability determination, reduce parallel activities and inequities and most importantly, provide a basis for veterans to return to productive lives as fully and quickly as possible. To do this, we recommended a “transition payment” that would provide living expenses to the disabled veteran and their families during rehab, training and education. This was to be followed by an estimate of earnings-loss which may remain after training and/or education has been completed and which would also be accompanied by a quality of life payment, if appropriate. This division recognized that in an information and service economy, disabilities that previously would have produced earnings losses may no longer do so but quality of life decrements may continue. Three of the commissioners provided examples of how these differences might work.
Other areas also need strengthening to facilitate the transition from active duty service member to veteran. These include assuring that care is available to any veteran experiencing PTSD or TBI and working to reduce the stigma attached to both of these. The ongoing shortage of mental health professionals in the U.S. will make this a challenge. Efforts are also needed to continue strengthening support for families. We had recommended expanding respite care and extending FMLA for up to six months for spouses and parents of the seriously injured. The latter is a challenge in our fiscally-constrained environment.
On a positive note, most of the problems that were identified during the work of the Dole/Shalala Commission concerned the “hand-off” process and not the quality of care actually delivered. We need to ensure that both are appropriate for our returning wounded warriors.
Mr. Chairman and Members of the Veterans’ Affairs Subcommittee on Disability Assistance and Memorial Affairs: Thank you for inviting me here to testify about the transition from service member to Veteran, with a particular focus on the implementation of the Integrated Disability Evaluation System (IDES).
I am currently a senior fellow at Project HOPE, an international health education foundation that works to make health care available to people around the globe. I am also a Regent for the Uniformed Services University of the Health Sciences (USUHS). I have previously served as a Commissioner on the 2007 President’s Commission on the Care for America’s Returning Wounded Warriors (Dole/Shalala Commission), a co-chair for the Congressionally-mandated study on the Future of Military Health Care (2007-2008) and also as a co-chair on the 2001-2003 President’s Task Force to Improve Health Care Delivery for our Nation’s Veterans. The views I am presenting here reflect my training as an economist as well as the experiences I have had on these commissions and task forces. However, my testimony today reflects my personal views and not necessarily the views of Project HOPE or any of the other organizations with which I have been associated or continue to be associated.
I am here primarily to discuss the need for an integrated disability evaluation system and what has been reported about its early implementation as well as to remind the committee about the restructured compensation system that the Dole/Shalala Commission also recommended should be implemented. I will also briefly review some of the other issues that need to be considered in order to facilitate the transition from active duty service member to veteran status. Most of these are not new issues but rather have been recommended by various groups over the course of at least the last decade.
Before the introduction of the Integrated Disability Evaluation System, a service member needed to first separate from his or her service, with discharge papers in hand, before entering the VA process. Thus, two exams were required—one from the military services that determined fitness to serve and a second exam from the VA to determine a disability rating for purposes of compensation.
The process and the criteria for determining fitness to serve differed across services and the process for determining disability differed between the services and the VA, which raised perceptions of equity of treatment across the different services. Also, service members could potentially be rated at one level by their service and at another level by the VA, again raising questions of equity as well as causing confusion. In addition, these multiple steps ensured that the process was long and frequently contentious—averaging some 540 days.
Under the IDES, there is a single, comprehensive exam by VA certified physicians. A single-source disability rating is used that determines both for the purpose of fitness for continuing military service and also serves as the basis for the VA to rate the level of disability. Each military service continues to determine whether someone is able to continue military service.
Service members who are unable to return to active duty are referred to a medical evaluation board, assigned a physician evaluation board liaison officer whose job is to help them through the process. Each service member is also assigned a VA military service coordinator to help them navigate through the VA system.
The stated goal is to get the process done in 100 days. The estimates I have seen reported are that the former 540- day process was closer to 295 days as of mid 2011, indicating a clear improvement but also a time frame that is not as expeditious as might be desired. There are also still reports of inexplicable and frustrating delays such as was reported last summer at a Senate hearing where the application of a Marine who had lost both his arms and legs in Afghanistan in 2010 sat on a desk for 70 days, requiring a Senator’s personal intervention in order to get it dislodged.
Preliminary Assessment of the IDES
While the overall process is still relatively early in its implantation stage—having only gone fully live in the fall of 2011—there are some observations that can be made at this stage.
First, it is unclear why it has taken so long to get to this stage of the implementation process. The IDES was developed in 2007 in order to shorten the process of transition from active duty to veteran status. It followed from multiple recommendations that the Department of Defense and Veterans Administration use a single comprehensive standardized medical exam--including a recommendation from the Dole/Shalala Commission but certainly not limited to that Commission. While it is true that the Defense Department published guidance for a voluntary, expedited Disability Evaluation System in early 2009 for service members that had sustained catastrophic injuries, the full IDES was not implemented until later in 2011.
Having run the Medicare and Medicaid programs in the early 1990’s, I would agree that piloting a new system before taking it on-line is a reasonable and prudent step. Why it should take from 2007 until the fall of 2011 for a full transfer to the IDES is unclear to me.
Second, shortening the time to process a disability claim is important but the time involved per se is only part of the issue. Clearly agreeing on its function and making sure that this is fulfilled is a necessary step as well. Some ways that would shorten the process may not improve its fairness, such as eliminating a service member’s right of appeal.
Third, while the use of a single disability exam makes sense, it is important to recognize that there are different functions that medical exams serve, even though they may provide overlapping data fields. They can serve to define a course of clinical treatment, providing information about diagnoses and progress as opposed to a medical exam that is a single snapshot “finder of fact” that determines a level of disability. Both uses suggest the need for ongoing, periodic medical evaluations but done for different purposes.
Restructuring the Disability and Compensation System
The Dole/Shalala Commission also recommended a complete restructuring of the disability and compensation system. The purpose of the recommendation was to simplify the disability determination and compensation process, eliminate parallel activities, reduce inequities and perhaps, most importantly, provide a basis for veterans to return to productive lives as fully and quickly as possible.
Like the present system, the Commission advocated having the Defense Department determine fitness to serve. For those who are deemed “not fit”, the Commission recommended that the DoD provide a pension that reflects a payment for the years served. The payment should be determined only by the individual’s rank and the length of service. Those who are not fit because of combat-related injuries should receive TRICARE as should their dependents.
The VA should continue to have the responsibility for establishing the disability rating and compensation and benefits that follow from it. The VA should initiate its education and training programs as early as possible and adopt a policy of reviewing disability states on a three year basis.
The proposed restructuring of the VA disability payments was to work in steps. First, there would be a “transition payment”. This payment would be to cover living expenses for injured veterans and their families. It would be defined as three months of base pay in the event there is not further rehab going on or a longer term payment for living expenses if the veteran continues in some form of rehab or education program.
Second, following the completion of the rehab or education program, the disabled veteran would receive an “earnings-loss” payment in order to make up for any lower earning capacity that might remain after training, should that occur. In many cases, there should not be an earnings loss.
Third, a “quality of life” payment would be made to compensate for “non-work related” effects in the event of permanent physical or mental combat-related injuries.
The purpose of these steps is to support and encourage the injured veteran to advance as completely as possible using education and rehab and then to assess the effect on both earnings capacity and quality of life. It is recognition that in an information and service economy such as we have today, even significantly injured veterans may be able to be helped to a position where they would not experience an earnings-loss but would still be entitled to a quality of life payment.
Two of the commissioners on the Dole-Shalala Commission were examples of how VA or GI Bill financed education could put someone in such a position. Marc Giammatteo, an Army Captain had been severely wounded in his leg while in Iraq. He was also attending Harvard Business School, getting an MBA and spending his summer working at an investment bank. Jose Ramos was a Navy Corpsman who had also been serving in Iraq and had lost his right arm to the shoulder. He was completing a double major in Arabic and national security at George Mason. Both of these individuals should be in a position where they would not experience an earnings loss but would experience a quality of life decrement. On the other hand, Tammy Edwards, also on the Commission, is the wife of an Army enlisted man who was severely burned and experienced a brain injury while on active duty. His earnings loss would be significant in addition to his quality of life decrement.
Other Areas Needing Strengthening
As important as integrating the disability evaluation and restructuring the disability and compensations payment are to facilitating the transition from active duty to veterans’ status, there are other areas that need to be strengthened. Among the most important of these is making sure adequate care is available for any veteran who is experiencing PTSD or TBI. The DoD and the VA have been working hard to improve the prevention, diagnosis and treatment of both PTSD and TBI but much remains to be done. In addition, reducing the stigma associated with PTSD remains a problem for both active duty and veteran populations.
A major problem for both the Defense Department and the VA is that there is a national shortage of mental health professionals just as there is a national shortage of primary care professionals. Nonetheless, both departments will need to aggressively work on resolving this problem as aggressively and creatively as they can. It would also be helpful to provide programs to family members and caregivers to help them understand and deal with PTSD and TBI. Any efforts that can be undertaken to prevent PTSD and TBI from occurring, would be well worth-while on many fronts.
Efforts also need to continue to strengthen support for families. We had recommended expanding Defense Department respite care and extending the Family and Medical Leave Act for up to six months for spouses and parents of the seriously injured. The latter is especially a challenge in our currently constrained fiscal environment.
One of the most heartening findings of the Dole/Shalala Commission was that the quality of care provided to the wounded service members was of very high quality. Most of the problems that occurred, occurred during the “hand-offs”—that is, the transitioning from inpatient to outpatient status, from one facility to a second facility or from active duty to veteran status. Both the Defense Department and the VA have worked hard to reduce these problems and to simplify the path to recovery but more still needs to be done for our returning wounded warriors.
Thank you Mr. Chairman. I would be happy to answer any questions you or the Committee may have.