VA Disability Benefits and Health Care
Providing Certain Services to the Seriously Injured Poses Challenges Gao ID: GAO-05-444T March 17, 2005More than 10,000 U.S. military servicemembers, including members of the National Guard and Reserve, have been injured in the conflicts in Afghanistan and Iraq. Those with serious physical and psychological injuries are initially treated at the Department of Defense's (DOD) major military treatment facilities (MTF). The Department of Veterans Affairs (VA) has made provision of services to these servicemembers a high priority. This testimony focuses on the steps VA has taken and the challenges it faces in providing services to the seriously injured and highlights findings from three recent GAO reports that addressed VA's efforts to provide services to the seriously injured. These services include vocational rehabilitation and employment (VR&E) and health care for those with post-traumatic stress disorder (PTSD).
VA has taken steps to provide services as a high priority to seriously injured servicemembers returning from Afghanistan and Iraq. To identify and monitor those who may require VA's services, VA and DOD are working on a formal agreement to share data about servicemembers with serious injuries. Meanwhile, VA has relied on its regional offices to coordinate with staff at MTFs and VA medical centers to learn the identities, medical conditions, and military status of seriously injured servicemembers. For servicemembers with PTSD, VA has taken steps to improve care including developing with DOD a clinical practice guideline for identifying and treating individuals with PTSD. The guideline contains a four-question screening tool, which both VA and DOD use to identify those who may be at risk for PTSD. VA faces significant challenges in providing services to seriously injured servicemembers. For example, the individualized nature of recovery makes it difficult to determine when a seriously injured servicemember will be ready for vocational rehabilitation, and DOD has expressed concern that VA's outreach to servicemembers could affect retention for those whose discharge from military service is uncertain. VA is also challenged by the lack of access to DOD data; although VA staff have developed ad hoc arrangements, such informal agreements can break down. Regarding PTSD, inaccurate data limit VA's ability to estimate its capacity for treating additional veterans and to plan for an increased demand for these services.
GAO-05-444T, VA Disability Benefits and Health Care: Providing Certain Services to the Seriously Injured Poses Challenges
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Testimony:
Before the Committee on Veterans' Affairs, U.S. Senate:
United States Government Accountability Office:
GAO:
For Release on Delivery Expected at 10:00 a.m. EST:
Thursday, March 17, 2005:
VA Disability Benefits and Health Care:
Providing Certain Services to the Seriously Injured Poses Challenges:
Statement of Cynthia A. Bascetta:
Director, Health Care--Veterans' Health and Benefits Issues:
GAO-05-444T:
GAO Highlights:
Highlights of GAO-05-444T, a testimony before the Committee on
Veterans' Affairs, U.S. Senate:
Why GAO Did This Study:
More than 10,000 U.S. military servicemembers, including members of the
National Guard and Reserve, have been injured in the conflicts in
Afghanistan and Iraq. Those with serious physical and psychological
injuries are initially treated at the Department of Defense's (DOD)
major military treatment facilities (MTF). The Department of Veterans
Affairs (VA) has made provision of services to these servicemembers a
high priority. This testimony focuses on the steps VA has taken and the
challenges it faces in providing services to the seriously injured and
highlights findings from three recent GAO reports that addressed VA's
efforts to provide services to the seriously injured. These services
include vocational rehabilitation and employment (VR&E) and health care
for those with post-traumatic stress disorder (PTSD).
What GAO Found:
VA has taken steps to provide services as a high priority to seriously
injured servicemembers returning from Afghanistan and Iraq. To identify
and monitor those who may require VA's services, VA and DOD are working
on a formal agreement to share data about servicemembers with serious
injuries. Meanwhile, VA has relied on its regional offices to
coordinate with staff at MTFs and VA medical centers to learn the
identities, medical conditions, and military status of seriously
injured servicemembers. For servicemembers with PTSD, VA has taken
steps to improve care including developing with DOD a clinical practice
guideline for identifying and treating individuals with PTSD. The
guideline contains a four-question screening tool, which both VA and
DOD use to identify those who may be at risk for PTSD.
VA faces significant challenges in providing services to seriously
injured servicemembers. For example, the individualized nature of
recovery makes it difficult to determine when a seriously injured
servicemember will be ready for vocational rehabilitation, and DOD has
expressed concern that VA's outreach to servicemembers could affect
retention for those whose discharge from military service is uncertain.
VA is also challenged by the lack of access to DOD data; although VA
staff have developed ad hoc arrangements, such informal agreements can
break down. Regarding PTSD, inaccurate data limit VA's ability to
estimate its capacity for treating additional veterans and to plan for
an increased demand for these services.
Seriously Injured Army Servicemembers Receive Treatment at Five Major
Military Treatment Facilities and Relocate to 1 of 57 VA Regions After
Medical Stabilization:
[See PDF for image]
[End of figure]
What GAO Recommends:
In the three previous reports, GAO made recommendations including that
VA:
* reach an agreement with DOD on access to data;
* develop policy and procedures to keep contact with seriously injured
servicemembers; and:
* determine the total number of veterans receiving PTSD services.
VA and DOD generally concurred with our recommendations.
www.gao.gov/cgi-bin/getrpt?GAO-05-444T.
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]
Mr. Chairman and Members of the Committee:
Thank you for inviting me to discuss the Department of Veterans
Affairs' (VA) efforts to provide disability benefits and health care to
seriously injured servicemembers returning from Afghanistan and
Iraq.[Footnote 1] Since the onset of U.S. operations in Afghanistan in
October 2001 and Iraq in March 2003, more than 10,000 U.S. military
servicemembers have sustained physical and psychological injuries. It
is especially fitting, with the continuing deployment of our military
forces to armed conflict, that we reaffirm our commitment to those who
serve our nation in its times of need. Therefore, effective and
efficient management of VA's disability and health programs is of
paramount importance.
You expressed concerns about servicemembers and veterans who may seek
services from VA. Today, I would like to focus on the steps VA has
taken and the challenges it faces in providing services to those who
have been seriously injured in these conflicts. Specifically I would
like to highlight the findings of our work on VA's disability program
and health care services for seriously injured servicemembers returning
from Afghanistan and Iraq. My comments are based on our reviews of VA's
programs for vocational rehabilitation and employment (VR&E)[Footnote
2] and health care,[Footnote 3] specifically post-traumatic stress
disorder (PTSD) services. This work included visits to four Department
of Defense (DOD) major military treatment facilities (MTF), including
Walter Reed Army Medical Center where most seriously injured
servicemembers are initially treated. We interviewed officials at VA's
central office and at 12 of VA's 57 regional offices. We also
interviewed officials at seven VA medical facilities where large
numbers of servicemembers were returning from Afghanistan and Iraq 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
did our work in accordance with generally accepted government auditing
standards.
In summary, VA is taking steps to provide services to seriously injured
servicemembers as a high priority but faces significant challenges in
doing so. Specifically, VA has taken steps to expedite VR&E services to
seriously injured servicemembers, but challenges such as the inherent
differences and uncertainties in individual recovery processes make it
difficult to determine when an individual may be receptive to services.
VA has also faced difficulties in obtaining specific data from DOD
about seriously injured servicemembers; instead, VA has had to rely on
ad hoc regional office arrangements at the local level. Because such
informal data sharing relationships could break down with changes in
personnel at either the MTF or the regional office, we recommended that
VA and DOD reach an agreement for VA to have access to information that
both agencies agree is needed to promote servicemembers' recovery and
return to work. Similarly, VA requires that every returning
servicemember from the Afghanistan and Iraq conflicts who needs health
care services receive priority consideration for VA health care
appointments, including PTSD services. VA, however, faces challenges
such as developing accurate data on current workloads and estimating
potential PTSD workloads. Without this information, VA will be unable
to accurately assess its capacity to serve those servicemembers at risk
for PTSD. Based on our work, we recommended ways for VA and DOD to
address these issues.
Background:
VA offers a broad array of disability benefits and health care through
its Veterans Benefits Administration (VBA) and its Veterans Health
Administration (VHA), respectively. VBA provides benefits and services
such as disability compensation and VR&E to veterans through its 57
regional offices. The VR&E program is designed to ensure that veterans
with disabilities find meaningful work and achieve maximum independence
in daily living. VR&E services include vocational counseling,
evaluation, and training that can include payment for tuition and other
expenses for education, as well as job placement assistance.
VHA manages one of the largest health care systems in the United States
and provides PTSD services in its medical facilities, community
settings, and Vet Centers.[Footnote 4] VA is a world leader in PTSD
treatment and offers PTSD services to veterans. PTSD can result from
having experienced an extremely stressful event such as the threat of
death or serious injury, as happens in military combat, and is the most
prevalent mental disorder resulting from combat.
Servicemembers injured in Afghanistan and Iraq are surviving injuries
that would have been fatal in past conflicts, due, in part, to advanced
protective equipment and medical treatment. However, the severity of
their injuries can result in a lengthy transition involving
rehabilitation and complex assessments of their ability to function.
Many also sustain psychological injuries. Mental health experts predict
that because of the intensity of warfare in Afghanistan and Iraq 15
percent or more of the servicemembers returning from these conflicts
will develop PTSD.[Footnote 5]
VA Has Taken Steps to Provide Services to Seriously Injured
Servicemembers as a High Priority:
In our January 2005 report on VA's efforts to expedite VR&E services
for seriously injured servicemembers returning from Afghanistan and
Iraq, we noted that VA instructed its VBA regional offices, in a
September 2003 letter, to provide priority consideration and assistance
for all VA services, including health care, to these servicemembers. VA
specifically instructed regional offices to focus on servicemembers
whose disabilities will definitely or are likely to result in military
separation. Because most seriously injured servicemembers are initially
treated at major MTFs, VA has deployed staff to the sites where the
majority of the seriously injured are treated. These staff have
included VA social workers and disability compensation benefit
counselors. VA has placed social workers and benefit counselors at
Walter Reed and Brooke Army Medical Centers and at several other MTFs.
In addition to these staff, VA has provided a vocational rehabilitation
counselor to work with hospitalized patients at Walter Reed Army
Medical Center, where the largest number of seriously injured
servicemembers has been treated.
To identify and monitor those whose injuries may result in a need for
VA disability and health services, VA has asked DOD to share data about
seriously injured servicemembers. VA has been working with DOD to
develop a formal agreement on what specific information to share. VA
requested personal identifying information, medical information, and
DOD's injury classification for each listed servicemember. VA also
requested monthly lists of servicemembers being evaluated for medical
separation from military service. VA officials said that systematic
information from DOD would provide them with a way to more reliably
identify and monitor seriously injured servicemembers. As of the end of
2004, a formal agreement with DOD was still pending.
In the absence of a formal arrangement for DOD data on seriously
injured servicemembers, VA has relied on its regional offices to obtain
information about them. In its September 2003 letter, VA asked the
regional offices to coordinate with staff at MTFs and VA medical
centers in their areas to ascertain the identities, medical conditions,
and military status of the seriously injured.
In regard to psychological injuries, our September 2004 report noted
that mental health experts have recognized the importance of early
identification and treatment of PTSD. VA and DOD jointly developed a
clinical practice guideline for identifying and treating individuals
with PTSD. The guideline includes a four-question screening tool to
identify servicemembers and veterans who may be at risk for PTSD. VA
uses these questions to screen all veterans who visit VA for health
care, including those previously deployed to Afghanistan and Iraq. The
screening questions are:
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?
DOD is also using these four questions in its post-deployment health
assessment questionnaire (form DD 2796) to identify servicemembers at
risk for PTSD. DOD requires the questionnaire be completed by all
servicemembers, including Reserve and National Guard members, returning
from a combat theater and is planning to conduct follow-up screenings
within 6 months after return.
VA Faces Significant Challenges in Providing Services to the Seriously
Injured:
VA faces significant challenges in providing services to servicemembers
who have sustained serious physical and psychological injuries. For
example, in providing VR&E services, individual differences and
uncertainties in the recovery process make it inherently difficult to
determine when a seriously injured servicemember will be most receptive
to assistance. The nature of the recovery process is highly
individualized and depends to a large extent on the individual's
medical condition and personal readiness. Consequently, VA
professionals exercise judgment to determine when to contact the
seriously injured and when to begin services.
In our January 2005 report on VA's efforts to expedite VR&E services to
seriously injured servicemembers, we noted that many need time to
recover and adjust to the prospect that they may be unable to remain in
the military and will need to prepare instead for civilian employment.
Yet we found that VA has no policy for maintaining contact with those
servicemembers who may not apply for VR&E services prior to discharge
from the hospital. As a result, several regional offices reported that
they do not stay in contact with these individuals, while others use
various ways to maintain contact.
VA is also challenged by DOD's concern that outreach about VA benefits
could work at cross purposes to military retention goals. In our
January 2005 report, we stated that DOD expressed concern about the
timing of VA's outreach to servicemembers whose discharge from military
service is not yet certain. To expedite VR&E services, VA's outreach
process may overlap with the military's process for evaluating
servicemembers who may be able to return to duty. According to DOD
officials, it may be premature for VA to begin working with injured
servicemembers who may eventually return to active duty. With advances
in medicine and prosthetic devices, many serious injuries no longer
result in work-related impairments. Army officials who track injured
servicemembers told us that many seriously injured servicemembers
overcome their injuries and return to active duty.
Further, VA is challenged by the lack of access to systematic data
regarding seriously injured servicemembers. In the absence of a formal
information-sharing agreement with DOD, VA does not have systematic
access to DOD data about the population who may need its services.
Specifically, VA cannot reliably identify all seriously injured
servicemembers or know with certainty when they are medically
stabilized, when they are undergoing evaluation for a medical
discharge, or when they are actually medically discharged from the
military. VA has instead had to rely on ad hoc regional office
arrangements at the local level to identify and obtain specific data
about seriously injured servicemembers. While regional office staff
generally expressed confidence that the information sources they
developed enabled them to identify most seriously injured
servicemembers, they have no official data source from DOD with which
to confirm the completeness and reliability of their data nor can they
provide reasonable assurance that some seriously injured servicemembers
have not been overlooked. In addition, informal data-sharing
relationships could break down with changes in personnel at either the
MTF or the regional office.
In our review of 12 regional offices, we found that they have developed
different information sources resulting in varying levels of
information. The nature of the local relationships between VA staff and
military staff at MTFs was a key factor in the completeness and
reliability of the information the military provided. For example, the
MTF staff at one regional office provided VA staff with only the names
of new patients and no indication of the severity of their condition or
the theater from which they were returning. Another regional office
reported receiving lists of servicemembers for whom the Army had
initiated a medical separation in addition to lists of patients with
information on the severity of their injuries. Some regional offices
were able to capitalize on long-standing informal relationships. For
example, the VA coordinator responsible for identifying and monitoring
the seriously injured at one regional office had served as an Army
nurse at the local MTF and was provided all pertinent information. In
contrast, staff at another regional office reported that local military
staff did not until recently provide them with any information on
seriously injured servicemembers admitted to the MTF.
DOD officials expressed their concerns about the type of information to
be shared and when the information would be shared. DOD noted that it
needed to comply with legal privacy rules on sharing individual patient
information. DOD officials told us that information could be made
available to VA upon separation from military service, that is, when a
servicemember enters the separation process. However, prior to
separation, information can only be provided under certain
circumstances, such as when a patient's authorization is obtained.
Based on our review of VA's efforts to expedite VR&E services to
seriously injured servicemembers, we recommended that VA and DOD
collaborate to reach an agreement for VA to have access to information
that both agencies agree is needed to promote recovery and return to
work for seriously injured servicemembers. We also recommended that VA
develop policy and procedures for regional offices to maintain contact
with seriously injured servicemembers who do not initially apply for
VR&E services. VA and DOD generally concurred with our recommendations.
VA also told us that its follow-up policies and procedures include
sending veterans information on VR&E benefits upon notification of
disability compensation award and 60 days later. However, we believe a
more individualized approach, such as maintaining personal contact,
could better ensure the opportunity for veterans to participate in the
program when they are ready.
In dealing with psychological injuries such as PTSD, VA also faces
challenges in providing services. Specifically, the inherent
uncertainty of the onset of PTSD symptoms poses a challenge because
symptoms may be delayed for years after the stressful event. Symptoms
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 it can lead to substance
abuse, severe depression, and suicide.
Another challenge VA faces in dealing with veterans with PTSD is the
lack of accurate data on its workload for PTSD. Inaccurate data limit
VA's ability to estimate its capacity for treating additional veterans
and to plan for an increased demand for these services. For example, we
noted in our September 2004 report that VA publishes two reports that
include information on veterans receiving PTSD services at its medical
facilities. However, neither report includes all the veterans receiving
PTSD services. We found that veterans may be double counted in these
two reports, counted in only one report, or omitted from both reports.
Moreover, the VA Office of Inspector General found that the data in
VA's annual capacity report, which includes information on veterans
receiving PTSD services, are not accurate. Thus, VA does not have an
accurate count of the number of veterans being treated for PTSD.
In our September 2004 report, we recommended that VA determine the
total number of veterans receiving PTSD services and provide facility-
specific information to VA medical centers. VA concurred with our
recommendation and later provided us with information on the number of
Operation Enduring Freedom and Operation Iraqi Freedom veterans that
has accessed VA services in its medical centers, as well as its Vet
Centers. However, VA acknowledged that estimating workload demand and
resource readiness remains limited. VA stated that the provision of
basic post-deployment health data from DOD to VA would better enable VA
to provide health care to individual veterans and help VA to better
understand and plan for the health problems of servicemembers returning
from Afghanistan and Iraq. In February 2005,[Footnote 6] we reported on
recommendations made by VA's Special Committee on PTSD; some of the
recommendations were long-standing. We recommended that VA prioritize
implementation of those recommendations that would improve PTSD
services. VA disagreed with our recommendation and stated the report
failed to address the many efforts undertaken by the agency to improve
the care delivered to veterans with PTSD. We believe our report
appropriately raised questions about VA's capacity to meet veterans'
needs for PTSD services. We noted that, given VA's outreach efforts,
expanded access to VA health care for many new combat veterans, and the
large number of servicemembers returning from Afghanistan and Iraq who
may seek PTSD services, it is critical that VA's PTSD services be
available when servicemembers return from military combat.
Concluding Observations:
VA has taken steps to help the nation's newest generation of veterans
who returned from Afghanistan and Iraq seriously injured move forward
with their lives, particularly those who return from combat with
disabling physical injuries. While physical injuries may be more
apparent, psychological injuries, although not visible, are also
debilitating. VA has made seriously injured servicemembers and veterans
a priority, but faces challenges in providing services to both the
physically and psychologically injured. For example, VA must be mindful
to balance effective outreach with an approach that could be viewed as
intrusive. Moreover, overcoming these challenges requires VA and DOD to
work more closely to identify those who need services and to share data
about them so that seriously injured servicemembers and veterans
receive the care they need.
Mr. Chairman, this concludes my prepared remarks. I will be happy to
answer any questions that you or Members of the Committee might have.
Contact and Acknowledgments:
For further information, please contact Cynthia A. Bascetta at (202)
512-7101. Also contributing to this statement were Irene Chu, Linda
Diggs, Martha A. Fisher, Lori Fritz, and Janet Overton.
[End of section]
Related GAO Products:
VA Health Care: VA Should Expedite the Implementation of
Recommendations Needed to Improve Post-Traumatic Stress Disorder
Services. GAO-05-287. Washington, D.C.: February 14, 2005.
Vocational Rehabilitation: More VA and DOD Collaboration Needed to
Expedite Services for Seriously Injured Servicemembers. GAO-05-167.
Washington, D.C.: January 14, 2005.
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. Washington, D.C.: September 20, 2004.
VA Vocational Rehabilitation and Employment Program: GAO Comments on
Key Task Force Findings and Recommendations. GAO-04-853. Washington,
D.C.: June 15, 2004.
Defense Health Care: DOD Needs to Improve Force Health Protection and
Surveillance Processes. GAO-04-158T. Washington, D.C.: October 16, 2003.
Defense Health Care: Quality Assurance Process Needed to Improve Force
Health Protection and Surveillance. GAO-03-1041. Washington, D.C.:
September 19, 2003.
VA Benefits: Fundamental Changes to VA's Disability Criteria Need
Careful Consideration. GAO-03-1172T. Washington, D.C.: September 23,
2003.
High-Risk Series: An Update. GAO-03-119. Washington, D.C.: January 1,
2003.
Major Management Challenges and Program Risks: Department of Veterans
Affairs. GAO-03-110. Washington, D.C.: January 2003.
SSA and VA Disability Programs: Re-Examination of Disability Criteria
Needed to Help Ensure Program Integrity. GAO-02-597. Washington, D.C.:
August 9, 2002.
Military and Veterans' Benefits: Observations on the Transition
Assistance Program. GAO-02-914T. Washington, D.C.: July 18, 2002.
Disabled Veterans' Care: Better Data and More Accountability Needed to
Adequately Assess Care. GAO/HEHS-00-57. Washington, D.C.: April 21,
2000.
FOOTNOTES
[1] Servicemembers include active duty members of the Army, Marines,
Air Force, and Navy, and members of the Reserves and National Guard.
[2] GAO, More VA and DOD Collaboration Needed to Expedite Services for
Seriously Injured Servicemembers, GAO-05-167 (Washington, D.C.: Jan.
14, 2005).
[3] GAO, More Information Needed to Determine if VA Can Meet an
Increase in Demand for Post-Traumatic Stress Disorder Services, GAO-04-
1069 (Washington, D.C.: Sept. 20, 2004). GAO, VA Should Expedite the
Implementation of Recommendations Needed to Improve Post-Traumatic
Stress Disorder Services, GAO-05-287 (Washington, D.C.: Feb. 14, 2005).
[4] Vet Centers are community-based VA facilities that offer PTSD,
readjustment, 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.
[5] Based on data under the broad definition of PTSD provided in 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.
[6] GAO-05-287.
