VA and Defense Health Care
More Information Needed to Determine If VA Can Meet an Increase in Demand for Post-Traumatic Stress Disorder Services Gao ID: GAO-04-1069 September 20, 2004Post-traumatic stress disorder (PTSD) is caused by an extremely stressful event and can develop after the threat of death or serious injury as in military combat. Experts predict that about 15 percent of servicemembers serving in Iraq and Afghanistan will develop PTSD. Efforts by VA to inform new veterans, including Reserve and National Guard members, about the expanded availability of VA health care services could result in an increased demand for VA PTSD services. GAO identified the approaches DOD uses to identify servicemembers at risk for PTSD and examined if VA has the information it needs to determine whether it can meet an increase in demand for PTSD services. GAO visited military bases and VA facilities, reviewed relevant documents, and interviewed DOD and VA officials to determine how DOD identifies servicemembers at risk for PTSD, and what information VA has to estimate demand for VA PTSD services.
DOD uses two approaches to identify servicemembers at risk for PTSD: the combat stress control program and the post-deployment health assessment questionnaire. The combat stress control program trains servicemembers to recognize the early onset of combat stress, which can lead to PTSD. Symptoms of combat stress and PTSD include insomnia, nightmares, and difficulties coping with relationships. To assist servicemembers in the combat theater, teams of DOD mental health professionals travel to units to reinforce the servicemembers' knowledge of combat stress symptoms and to help identify those who may be at risk for combat stress and PTSD. DOD also uses the post-deployment health assessment questionnaire to identify physical ailments and mental health issues commonly associated with deployments, including PTSD. The questionnaire includes the following four screening questions that VA and DOD mental health experts developed to identify servicemembers at risk for PTSD: Have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you (1) have had any nightmares about it or thought about it when you did not want to; (2) tried hard not to think about it or went out of your way to avoid situations that remind you of it; (3) were constantly on guard, watchful, or easily startled; and/or (4) felt numb or detached from others, activities, or your surroundings? VA lacks the information it needs to determine whether it can meet an increase in demand for VA PTSD services. VA does not have a count of the total number of veterans currently receiving PTSD services at its medical facilities and Vet Centers--community-based VA facilities that offer trauma and readjustment counseling. Without this information, VA cannot estimate the number of new veterans its medical facilities and Vet Centers could treat for PTSD. VA has two reports on the number of veterans it currently treats, with each report counting different subsets of veterans receiving PTSD services. Veterans who are receiving VA PTSD services may be counted in both reports, one of the reports, or not included in either report. VA does receive demographic information from DOD, which includes home addresses of servicemembers that could help VA predict which medical facilities or Vet Centers servicemembers may access for health care. By assuming that 15 percent or more of servicemembers who have left active duty status will develop PTSD, VA could use the home zip codes of servicemembers to broadly estimate the number of servicemembers who may need VA PTSD services and identify the VA facilities located closest to their homes. However, predicting which veterans will seek VA care and at which facilities is inherently uncertain, particularly given that the symptoms of PTSD may not appear for years.
RecommendationsOur recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.
Director: Team: Phone:GAO-04-1069, VA and Defense Health Care: More Information Needed to Determine If VA Can Meet an Increase in Demand for Post-Traumatic Stress Disorder Services
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Report to the Ranking Democratic Member, Committee on Veterans'
Affairs, House of Representatives:
September 2004:
VA AND DEFENSE HEALTH CARE:
More Information Needed to Determine If VA Can Meet an Increase in
Demand for Post-Traumatic Stress Disorder Services:
GAO-04-1069:
GAO Highlights:
Highlights of GAO-04-1069, a report to the Ranking Democratic Member,
Committee on Veterans' Affairs, House of Representatives
Why GAO Did This Study:
Post-traumatic stress disorder (PTSD) is caused by an extremely
stressful event and can develop after the threat of death or serious
injury as in military combat. Experts predict that about 15 percent of
servicemembers serving in Iraq and Afghanistan will develop PTSD.
Efforts by VA to inform new veterans, including Reserve and National
Guard members, about the expanded availability of VA health care
services could result in an increased demand for VA PTSD services. GAO
identified the approaches DOD uses to identify servicemembers at risk
for PTSD and examined if VA has the information it needs to determine
whether it can meet an increase in demand for PTSD services. GAO
visited military bases and VA facilities, reviewed relevant documents,
and interviewed DOD and VA officials to determine how DOD identifies
servicemembers at risk for PTSD, and what information VA has to
estimate demand for VA PTSD services.
What GAO Found:
DOD uses two approaches to identify servicemembers at risk for PTSD:
the combat stress control program and the post-deployment health
assessment questionnaire. The combat stress control program trains
servicemembers to recognize the early onset of combat stress, which
can lead to PTSD. Symptoms of combat stress and PTSD include insomnia,
nightmares, and difficulties coping with relationships. To assist
servicemembers in the combat theater, teams of DOD mental health
professionals travel to units to reinforce the servicemembers‘
knowledge of combat stress symptoms and to help identify those who may
be at risk for combat stress and PTSD. DOD also uses the post-
deployment health assessment questionnaire to identify physical
ailments and mental health issues commonly associated with deployments,
including PTSD. The questionnaire includes the following four screening
questions that VA and DOD mental health experts developed to identify
servicemembers at risk for PTSD:
Have you ever had any experience that was so frightening, horrible,
or upsetting that, in the past month, you
* have had any nightmares about it or thought about it when you did
not want to?
* tried hard not to think about it or went out of your way to avoid
situations that remind you of it?
* were constantly on guard, watchful, or easily startled?
* felt numb or detached from others, activities, or your surroundings?
VA lacks the information it needs to determine whether it can meet an
increase in demand for VA PTSD services. VA does not have a count of
the total number of veterans currently receiving PTSD services at its
medical facilities and Vet Centers”community-based VA facilities that
offer trauma and readjustment counseling. Without this information, VA
cannot estimate the number of new veterans its medical facilities and
Vet Centers could treat for PTSD. VA has two reports on the number of
veterans it currently treats, with each report counting different
subsets of veterans receiving PTSD services. Veterans who are
receiving VA PTSD services may be counted in both reports, one of the
reports, or not included in either report. VA does receive demographic
information from DOD, which includes home addresses of servicemembers
that could help VA predict which medical facilities or Vet Centers
servicemembers may access for health care. By assuming that 15 percent
or more of servicemembers who have left active duty status will
develop PTSD, VA could use the home zip codes of servicemembers to
broadly estimate the number of servicemembers who may need VA PTSD
services and identify the VA facilities located closest to their
homes. However, predicting which veterans will seek VA care and at
which facilities is inherently uncertain, particularly given that the
symptoms of PTSD may not appear for years.
What GAO Recommends:
GAO recommends that VA determine the total number of veterans
receiving VA PTSD services and provide facility-specific information
to VA medical facilities and Vet Centers. VA concurred with GAO‘s
recommendation and plans to aggregate data on the total number of
veterans it treats for PTSD at VA facilities. DOD concurred with GAO‘s
findings and conclusions.
www.gao.gov/cgi-bin/getrpt?GAO-04-1069.
To view the full product, including the scope and methodology, click
on the link above. For more information, contact Cynthia A. Bascetta
at (202) 512-7101.
[End of section]
Contents:
Letter:
Results In Brief:
Background:
DOD Uses Two Approaches to Identify Servicemembers At Risk for PTSD:
VA Lacks Information Needed to Determine Whether It Can Meet an
Increase in Demand for PTSD Services:
Conclusions:
Recommendation for Executive Action:
Agency Comments:
Appendixes:
Appendix I: Scope and Methodology:
Appendix II: Department of Defense Post-Deployment Health Assessment
Questionnaire DD-2796:
Appendix III: Comments from the Department of Veterans Affairs:
Appendix IV: Comments from the Department of Defense:
Appendix V: GAO Contact and Staff Acknowledgments:
GAO Contact:
Acknowledgments:
Related GAO Products:
Figures:
Figure 1: DOD's Process for "Yes" Responses to PTSD Questions on DD
2796:
Figure 2: Veterans Included in VA's Annual Reports:
Abbreviations:
DOD: Department of Defense:
NEPEC: Northeast Program Evaluation Center:
OIG: Office of Inspector General:
PTSD: post-traumatic stress disorder:
VA: Department of Veterans Affairs:
Letter September 20, 2004:
The Honorable Lane Evans:
Ranking Democratic Member:
Committee on Veterans' Affairs:
House of Representatives:
Dear Mr. Evans:
Mental health experts predict that because of the intensity of warfare
in Iraq and Afghanistan 15 percent or more of the servicemembers
returning from these conflicts will develop post-traumatic stress
disorder (PTSD).[Footnote 1],[Footnote 2] his rate approximates the
PTSD rate for Vietnam War veterans.[Footnote 3] PTSD, which is caused
by an extremely stressful event, can develop after military combat and
exposure to the threat of death or serious injury. Symptoms of PTSD,
which may appear within months or be delayed for years after the
stressful event, include insomnia, intense anxiety, nightmares about
the event, and difficulties coping with work, family, and social
relationships. Although there is no cure for PTSD, experts believe that
early identification and treatment of PTSD symptoms may lessen the
severity of the condition and improve the overall quality of life for
servicemembers and veterans. If left untreated, PTSD can lead to
substance abuse, severe depression, and suicide.
The Department of Veterans Affairs (VA) has intensified its efforts to
inform new veterans from the Iraq and Afghanistan conflicts about the
health care services--including treatment for PTSD--it offers to
eligible veterans. These efforts, along with expanded availability of
VA health care services for Reserve and National Guard members, could
result in an increased percentage of veterans from Iraq and Afghanistan
seeking PTSD services through VA. Concerns have been raised about
whether VA can provide PTSD services for a new influx of veterans,
while at the same time continuing these services for veterans that VA
currently treats for PTSD.
You asked that we review the Department of Defense's (DOD) efforts to
identify servicemembers who have served in Iraq and Afghanistan and are
at risk for PTSD, and VA's efforts to ensure that PTSD services are
available for all veterans. Specifically, we identified the approaches
DOD uses to identify servicemembers who are at risk for PTSD. We also
examined if VA has the information it needs to determine whether it can
meet an increase in demand for VA PTSD services.
To determine the approaches DOD uses to identify servicemembers who are
at risk for PTSD, we reviewed documents, interviewed DOD officials, and
visited a military installation for each of DOD's uniform services,
some of which had large numbers of servicemembers returning from Iraq
and Afghanistan. We have reviewed how well DOD's uniform services
implemented these approaches in previous work and did not address that
issue in this review.[Footnote 4] To determine whether VA has the
information it needs to estimate the future demand for VA PTSD
services, we interviewed VA headquarters and facility officials to
discuss the number of veterans receiving treatment for PTSD and future
demand for these services in areas of the country where large numbers
of servicemembers were returning from Iraq and Afghanistan. To obtain
additional information on identifying and treating veterans with PTSD,
we interviewed VA's PTSD experts at the National Center for
PTSD.[Footnote 5] We reviewed VA's annual capacity reports, which
include information on the number of seriously mentally ill veterans
receiving PTSD services. We also reviewed the findings of the VA Office
of Inspector General (OIG) who is responsible for reporting to Congress
on the accuracy of VA's capacity reports. We did not include data from
VA's annual capacity reports because the OIG found that the data were
not sufficiently reliable. We also interviewed VA headquarters and
facility officials and DOD officials to determine what information they
share about returning servicemembers. For a complete description of our
scope and methodology, see appendix I. Our work was conducted from May
through September 2004 in accordance with generally accepted government
auditing standards.
Results In Brief:
DOD uses two approaches to identify servicemembers at risk for PTSD:
the combat stress control program and the post-deployment health
assessment questionnaire. The combat stress control program trains
servicemembers to recognize the early symptoms of combat stress, which
can be a precursor to PTSD. To assist servicemembers in the combat
theater, teams of DOD mental health professionals travel to units to
reinforce the servicemembers' knowledge of combat stress symptoms and
to help identify those who may be at risk for combat stress or PTSD.
DOD uses the post-deployment health assessment questionnaire to
identify physical ailments and mental health issues commonly associated
with deployments, including PTSD. The questionnaire includes four
screening questions that VA and DOD mental health experts developed to
identify servicemembers who may be at risk of developing PTSD. DOD
generally requires servicemembers deployed outside of the United States
to complete this questionnaire within 30 days before leaving a
deployment location or within 5 days after returning to the United
States. Completed questionnaires must be reviewed by a DOD clinical
provider, who interviews servicemembers to determine if further medical
evaluation is necessary.
VA lacks the information it needs to determine whether it can meet an
increase in demand for VA PTSD services. VA does not have a count of
the total number of veterans currently receiving PTSD services at its
medical facilities and Vet Centers--community-based VA facilities that
offer trauma and readjustment counseling. Without this information, VA
cannot estimate the number of additional veterans its medical
facilities and Vet Centers could treat for PTSD. A VA official told us
that a count of the total number of veterans with a diagnosis of PTSD
who receive VA services at medical facilities could be obtained from
VA's existing database. However, this database does not include Vet
Centers' information because this information is kept separate from the
medical facilities' data. VA has two reports on the number of veterans
it currently treats, with each report counting different subsets of
veterans receiving PTSD services. Veterans who are receiving VA PTSD
services may be counted in both reports, one of the reports, or not
included in either report. For example, veterans receiving PTSD
services exclusively in Vet Centers may not be counted in either
report. On the other hand, VA does have information it can use to
broadly estimate the number of servicemembers who may access VA health
care, including PTSD services. In September 2003, DOD provided VA with
demographic information on servicemembers from the Iraq and Afghanistan
conflicts who have left active duty status and are eligible for VA
health care. The demographic information includes the names and home
addresses of servicemembers. In July 2004, VA provided this information
to its facilities for planning future services for additional veterans.
By assuming that 15 percent or more of returning servicemembers will
develop PTSD, based on the predictions of mental health experts, VA and
its facilities could use DOD's demographic information to broadly
estimate demand for PTSD services. However, predicting which veterans
will seek VA care and at which facilities is inherently uncertain,
particularly given that the symptoms of PTSD may not appear for years.
Based on DOD's demographic information, some VA medical facility
officials expressed concern about their ability to meet an increase in
demand for VA PTSD services from servicemembers returning from Iraq and
Afghanistan.
To help VA better estimate the number of additional veterans it could
treat for PTSD and to plan for the future demand for VA PTSD services,
we recommend that VA determine the total number of veterans receiving
VA PTSD services and provide facility-specific information to VA
medical facilities and Vet Centers. VA and DOD commented on a draft of
this report. In its comments VA concurred with our recommendation and
acknowledged that more coordinated efforts are needed to improve its
existing PTSD data. VA stated that it plans to aggregate at the
national level the number of veterans receiving PTSD services at VA
medical facilities and Vet Centers. DOD concurred with the findings and
conclusions in this report and provided technical comments on the
report, which we incorporated as appropriate.
Background:
PTSD can develop following exposure to life-threatening events, natural
disasters, terrorist incidents, serious accidents, or violent personal
assaults like rape. PTSD is the most prevalent mental disorder arising
from combat. People who experience stressful events often relive the
experience through nightmares and flashbacks, have difficulty sleeping,
and feel detached or estranged. These symptoms may occur within the
first 4 days after exposure to the stressful event or be delayed for
months or years. Symptoms that appear within the first 4 days after
exposure to a stressful event are generally diagnosed as acute stress
reaction or combat stress. If the symptoms of acute stress reaction or
combat stress continue for more than 1 month, PTSD is diagnosed.
PTSD services are provided in VA medical facilities and VA community
settings. VA medical facilities offer PTSD services as well as other
services, which range from complex specialty care, such as cardiac or
spinal cord injury, to primary care. VA's community settings include
more than 800 community-based outpatient clinics and 206 Vet Centers.
Community-based outpatient clinics are an extension of VA's medical
facilities and mainly provide primary care services.[Footnote 6] Vet
Centers offer PTSD and family counseling, employment services, and a
range of social services to assist veterans in readjusting from wartime
military service to civilian life. Vet Centers also function as
community points of access for many returning veterans, providing them
with information and referrals to VA medical facilities. Vet Centers
were established as entities separate from VA medical facilities to
serve Vietnam veterans, who were reluctant to access health care
provided in a federal building. As a result, Vet Centers are not
located on the campuses of VA medical facilities.
VA has specialized PTSD programs that are staffed by clinicians who
have concentrated their clinical work in the area of PTSD treatment. VA
specialized PTSD programs are located in 97 VA medical facilities and
provide services on an inpatient and outpatient basis. VA PTSD services
include individual counseling, support groups, and drug therapy and can
be provided in non-specialized clinics, such as general mental health
clinics.
Veterans who served in any conflict after November 11, 1998 are
eligible for VA health care services for any illness, including PTSD
services, for 2 years from the date of separation from military
service, even if the condition is not determined to be attributable to
military service.[Footnote 7] This 2-year eligibility includes those
Reserve and National Guard members who have left active duty and
returned to their units. After 2 years, these veterans will be subject
to the same eligibility rules as other veterans, who generally have to
prove that a medical problem is connected to their military service or
have relatively low incomes. In July 2004, VA reported that so far
32,684 or 15 percent of veterans who have returned from service in Iraq
or Afghanistan, including Reserve and National Guard members, have
accessed VA for various health care needs.
DOD and VA have formed a Seamless Transition Task Force with the goal
of meeting the needs of servicemembers returning from Iraq and
Afghanistan who will eventually become veterans and may seek health
care from VA. To achieve this goal, DOD and VA plan to improve the
sharing of information, including individual health information,
between the two departments in order to enhance VA's outreach efforts
to identify and serve returning servicemembers, including Reserve and
National Guard members, in need of VA health care services. Since April
2003, VA requires that every returning servicemember from the Iraq and
Afghanistan conflicts who needs health care services receive priority
consideration for VA health care appointments.[Footnote 8]
DOD Uses Two Approaches to Identify Servicemembers At Risk for PTSD:
DOD uses two approaches to identify servicemembers who may be at risk
of developing PTSD: the combat stress control program and the post-
deployment health assessment questionnaire. DOD's combat stress control
program identifies servicemembers at risk for PTSD by training all
servicemembers to identify the early onset of combat stress, which if
left untreated, could lead to PTSD. DOD uses the post-deployment health
assessment questionnaire to screen servicemembers for physical ailments
and mental health issues commonly associated with deployments,
including PTSD. The questionnaire contains four screening questions
that were developed jointly by DOD and VA mental health experts to
identify servicemembers at risk for PTSD.
DOD Trains Servicemembers to Identify Symptoms That Could Lead to PTSD:
DOD's combat stress control program identifies servicemembers at risk
for PTSD by training all servicemembers to identify the early onset of
combat stress symptoms, which if left untreated, could lead to PTSD.
The program is based on the principle of promptly identifying
servicemembers with symptoms of combat stress in a combat theater, with
the goal of treating and returning them to duty.[Footnote 9] This
principle is consistent with the views of PTSD experts, who believe
that early identification and treatment of combat stress symptoms may
reduce the risk of PTSD. To assist servicemembers in the combat
theater, teams of DOD mental health professionals travel to units to
reinforce the servicemembers' knowledge of combat stress symptoms and
to help identify those who may be at risk for combat stress or PTSD.
The teams may include psychiatrists, psychologists, social workers,
nurses, mental health technicians, and chaplains. DOD requires that the
effectiveness of the combat stress control program be monitored on an
annual basis.
DOD Uses the Post-Deployment Questionnaire to Identify Servicemembers
At Risk for PTSD:
DOD generally uses the post-deployment health assessment questionnaire,
DD 2796, to identify servicemembers at risk for PTSD following
deployment outside of the United States.[Footnote 10] (See app. II for
a copy of the DD 2796.) DOD requires certain servicemembers deployed to
locations outside of the United States to complete a DD 2796 within 30
days before leaving a deployment location or within 5 days after
returning to the United States.[Footnote 11]This applies to all
servicemembers returning from a combat theater, including Reserve and
National Guard members.
The DD 2796 is a questionnaire used to determine the presence of any
physical ailments and mental health issues commonly associated with
deployments, any special medications taken during deployment, and
possible environmental or occupational exposures. The DD 2796 includes
the following four screening questions that VA and DOD mental health
experts developed to identify servicemembers at risk for PTSD:
Have you ever had any experience that was so frightening, horrible, or
upsetting that, in the past month, you;
* have had any nightmares about it or thought about it when you did
not want to?
* tried hard not to think about it or went out of your way to avoid
situations that remind you of it?
* were constantly on guard, watchful, or easily startled?
* felt numb or detached from others, activities, or your surroundings?
[End of table]
Once completed, the DD 2796 must be initially reviewed by a DOD health
care provider, which could range from a physician to a medic or
corpsman.[Footnote 12] Figure 1 illustrates DOD's process for
completion and review of the DD 2796. The form is then reviewed,
completed, and signed by a health care provider, who can be a
physician, physician assistant, nurse practitioner, or an independent
duty medical technician or corpsman. This health care provider reviews
the completed DD 2796 to identify any "yes" responses to the screening
questions--including questions related to PTSD--that may indicate a
need for further medical evaluation. The review is to take place in a
face-to-face interview with the servicemember and be conducted either
on an individual basis, as we observed at the Army's Fort Lewis in
Washington, or in a group setting, as we found at the Marine Corps'
Camp Lejeune in North Carolina. If a servicemember answers "yes" to a
PTSD question, the health care provider is instructed to gather
additional information from the servicemember and use clinical judgment
to determine if the servicemember should be referred for further
medical evaluation to a physician, physician's assistant, nurse, or an
independent duty medical technician.[Footnote 13],[Footnote 14]To
document completion of the DD 2796, DOD requires that the
questionnaire be placed in the servicemember's permanent medical
record and a copy sent to the Army Medical Surveillance Activity,
which maintains a database of all servicemembers' completed health
assessment questionnaires.[Footnote 15]
Figure 1: DOD's Process for "Yes" Responses to PTSD Questions on DD
2796:
[See PDF for image]
[End of figure]
The National Defense Authorization Act for Fiscal Year 1998 required
DOD to establish a quality assurance program to ensure, among other
things, that post-deployment mental health assessments are
completed[Footnote 16] for servicemembers who are deployed outside of
the United States. Completion of the DD 2796 is tracked as part of this
quality assurance program.[Footnote 17] DOD delegated responsibility
for developing procedures for the required quality assurance program to
each of its uniform services. The uniform services have given unit
commanders the responsibility to ensure completion of the DD 2796 by
all servicemembers under their command. To ensure the DD 2796 is
completed, one DOD official we interviewed told us that servicemembers
would not be granted leave to go home until the DD 2796 was completed.
Another official told us that Reserve and National Guard members would
not be given their active duty discharge paperwork until the DD 2796
was completed.
VA Lacks Information Needed to Determine Whether It Can Meet an
Increase in Demand for PTSD Services:
VA does not have all the information it needs to determine whether it
can meet an increase in demand for VA PTSD services. VA does not have a
count of the total number of veterans currently receiving PTSD services
at its medical facilities and Vet Centers. Without this information, VA
cannot estimate the number of veterans its medical facilities and Vet
Centers could treat for PTSD. VA could use demographic information it
receives from DOD to broadly estimate the number of servicemembers who
may access VA health care, including PTSD services. By assuming that 15
percent or more of returning servicemembers will develop PTSD, VA could
use the demographic information to broadly estimate demand for PTSD
services. However, predicting which veterans will seek VA care and at
which facilities is inherently uncertain, particularly given that the
symptoms of PTSD may not appear for years.
VA Does Not Have Information on the Total Number of Veterans Currently
Receiving PTSD Services:
VA does not have a count of the total number of veterans currently
receiving PTSD services at its medical facilities and Vet Centers.
Without this information, VA cannot estimate the number of additional
veterans its facilities could treat for PTSD. On August 27, 2004, a
Northeast Program Evaluation Center (NEPEC) official told us that a
count of the total number of veterans with a diagnosis of PTSD who
receive VA services at medical facilities could be obtained from VA's
existing database. However, this database does not include Vet Centers'
information because this information is kept separate from the medical
facilities' data.
VA publishes two reports that contain information on some of the
veterans receiving PTSD services at its medical facilities. Neither
report includes all veterans receiving PTSD services at VA medical
facilities and Vet Centers. VA's annual capacity report, which is
required by law,[Footnote 18] provides data on VA's most vulnerable
populations, such as veterans with spinal cord injuries, blind
veterans, and seriously mentally ill veterans with PTSD.[Footnote 19]
The NEPEC annual report mainly provides data on veterans with a primary
diagnosis of PTSD.[Footnote 20] VA has not developed a methodology that
would allow it to count the number of veterans receiving PTSD services
at its medical facilities and Vet Centers.
The PTSD data used in VA's annual capacity report and the data used in
NEPEC's annual report are drawn from different--though not mutually
exclusive--subgroups of veterans receiving PTSD services at VA's
medical facilities. VA developed criteria that allow it to determine
which veterans should be included in each subgroup. VA's criteria,
which differ in each report, are based on the type and frequency of
mental health services provided to veterans with PTSD at its medical
facilities. (See Figure 2 for the veterans included in each of VA's
annual reports.)
Figure 2: Veterans Included in VA's Annual Reports:
[See PDF for image]
Note: Analysis of VA's Fiscal Year 2002 "Maintaining Capacity to
Provide for the Specialized Treatment and Rehabilitative Needs of
Disabled Veterans" and NEPEC's "Long Journey Home XII Treatment of
Posttraumatic Stress Disorder in the Department of Veterans Affairs:
Fiscal Year 2003 Service Delivery and Performance." Examples of VA
specialized mental health services include PTSD and substance abuse.
[A] This refers to Table E1 in Appendix E of The Long Journey Home XII
Treatment of Posttraumatic Stress Disorder in the Department of
Veterans Affairs: Fiscal Year 2003 Service Delivery and Performance
Northeast Program Evaluation Center, VA Connecticut Healthcare System
(Connecticut: April 2004).
[End of figure]
Veterans who are receiving VA PTSD services may be counted in both
reports, only counted in the NEPEC report, or not included in either
report. For example, a veteran who is seriously mentally ill and has a
primary diagnosis of PTSD is counted in both reports. On the other
hand, a veteran who has a primary diagnosis of PTSD but is not defined
as seriously mentally ill is counted in the NEPEC report but not in the
capacity report. Finally, a veteran who is receiving PTSD services only
at a Vet Center is not counted in either report.
Furthermore, both the VA OIG and VA's Committee on Care of Veterans
with Serious Mental Illness have found inaccuracies in the data used in
VA's annual capacity report.[Footnote 21]For example, OIG found
inconsistencies in the PTSD program data reported by some VA medical
facilities. OIG found that some medical facilities reported having
active PTSD programs, although the facilities reported having no staff
assigned to these programs. Additionally, the Committee on Care of
Veterans with Serious Mental Illness, commenting on VA's fiscal year
2002 capacity report, stated the data VA continues to use for reporting
information on specialized programs are inaccurate and recommended
changes in future reporting.[Footnote 22],, VA agreed with OIG that the
data were inaccurate and is continuing to make changes to improve the
accuracy of the data in its annual capacity report. VA's fiscal year
2003 capacity report to Congress is currently undergoing review by OIG,
which informed us that VA has not incorporated all of the changes
necessary for OIG to certify that the report is accurate. OIG further
stated that it will continue to oversee this process.
VA Has Information to Broadly Estimate Future Demand for PTSD Services:
VA has information it can use to broadly estimate what the increase in
demand for VA PTSD services may be from returning servicemembers. In
September 2003, DOD began providing VA with demographic information on
servicemembers returning from the Iraq and Afghanistan conflicts who
have left active duty status and are eligible for VA health
care.[Footnote 23] The information includes name, home address
including zip code, branch of service, and gender.[Footnote 24] Using
servicemembers' home zip codes could help VA predict the facilities or
Vet Centers that could experience an increase in demand for care. By
assuming that 15 percent or more of returning servicemembers will
eventually develop PTSD, based on the predictions of mental health
experts, VA could use the demographic information to broadly estimate
the number of returning servicemembers who may need VA PTSD services
and the VA facilities located closest to servicemembers' homes.
However, predicting which veterans will seek VA care and at which
facilities is inherently uncertain, particularly given that the
symptoms of PTSD may not appear for years.
VA headquarters received demographic information from DOD in September
2003; however, during our review we found that VA had not shared this
information with its facilities. On July 21, 2004, VA provided this
information to its medical facilities for planning future services for
veterans returning from the Iraq and Afghanistan conflicts. However, VA
did not provide the demographic information to Vet Centers. Officials
at seven VA medical facilities told us that while the demographic
information VA receives from DOD has limitations, it is the best
national data currently available and would help them plan for new
veterans seeking VA PTSD services.
Officials at six of the seven VA medical facilities we visited
explained that while they are now able to keep up with the current
number of veterans seeking PTSD services, they may not be able to meet
an increase in demand for these services.[Footnote 25] In addition,
some of the officials expressed concern about their ability to meet an
increase in demand for VA PTSD services from servicemembers returning
from Iraq and Afghanistan based on DOD's demographic information.
Officials are concerned because facilities have been directed by VA to
give veterans of the Iraq and Afghanistan conflicts priority
appointments for health care services, including PTSD service. As a
result, VA medical facility officials estimate that follow-up
appointments for veterans currently receiving care for PTSD may be
delayed. VA officials estimate the delay may be up to 90 days. Veterans
of the Iraq and Afghanistan conflicts will not be given priority
appointments over veterans who have a service-connected disability and
are currently receiving services.[Footnote 26]
Conclusions:
While the VA OIG continues to oversee VA's efforts to improve the
accuracy of data in the capacity reports, VA does not have a report
that counts all veterans receiving VA PTSD services. Although VA can
use DOD's demographic information to broadly estimate demand for VA
PTSD services, VA does not know the number of veterans it now treats
for PTSD at its medical facilities and Vet Centers. As a result, VA
will be unable to estimate its capacity for treating additional
veterans who choose to seek VA's PTSD services, and therefore, unable
to plan for an increase in demand for these services.
Recommendation for Executive Action:
To help VA estimate the number of additional veterans it could treat
for PTSD and to plan for the future demand for VA PTSD services from
additional veterans seeking these services, we recommend that the
Secretary of Veterans Affairs direct the Under Secretary for Health to
determine the total number of veterans receiving VA PTSD services and
provide facility-specific information to VA medical facilities and Vet
Centers.
Agency Comments:
In commenting on a draft of this report, VA concurred with our
recommendation and acknowledged that more coordinated efforts are
needed to improve its existing PTSD data. VA stated that it plans to
aggregate, at the national level, the number of veterans receiving PTSD
services at VA medical facilities and Vet Centers. We believe VA should
provide these data to both its medical facilities and Vet Centers so
they have the information needed to plan for future demand for PTSD
services. In addition, VA provided two points of clarification. First,
VA stated that it is in the process of developing a mental health
strategic plan that will project demand by major diagnoses and identify
where projected demand may exceed resource availability. VA stated that
future revisions to the mental health strategic plan would include Vet
Center data. Second, VA stated that it would seek additional
information from DOD on servicemembers who have served in Iraq and
Afghanistan to improve its provision of health care services to these
new veterans. VA's written comments are reprinted in appendix III. DOD
concurred with the findings and conclusions in this report and provided
technical comments, which we incorporated as appropriate. DOD's written
comments are reprinted in appendix IV.
As agreed with your office, unless you publicly announce its contents
earlier, we plan no further distribution of this report until 30 days
after its date. We will then send copies of this report to the
Secretary of Veterans Affairs and other interested parties. We also
will make copies available to others upon request. In addition, the
report will be available at no charge at the GAO Web site at
[Hyperlink, http://www.gao.gov].
If you or your staff have any questions about this report, please call
me at (202) 512-7101. Another contact and key contributors are listed
in appendix V.
Sincerely yours,
Signed by:
Cynthia A. Bascetta:
Director, Health Care--Veterans' Health and Benefits Issues:
[End of section]
Appendixes:
Appendix I: Scope and Methodology:
To determine the approaches DOD uses to identify servicemembers who are
at risk for PTSD, we reviewed directives on screening servicemembers
deployed to locations outside of the United States, interviewed DOD
officials, and visited a military installation for each of DOD's
uniformed services. At each of the military installations, we discussed
with officials the steps taken by each of the uniformed services to
implement DOD's approaches, particularly the steps involved in
completing the post-deployment health assessment questionnaire, DD
2796, as it relates to PTSD. How well the uniformed services
implemented DOD's approaches were reported in other GAO reports. The
uniformed services included in our review were Army, Marines, Air
Force, and Navy. We did not include the Coast Guard in this review
because few Coast Guard servicemembers are involved in the Iraq and
Afghanistan conflicts. The military installations visited were: Fort
Lewis Army Base and Madigan Army Medical Center in Washington, Seymour
Johnson Air Force Base in North Carolina, Camp Lejeune Marine Base and
the Naval Hospital Camp Lejeune in North Carolina, and the Naval
Medical Center San Diego in California. We also asked DOD officials
whether they provide information to VA that could help VA plan how to
meet the demand for VA PTSD services from servicemembers returning from
the Iraq and Afghanistan conflicts.
To determine whether VA has the information it needs to determine
whether it can meet an increase in demand for PTSD services, we
interviewed PTSD experts from the National Center for PTSD established
within VA and members of the Under Secretary for Health's Special
Committee on PTSD.[Footnote 27] We also visited three divisions of the
National Center for PTSD: the Executive Division in White River
Junction, Vermont; the Education Division in Palo Alto, California; and
NEPEC in West Haven, Connecticut to review the Center's reports on
specialized PTSD programs.
We also reviewed VA's fiscal year 2001 and 2002 annual reports on VA's
capacity to provide services to special populations, including veterans
with PTSD, and NEPEC's annual reports on specialized PTSD programs to
determine the criteria VA uses to count the number of veterans
receiving VA PTSD services. We reviewed the findings of VA's Committee
on Care of Veterans with Serious Mental Illness and the VA OIG, who
have reported on the accuracy of VA's annual capacity report to
Congress on the number of veterans receiving specialized services,
including PTSD services. We interviewed officials from each of these
groups to clarify their findings. We did not include data from the
annual capacity reports because the OIG reported that the data were not
sufficiently reliable. We also interviewed the director of NEPEC to
discuss the information included in NEPEC's annual reports.
To determine whether VA facilities have the information needed to
determine whether they can meet an increase in demand for PTSD
services, we interviewed officials at 7 VA medical facilities, and 15
Vet Centers located near the medical facilities to discuss the number
of veterans currently receiving VA PTSD services and the impact that an
increase in demand would have on these services. We also discussed
DOD's demographic information with four of the seven medical facilities
we visited. We contacted VA medical facilities located in Palo Alto and
San Diego in California; Durham and Fayetteville in North Carolina;
White River Junction, Vermont; West Haven, Connecticut; and Seattle,
Washington. We also contacted Vet Centers located in Vista, San Diego,
and San Jose in California; Raleigh, Charlotte, Greenville, Greensboro,
and Fayetteville in North Carolina; South Burlington and White River
Junction in Vermont; Hartford, Norwich, and New Haven in Connecticut;
and Seattle and Tacoma in Washington.
Our work was conducted from May through September 2004 in accordance
with generally accepted government auditing standards.
[End of section]
Appendix II: Department of Defense Post-Deployment Health Assessment
Questionnaire DD-2796:
[See PDF for image]
[End of figure]
[End of section]
Appendix III: Comments from the Department of Veterans Affairs:
THE SECRETARY OF VETERANS AFFAIRS:
WASHINGTON:
September 14, 2004:
Ms. Cynthia A. Bascetta:
Director:
Health Care Team:
U. S. Government Accountability Office:
441 G Street, NW:
Washington, DC 20548:
Dear Ms. Bascetta:
The Department of Veterans Affairs (VA) has reviewed the Government
Accountability Office's (GAO) draft report, VA AND DEFENSE HEALTH CARE:
More Information Needed to Determine If VA Can Meet an Increase in
Demand for Post-Traumatic Stress Disorder Services, (GAO-04-1069).
While we concur with GAO's recommendation, several points of
clarification are indicated and are discussed in the enclosure.
The Department will continue efforts to refine workload estimates and
improve coordination of PTSD-related program elements. VA appreciates
the opportunity to comment on your draft report.
Sincerely yours,
Signed by:
Anthony J. Principi:
Enclosure:
Enclosure:
THE DEPARTMENT OF VETERANS AFFAIRS (VA) COMMENTS TO GOVERNMENT
ACCOUNTABILITY OFFICE (GAO) DRAFT REPORT:
VA AND DEFENSE HEALTH CARE: More Information Needed To Determine if VA
Can Meet an Increase in Demand for Post-Traumatic Stress Disorder
Services (GAO-04-1069):
To help VA estimate the number of additional veterans it could treat
for PTSD and to plan for the future demand for VA PTSD services from
additional veterans seeking these services, we recommend that the
Secretary of Veterans Affairs direct the Under Secretary for Health to
determine the total number of veterans receiving VA PTSD services and
provide facility-specific information to VA medical facilities and Vet
Centers.
Concur - GAO reports that VA lacks the information needed to determine
whether it can meet an increase in demand for Post-Traumatic Stress
Disorder (PTSD) services by post-deployment veterans. Facility-
specific and Vet Center-specific data currently exist. Medical care
utilization, including mental health care and PTSD care, is already
analyzed at a national level. The Veterans Health Administration (VHA)
plans to aggregate this information with Vet Center utilization data to
provide a national report of network, medical center and Vet Center
utilization. VHA will provide this information to GAO. Although the
ability of this workload data to project future demand is limited, it
will provide some assistance in estimating workload demand and resource
readiness. Additionally, VA has developed a mental health strategic
plan that will project demand by major diagnoses and provide capability
for gap analysis. VHA will consider PTSD-specific workload information
from Vet Center workload in future revisions of this demand model.
Existing data from medical center utilization will be used on an
interim basis until the new model completes reliability testing and
refinement. The mental health strategic plan is under final review.
Estimated completion date is October 31, 2004.
While VA concurs with GAO's overall conclusions and recommendation, VA
offers the following points of clarification as an adjunct:
* The narrowly defined scope of analysis in GAO's review does not
account for the multiple health concerns that are also associated with
veterans who are returning from combat. PTSD treatment cannot be
effectively addressed in isolation, and VHA's approach to treating
post-deployment veterans focuses on all associated health concerns, not
just PTSD. VHA acknowledges that more coordinated efforts are needed
to consolidate and trend existing PTSD workload information. The
complexity of problems associated with veterans' military experiences
and post-deployment adjustment requires VA to maintain a comprehensive
mental health and health care system.
Fundamental to VA's efforts is DoD's timely provision of demographic,
health and exposure information to VA. DoD has supplied demographic
data for returning veterans. VHA analyzes and trends these data
quarterly. These data are provided to the network offices for follow-up
outreach efforts. As GAO suggests, VHA will identify related
demographic data requirements that might assist in determining expanded
workload demands prior to implementing the mental health strategic
plan. Provision of basic post-deployment health data would assist VA in
providing health care to individual veterans and in supporting improved
rating decisions on disability compensation claims by returning
veterans. These data would also assist VA in better understanding and
planning for the health problems for all returning Operations Enduring
Freedom and Iraqi Freedom veterans. Although DoD officials have
provided VA with useful demographics on separated veterans, DoD has not
provided the collective electronic records from the post-deployment
health screening, including PTSD and other mental health information.
VA continues to seek access to these records and to strengthen the
Department's cooperative ties with DoD mental health officials and is
hopeful that information sharing will be expedited. Recent
deliberations of the VA/DoD Health Executive Council to highlight
mental health issues as a primary focus are encouraging.
[End of section]
Appendix IV: Comments from the Department of Defense:
OFFICE OF THE ASSISTANT SECRETARY OF DEFENSE:
HEALTH AFFAIRS:
TRICARE MANAGEMENT ACTIVITY:
SKYLINE FIVE, SUITE 810,
5111 LEESBURG PIKE:
FALLS CHURCH, VIRGINIA 22041-3206:
Ms. Cynthia A. Bascetta:
Director, Health Care-Veterans' Health and Benefits Issues:
U.S. Government Accountability Office:
441 G Street, N.W.
Washington, DC 20548:
SEP 10 2004:
Dear Ms. Bascetta:
This is the Department of Defense (DoD) response to the Government
Accountability Office (GAO) draft report, "VA AND DEFENSE HEALTH CARE:
More Information Needed to Determine If VA Can Meet an Increase in
Demand for Post Traumatic Stress Disorder Services," dated September 2,
2004 (GAO Code 290387/GAO-04-1069).
The Department appreciates the opportunity to comment on the draft
report and concurs with the GAO findings and conclusions.
Please direct any questions to my points of contact on this matter, Mr.
Kenneth Cox (functional) at (703) 681-0039, ext. 3602 and Mr. Gunther
J. Zimmerman (Audit Liaison) at (703) 681-3492, ext. 4065.
Sincerely,
Signed for:
Richard A. Mayo, RADM, MC,
USN Deputy Director:
Enclosures:
1. Overall Comments
2. Technical Comments:
[End of section]
Appendix V: GAO Contact and Staff Acknowledgments:
GAO Contact:
Marcia A. Mann, 202-512-9526:
Acknowledgments:
In addition to the contact named above Mary Ann Curran, Linda Diggs,
Martha Fisher, Krister Friday, and Marion Slachta made key
contributions to this report.
[End of section]
Related GAO Products:
Defense Health Care: DOD Needs to Improve Force Health Protection and
Surveillance Processes.
[Hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-04-158T]
Washington, D.C.: October 16, 2003.
Defense Health Care: Quality Assurance Process Needed to Improve Force
Health Protection and Surveillance.
[Hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-03-1041]
Washington, D.C.: September 19, 2003.
Disabled Veterans' Care: Better Data and More Accountability Needed to
Adequately Assess Care.
[Hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO/HEHS-00-57]
Washington, D.C.: April 21, 2000.
(290387):
FOOTNOTES
[1] Servicemembers include active duty members of the Army, Marines,
Air Force, and Navy and members of the Reserves and National Guard.
[2] Hoge, Charles W., MD et. al. "Combat Duty in Iraq and Afghanistan,
Mental Health Problems, and Barriers to Care", The New England Journal
of Medicine, 351 (2004): 13-22.
[3] Kulka, R., et.al. Trauma and the Vietnam War Generation: Report of
Findings from the National Vietnam Veterans Readjustment Study. (New
York: 1990).
[4] Previous GAO reports have addressed DOD's compliance with screening
requirements for returning servicemembers deployed outside of the U.S.:
GAO, Defense Health Care: Quality Assurance Process Needed to Improve
Force Health Protection and Surveillance, GAO-03-1041 (Washington,
D.C.: Sept. 19, 2003) and Defense Health Care: DOD Needs to Improve
Force Health Protection and Surveillance Processes, GAO-04-158T
(Washington, D.C.: Oct. 16, 2003).
[5] The Veterans' Health Care Act of 1984 required the establishment of
the National Center on PTSD (now known as National Center for PTSD) as
a research and education organization within VA. See Pub. L. No. 98-
528, § 110(c), 98 Stat. 2686, 2692 (codified at 38 U.S.C. § 1712A
note). The Center advances the clinical care and social welfare of
veterans through research, education, and training clinicians in the
causes, diagnosis, and treatment of PTSD, but does not provide clinical
care for veterans.
[6] Veterans treated at community-based outpatient clinics are included
in the medical facility's count of veterans treated for PTSD.
[7] See 38 U.S.C. § 1710(e)(1)(D); VHA Directive 2004-017, Establishing
Combat Veteran Eligibility. Conflicts are situations in which the
servicemembers are subjected to danger comparable to the danger
encountered in combat with enemy armed forces during a period of war,
as determined by the Secretary of VA. Veterans who served on active
duty in combat operations during a period of war after the Persian Gulf
War will also be eligible for care under section 1710(e)(1)(D).
Eligibility under 38 U.S.C. § 1710(e)(1)(D) does not extend, however,
to veterans whose disabilities are found to have resulted from a cause
other than the service described in the statute.
[8] Servicemembers who served in the Iraq and Afghanistan conflicts do
not have priority over veterans with service-connected disabilities.
[9] If a servicemember's symptoms persist, the servicemember is
transferred to a medical facility where specialty care is available.
[10] The questionnaire is used to satisfy the requirement for post-
deployment mental health assessments established by the National
Defense Authorization Act for Fiscal Year 1998. See Pub. L. No. 105-85,
§ 765(a)(1), 111 Stat. 1629, 1826 (adding new section 1074f(b) to title
10, United States Code).
[11] Servicemembers who are deployed for 30 or more continuous days to
locations without permanent treatment facilities are required to
complete DD 2796. Servicemembers who are deployed to locations with
permanent treatment facilities are not required to complete the
questionnaire because these locations are not high risk for
environmental or occupational exposures.
[12] Medics and corpsmen are enlisted personnel who have been trained
to give first aid and basic medical treatment, especially in combat
situations.
[13] Independent duty medical technicians are enlisted personnel who
receive advanced training and are certified to provide treatment and
prescribe medications within defined parameters.
[14] Reserve and National Guard members who are referred for further
medical evaluation may remain on active duty status until the medical
problem is treated and resolved or the condition becomes stable.
[15] The Army has lead responsibility for DOD's medical surveillance
and operates a centralized data repository.
[16] See Section 765(a)(1), 111 Stat. at 1826 (codified at 10 U.S.C. §
1074f(d)).
[17] In September 2003, we found that DOD had not established an
effective quality assurance program and recommended that this be done.
See GAO-03-1041.
[18] See 38 U.S. C. § 1706(b)(5).
[19] Seriously mentally ill veterans are those diagnosed with a mental,
behavioral or emotional disorder of sufficient duration to
substantially interfere with one or more life activities, including
basic daily living skills such as eating, bathing, or dressing.
[20] Department of Veterans Affairs, The Long Journey Home XII
Treatment of Posttraumatic Stress Disorder in the Department of
Veterans Affairs: Fiscal Year 2003 Service Delivery and Performance,
Northeast Program Evaluation Center, VA Connecticut Healthcare System
(Connecticut: April 2004). The Northeast Program Evaluation Center, a
division of the National Center for PTSD, monitors and evaluates the
implementation and performance of VA's specialized PTSD programs.
[21] The VA OIG is required to examine each of VA's annual reports on
its specialized services, including PTSD, and submit to Congress a
certification as to its accuracy. See 38 U.S.C. § 1706(b)(5)(C).
[22] The Committee on Care of Severely Chronically Mentally Ill
Veterans assesses VA's capability to meet the rehabilitation and
treatment needs of such veterans. See 38 U.S.C. § 7321. The Committee,
established within VA, is generally referred to as the Committee on
Care of Veterans with Serious Mental Illness.
[23] Not all such servicemembers are eligible for VA health care. For
example, a servicemember who has been dishonorably discharged would not
be eligible for VA services.
[24] VA has used this information to send letters to servicemembers who
have left active duty status, informing them of their eligibility for
VA's health care services.
[25] One medical facility believed it could accommodate, with the
facility's current staffing levels, a one to two percent increase in
additional veterans seeking PTSD services. However, it would have to
restructure its PTSD services provided to current veterans.
[26] A service-connected disability is an injury or disease that was
incurred or aggravated while on active military duty.
[27] VA was required to establish a Special Committee on PTSD by the
Veterans' Health Care Act of 1984. See Section 110(b), 98 Stat. at 2691
(codified at 38 U.S.C. § 1712A note). Among other things, the committee
assesses VA's care of veterans who require specialized treatment for
PTSD.
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