Military and Veterans Disability System
Pilot Has Achieved Some Goals, but Further Planning and Monitoring Needed Gao ID: GAO-11-69 December 6, 2010Since 2007, the Departments of Defense (DOD) and Veterans Affairs (VA) have been testing a new disability evaluation system designed to integrate their separate processes and thereby expedite veterans' benefits for wounded, ill, and injured servicemembers. Having piloted the integrated disability evaluation system (IDES) at 27 military facilities, they are now planning for its expansion military-wide. Part of the National Defense Authorization Act for Fiscal Year 2008 required GAO to report on DOD and VA's implementation of policies on disability evaluations. This report examines: (1) the results of the agencies' evaluation of the IDES pilot, (2) challenges in implementing the IDES pilot to date, and (3) whether DOD and VA's plans to expand the IDES adequately address potential future challenges. GAO analyzed data from DOD and VA, conducted site visits at 10 military facilities, and interviewed DOD and VA officials.
In their evaluation of the IDES pilot as of February 2010, DOD and VA concluded that it had improved servicemember satisfaction relative to the existing "legacy" system and met their established goal of delivering VA benefits to active duty and reserve component servicemembers within 295 and 305 days, respectively, on average. While these results are promising, average case processing times have steadily increased since the February 2010 evaluation. At 296 days for active duty servicemembers, as of August 2010, processing time for the IDES is still an improvement over the 540 days that DOD and VA estimated the legacy process takes to deliver VA benefits to members. However, the full extent of improvement of the IDES over the legacy system is unknown because (1) the 540-day estimate was based on a small, nonrepresentative sample of cases and (2) limitations in legacy case data prevent a comprehensive comparison of timeliness, as well as appeal rates. Piloting of the IDES has revealed several implementation challenges that have contributed to delays in the process, the most significant being insufficient staffing by DOD and VA. Staffing shortages were severe at a few pilot sites that experienced caseload surges. For example, at one of these sites, due to a lack of VA medical staff, it took 140 days on average to complete one of the key features of the pilot--the single exam--compared with the agencies' goal to complete this step of the process in 45 days. The single exam posed other challenges that contributed to process delays, such as exam summaries that did not contain sufficient information for VA to determine the servicemember's benefits and disagreements between DOD and VA medical staff about diagnoses for servicemembers' medical conditions. Cases with these problems were returned for further attention, adding time to the process. Pilot sites also experienced logistical challenges, such as incorporating VA staff at military facilities and housing and managing personnel going through the process. As DOD and VA prepare to expand the IDES worldwide, they have made preparations to address a number of these challenges, but these efforts have yet to be tested, and not all challenges have been addressed. To address staffing shortages and ensure timely processing, VA is developing a contract for additional medical examiners, and DOD and VA are requiring local staff to develop written contingency plans for handling surges in caseloads. However, the agencies lack strategies for meeting some key challenges, such as ensuring enough military physicians to handle anticipated workloads. They also do not have a comprehensive monitoring plan for identifying problems as they occur--such as staffing shortages and insufficiencies in medical exams--in order to take remedial actions as early as possible. GAO is making several recommendations to improve DOD and VA's planning for expansion of the new disability evaluation system, including developing a systematic monitoring process and ensuring that adequate staff is in place. DOD and VA generally concurred with GAO's recommendations and provided technical comments that GAO incorporated into the report as appropriate.
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: Daniel Bertoni Team: Government Accountability Office: Education, Workforce, and Income Security Phone: (202) 512-5988GAO-11-69, Military and Veterans Disability System: Pilot Has Achieved Some Goals, but Further Planning and Monitoring Needed
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United States Government Accountability Office:
GAO:
Report to Congressional Committees:
December 2010:
Military And Veterans Disability System:
Pilot Has Achieved Some Goals, but Further Planning and Monitoring
Needed:
GAO-11-69:
GAO Highlights:
Highlights of GAO-11-69, a report to congressional committees.
Why GAO Did This Study:
Since 2007, the Departments of Defense (DOD) and Veterans Affairs (VA)
have been testing a new disability evaluation system designed to
integrate their separate processes and thereby expedite veterans‘
benefits for wounded, ill, and injured servicemembers. Having piloted
the integrated disability evaluation system (IDES) at 27 military
facilities, they are now planning for its expansion military-wide.
Part of the National Defense Authorization Act for Fiscal Year 2008
required GAO to report on DOD and VA‘s implementation of policies on
disability evaluations. This report examines: (1) the results of the
agencies‘ evaluation of the IDES pilot, (2) challenges in implementing
the IDES pilot to date, and (3) whether DOD and VA‘s plans to expand
the IDES adequately address potential future challenges. GAO analyzed
data from DOD and VA, conducted site visits at 10 military facilities,
and interviewed DOD and VA officials.
What GAO Found:
In their evaluation of the IDES pilot as of February 2010, DOD and VA
concluded that it had improved servicemember satisfaction relative to
the existing ’legacy“ system and met their established goal of
delivering VA benefits to active duty and reserve component
servicemembers within 295 and 305 days, respectively, on average.
While these results are promising, average case processing times have
steadily increased since the February 2010 evaluation. At 296 days for
active duty servicemembers, as of August 2010, processing time for the
IDES is still an improvement over the 540 days that DOD and VA
estimated the legacy process takes to deliver VA benefits to members.
However, the full extent of improvement of the IDES over the legacy
system is unknown because (1) the 540-day estimate was based on a
small, nonrepresentative sample of cases and (2) limitations in legacy
case data prevent a comprehensive comparison of timeliness, as well as
appeal rates.
Piloting of the IDES has revealed several implementation challenges
that have contributed to delays in the process, the most significant
being insufficient staffing by DOD and VA. Staffing shortages were
severe at a few pilot sites that experienced caseload surges. For
example, at one of these sites, due to a lack of VA medical staff, it
took 140 days on average to complete one of the key features of the
pilot”the single exam”compared with the agencies‘ goal to complete
this step of the process in 45 days. The single exam posed other
challenges that contributed to process delays, such as exam summaries
that did not contain sufficient information for VA to determine the
servicemember‘s benefits and disagreements between DOD and VA medical
staff about diagnoses for servicemembers‘ medical conditions. Cases
with these problems were returned for further attention, adding time
to the process. Pilot sites also experienced logistical challenges,
such as incorporating VA staff at military facilities and housing and
managing personnel going through the process.
As DOD and VA prepare to expand the IDES worldwide, they have made
preparations to address a number of these challenges, but these
efforts have yet to be tested, and not all challenges have been
addressed. To address staffing shortages and ensure timely processing,
VA is developing a contract for additional medical examiners, and DOD
and VA are requiring local staff to develop written contingency plans
for handling surges in caseloads. However, the agencies lack
strategies for meeting some key challenges, such as ensuring enough
military physicians to handle anticipated workloads. They also do not
have a comprehensive monitoring plan for identifying problems as they
occur”such as staffing shortages and insufficiencies in medical exams”
in order to take remedial actions as early as possible.
What GAO Recommends:
GAO is making several recommendations to improve DOD and VA‘s planning
for expansion of the new disability evaluation system, including
developing a systematic monitoring process and ensuring that adequate
staff is in place. DOD and VA generally concurred with GAO‘s
recommendations and provided technical comments that GAO incorporated
into the report as appropriate.
View [hyperlink, http://www.gao.gov/products/GAO-11-69] or key
components. For more information, contact Daniel Bertoni at (202) 512-
7215 or bertonid@gao.gov.
[End of table]
Contents:
Letter:
Background:
Pilot Evaluation Results Are Promising, but the Degree of Improvement
Achieved Is Unknown:
Pilot Sites Experienced Several Challenges:
DOD and VA Expansion Plans Address Some Though Not All Challenges:
Conclusions:
Recommendations for Executive Action:
Agency Comments and Our Evaluation:
Appendix I: Objectives, Scope, and Methodology:
Appendix II: IDES Pilot Processing Times for Reserve Component
Servicemembers:
Appendix III: Comments from the Department of Defense:
Appendix IV: Comments from the Department of Veterans Affairs:
Appendix V: GAO Contact and Staff Acknowledgments:
Tables:
Table 1: Military Treatment Facilities Piloting the IDES:
Table 2: Percentage of Legacy Cases with Referral and Appeal Dates, by
Military Service:
Table 3: Percentage of Legacy Cases with Data Used for DOD
Comparisons, by Military Service:
Table 4: Selected Characteristics of IDES Pilot Sites Visited:
Table 5: Percentage of Legacy Cases with Data Used for Comparison of
Time in Active Duty, by Military Service:
Figures:
Figure 1: Overview of the Legacy and IDES Processes:
Figure 2: Timeliness Goals for the Steps of the IDES Process:
Figure 3: Average Case Processing Times and Changes in Active Caseload
by Location at Least 1 Year After Implementation and in August 2010:
Figure 4: Active Duty IDES Case Processing Times by Service, as of
August 29, 2010:
Figure 5: Percentage of IDES Active Duty Cases Completed in 295 Days
or Less by Service, as of February 2010:
Figure 6: Army Servicemember IDES and Legacy Appeal Rates, as of early
2010:
Figure 7: Single Exam Processing Time for Active Duty Servicemembers
at IDES Pilot Sites, as of August 29, 2010:
Figure 8: MEB Processing Times for Active Duty Servicemembers at IDES
Pilot Sites, as of August 29, 2010:
Figure 9: Informal PEB Processing Times for Active Duty Servicemembers
in the IDES Pilot, by Military Service, as of August 29, 2010:
Figure 10: Average Cases per DOD Board Liaison at IDES Pilot Sites:
Figure 11: Average Number of Days to Deliver VA Benefits for Reserve
Component Servicemembers, by Military Service, as of August 29, 2010:
Figure 12: Percentage of Cases Meeting 305-Day Goal for Delivery of VA
Benefits to Reserve Component Servicemembers, by Military Service, as
of February 2010:
Figure 13: Average Number of Days to Complete Single Exams for Reserve
Component Servicemembers, by IDES Pilot Site, as of August 29, 2010:
Figure 14: Average Number of Days to Complete MEB Documentation for
Reserve Component Servicemembers, by IDES Pilot Site, as of August 29,
2010:
Figure 15: Average Number of Days to Complete the Informal PEB for
Reserve Component Servicemembers, by Military Service, as of August
29, 2010:
Abbreviations:
DOD: Department of Defense:
IDES: integrated disability evaluation system:
IT: information technology:
MEB: medical evaluation board:
NDAA: National Defense Authorization Act:
PEB: physical evaluation board:
PTSD: posttraumatic stress disorder:
VA: Department of Veterans Affairs:
VBA: Veterans Benefits Administration:
VHA: Veterans Health Administration:
VTA: Veterans Tracking Application:
WWCTP: Office of the Deputy Under Secretary of Defense for Wounded
Warrior Care & Transition Policy:
[End of section]
United States Government Accountability Office:
Washington, DC 20548:
December 6, 2010:
Congressional Committees:
Over 40,000 servicemembers have been wounded in the wars in Iraq and
Afghanistan, as of October 2010. After receiving medical treatment,
many wounded servicemembers must navigate a complex disability
evaluation system that begins with the Department of Defense (DOD)
determining whether they are medically fit to continue their military
service. If they are found unfit, servicemembers continue through the
system to obtain a determination of their eligibility for military
disability benefits. Once servicemembers are discharged from the
military, they may also be eligible to receive disability benefits
from the Department of Veterans Affairs (VA), but they must first
undergo an entirely separate VA disability evaluation process. A
series of articles in 2007 by The Washington Post concerning
conditions at Walter Reed Army Medical Center, and subsequent reports
from numerous high-level commissions and review groups, highlighted
problems with the DOD and VA disability evaluations systems.[Footnote
1] These included long delays, duplication in DOD and VA processes,
confusion among servicemembers, and distrust of systems regarded as
adversarial by servicemembers and veterans.
In response to these concerns, DOD and VA jointly designed a new
disability evaluation system that integrates DOD and VA processes,
with the goal of expediting the delivery of benefits to
servicemembers. DOD and VA began pilot testing the integrated
disability evaluation system (IDES) in November 2007 at three
Washington, D.C., area military treatment facilities and, by March
2010, added 24 more facilities to the pilot. DOD and VA are now
planning to expand the piloted system to 28 additional facilities, as
a first step toward replacing the military's existing--or "legacy"--
disability evaluation system with the IDES worldwide.
In January 2008, Congress enacted the National Defense Authorization
Act for Fiscal Year 2008 (NDAA 2008) requiring DOD and VA, to the
extent feasible, to jointly develop and implement a comprehensive
policy on improvements to the care, management, and transition of
recovering servicemembers, including improvements to the agencies'
disability evaluation systems.[Footnote 2] The NDAA 2008 also required
GAO to report on the progress DOD and VA have made in developing and
implementing the comprehensive policy.[Footnote 3] In agreement with
cognizant congressional staff, we reviewed DOD and VA's progress in
implementing policies related to their disability evaluation systems,
focusing on the agencies' joint pilot of the IDES. Specifically, we
examined: (1) the results of DOD and VA's evaluation of the pilot, (2)
challenges in implementing the piloted system to date, and (3) DOD and
VA plans to expand the piloted system and whether those plans
adequately address potential challenges.
To examine DOD and VA's evaluation of the IDES pilot, we identified
the goals that DOD and VA expected the pilot to achieve and reviewed
their assessment of whether those goals were met. As part of this
work, we assessed the reliability of two types of data that DOD and VA
planned to use as the basis of their pilot evaluation--case data from
both pilot and legacy disability evaluation systems, as well as data
from surveys DOD conducted to gauge servicemember satisfaction. We
obtained the case data and survey data as of early 2010, the same
cutoff dates that DOD and VA used for their pilot evaluation.[Footnote
4] To identify challenges in implementing the piloted system to date,
we visited 10 of the 27 military treatment facilities participating in
the pilot.[Footnote 5] We selected these 10 facilities to obtain
perspectives from sites in different military services and
geographical regions and with varying caseloads and organizational
structures. For all of the research objectives, we conducted
interviews with key officials involved in the pilot at DOD, VA, and
each of the military services. Furthermore, we analyzed pilot case
data and reviewed reports, guidance, plans, and other documents. We
also reviewed relevant federal laws and regulations. We conducted this
performance audit from November 2009 to December 2010, in accordance
with generally accepted government auditing standards. Those standards
require that we plan and perform the audit to obtain sufficient,
appropriate evidence to provide a reasonable basis for our findings
and conclusions based on our audit objectives. We believe that the
evidence obtained provides a reasonable basis for our findings and
conclusions based on our audit objectives.
The NDAA 2008 also requires us to certify whether we had timely access
to sufficient information to make informed judgments on the matters
covered by our report.[Footnote 6] We were provided sufficient
information in a timely manner to make informed judgments on the audit
objectives covered in this report.
Background:
The DOD Legacy Disability Evaluation System:
The military's legacy disability evaluation process begins at a
military treatment facility when a physician identifies a condition
that may interfere with a servicemember's ability to perform his or
her duties.[Footnote 7] On the basis of medical examinations and the
servicemember's medical records, a medical evaluation board (MEB)
identifies and documents any conditions that may limit a
servicemember's ability to serve in the military.
The servicemember's case is then evaluated by a physical evaluation
board (PEB) to make a determination of fitness or unfitness for duty.
Each of the services conducts this process for its servicemembers. The
Army has three PEBs, which are located at Fort Sam Houston, Texas;
Walter Reed Army Medical Center in Washington, D.C.; and Fort Lewis,
Washington. The Navy and Air Force each have one PEB: the Navy's is
located at the Washington Navy Yard in Washington, D.C., and the Air
Force's is located in San Antonio, Texas. The PEB process begins with
an "informal" PEB--an administrative review of the case file by PEB
adjudicators without the presence of the servicemember. If the
servicemember is found to be unfit due to medical conditions incurred
in the line of duty, the informal PEB assigns the servicemember a
combined percentage rating for those unfit conditions, and the
servicemember is discharged from duty. Disability ratings range from 0
(least severe) to 100 percent (most severe) in increments of 10
percent. Depending on the overall disability rating and number of
years of active duty or equivalent service, the servicemember found
unfit with compensable conditions is entitled to either monthly
disability retirement benefits or lump sum disability severance pay.
[Footnote 8]
Servicemembers have opportunities to appeal the results of their
disability evaluations. If servicemembers are dissatisfied with the
informal PEB's decisions, they may request a hearing with a "formal"
PEB. If they then disagree with the formal PEB's findings, they can,
under certain conditions, appeal to the reviewing authority of the
PEB.[Footnote 9]
As servicemembers navigate DOD's disability evaluation system, they
interface with staff who play key roles in supporting them through the
process. Military physicians involved in the MEB process play a
fundamental role because they are responsible for documenting in the
disability evaluation case file the medical conditions that may limit
a servicemember's ability to serve in the military. To prepare this
documentation, military physicians may require that servicemembers
obtain additional medical evidence from specialty physicians, such as
a psychiatrist. Throughout the MEB and PEB processes, board liaisons
serve a key role by explaining the process to servicemembers and
constructing the case files. The liaisons inform servicemembers of
board results and of deadlines at key decision points in the process.
The military also provides legal counsel to advise and represent
servicemembers going through the disability evaluation process,
although servicemembers may retain their own representative at their
own expense.
The VA Disability Claims Process:
In addition to receiving disability benefits from DOD, veterans with
service-connected disabilities may receive compensation from VA for
lost earnings capacity. In contrast to DOD's disability evaluation
system, which evaluates only medical conditions affecting
servicemembers' fitness for duty, VA evaluates all medical conditions
claimed by the veteran, whether or not they were previously evaluated
by the military services' medical evaluation process. Although a
servicemember may file a VA claim while still in the military, he or
she can only obtain disability compensation from VA as a veteran.
VA's disability compensation claims process starts when a veteran
submits a claim to VA's Veterans Benefits Administration (VBA). The
claim lists the medical conditions that the veteran believes are
service-connected. For each claimed condition, VA must determine if
credible evidence is available to support the veteran's contention of
service connection. A service representative assists the veteran in
gathering the relevant evidence to evaluate the claim, which may
include the veteran's military service records and treatment records
from VA medical facilities and private medical service providers.
Also, if necessary for reaching a decision on a claim, VBA arranges
for the veteran to receive a medical examination conducted by
clinicians (including physicians, nurse practitioners, or physician
assistants) certified to perform the exams under VA's Compensation and
Pension program. Once a claim has all of the necessary evidence, a VA
rating specialist evaluates the claim and determines whether the
claimant is eligible for benefits. If so, the rating specialist
assigns a percentage rating. If VA finds that a veteran has one or
more service-connected disabilities with a combined rating of at least
10 percent, the agency will pay monthly compensation. The veteran can
claim additional benefits over time, for example, if a service-
connected disability worsens or surfaces at a later point in time.
The Integrated Disability Evaluation System:
In November 2007, DOD and VA began piloting the IDES, a joint
disability evaluation system to eliminate duplication in their
separate systems and to expedite receipt of VA benefits for wounded,
ill, and injured servicemembers. The IDES merges DOD and VA processes,
so that servicemembers begin their VA disability claim while they
undergo their DOD disability evaluation, rather than sequentially,
making it possible for them to receive VA disability benefits shortly
after leaving military service. Specifically, the IDES:
* merges DOD and VA's separate exam processes into a single exam
process conducted to VA standards. This single exam--which may involve
more than one medical examination (for example, by different
specialists)--in conjunction with the servicemembers' medical records,
is used by military service PEBs to make a determination of
servicemembers' fitness for continued military service, and by VA as
evidence of service-connected disabilities. The single exam may be
performed by medical staff working for either VA, DOD, or a private
provider contracted with either agency.
* consolidates DOD and VA's separate rating phases into one VA rating
phase. If the informal PEB has determined that a servicemember is
unfit for duty, VA rating specialists prepare two ratings--one for the
conditions that DOD determined made a servicemember unfit for duty,
which DOD uses to provide military disability benefits, and the other
for all service-connected disabilities, which VA uses to determine VA
disability benefits. Ratings for the IDES are prepared by rating
specialists at VA's Baltimore and Seattle regional offices.
* provides VA case managers to perform outreach and nonclinical case
management and explain VA results and processes to servicemembers.
By consolidating DOD and VA's separate medical exams and ratings, the
IDES eliminates several steps from the existing "legacy" systems (see
figure 1).
Figure 1: Overview of the Legacy and IDES Processes:
[Refer to PDF for image: illustration]
Legacy process:
Actions performed by Department of Defense (DOD):
1. Service member referred to disability system.
2. Military medical providers conduct medical exam.
3. Medical Evaluation Board (MEB)identifies conditions that may make
member unfit for duty.
4. Physical Evaluation Board (PEB) assesses servicemember‘s fitness
for duty.
5. If found unfit, PEB rates the unfitting conditions to determine
benefits.
6. Service member discharged with DOD benefits if eligible.
Actions performed by Veterans Affairs (VA):
7. Veteran files claim for benefits with VA.
8. VA providers examine veteran.
9. VA rates all of veteran‘s service-connected conditions.
10. Veteran receives VA benefits if eligible.
IDES process:
Actions performed by DOD and VA:
1. Service member referred to disability system.
2. Medical providers conduct medical exam to VA standards[A].
3. Medical Evaluation Board (MEB) identifies conditions that may make
member unfit for duty.
4. Physical Evaluation Board (PEB) assesses service member‘s fitness
for duty.
5. If found unfit, VA rates the conditions to determine both DOD and
VA benefits.
6. Service member receives both DOD and VA benefits shortly after
discharge.
Sources: GAO analysis of DOD and VA policies.
Note: Under the legacy system, steps 1, 2, and 3 are not necessarily
performed in this order. For example, a Navy official told us that
under the legacy system, the servicemember is referred into the
disability evaluation system when the MEB completes the documentation
identifying the conditions that may make a member unfit for duty. With
regard to step 7, servicemembers may file a claim with VA while still
in the military, but they can only obtain disability compensation from
VA as a veteran. With regard to step 8, the exams may be conducted by
VA clinicians or by private-sector physicians contracted with VA.
[A] In the IDES process, the medical exam performed to VA standards
can be conducted by VA, DOD, or private-sector providers contracted
with either agency.
[End of figure]
In designing the IDES, DOD and VA established goals to provide VA
benefits to active duty servicemembers within 295 days of being
referred into the system, and to reserve component members within 305
days.[Footnote 10] In establishing the 295-and 305-day goals, they
also established timeliness goals for the specific steps of the IDES
process (see figure 2).
Figure 2: Timeliness Goals for the Steps of the IDES Process:
[Refer to PDF for image: timeline]
IDES goal (in days):
Service member referred to the IDES:
MEB phase:
10 days: DOD board liaison meets with servicemember, compiles medical
and personnel records (30 for Reserves);
10 days: VA case manager meets member, files VA claim (30 for
Reserves);
45 days: VA, DOD, or contracted providers perform medical exam;
35 days: MEB identifies potentially unfitting conditions.
PEB phase:
15 days: Informal PEB determines fitness for duty;
15 days: VA completes ratings;
30 days: Member may appeal fitness decision to formal PEB;
15 days: Member may appeal rating decision to VA;
30 days: Member may appeal formal PEB decision to military department;
15 days: Administrative processing throughout PEB phase;
End of PEB phase.
45 days: Servicemember separates from military;
30 days: VA issues benefits letter.
Total: 295 days (305 for Reserves[A]).
Sources: GAO analysis of DOD and VA policies and guidance.
[A] DOD guidance allows 40 more days for reserve component members
than for active duty members in completing the first two steps of the
process to provide for employer notification, establish orders for
active duty, and to compile medical records. However, DOD and VA's
goal for total IDES processing time is only 10 days longer for reserve
component members than for active duty members.
[End of figure]
DOD and VA first piloted the IDES at 3 Washington, D.C., area military
treatment facilities, beginning in November 2007 (see table 1). They
added 18 military facilities to the pilot in fiscal year 2009 and 6 in
fiscal year 2010. DOD and VA stated that expansion to additional sites
was intended to assess the IDES system in a variety of geographic
areas and to test the agencies' capacity to handle additional
caseload. According to DOD, the 27 pilot sites represented almost half
of the servicemembers in the military services' disability evaluation
systems.
Table 1: Military Treatment Facilities Piloting the IDES:
Military service: Air Force (6);
Initial pilot sites (3): Malcolm Grow Medical Center, Andrews Air
Force Base (MD);
Phase 1 expansion--fiscal year 2009 (18):
Elmendorf Air Force Base (AK);
MacDill Air Force Base (FL);
Nellis Air Force Base (NV);
Travis Air Force Base (CA);
Vance Air Force Base (OK);
Phase 2 expansion--fiscal year 2010 (6): [Empty].
Military service: Army (15);
Initial pilot sites (3): Walter Reed Army Medical Center (Washington,
D.C.);
Phase 1 expansion--fiscal year 2009 (18):
Fort Belvoir (VA);
Fort Carson (CO);
Fort Drum (NY);
Fort Meade (MD);
Fort Polk (LA);
Fort Richardson (AK);
Fort Sam Houston (TX);
Fort Stewart (GA);
Fort Wainwright (AK);
Phase 2 expansion--fiscal year 2010 (6):
Fort Benning (GA);
Fort Bragg (NC);
Fort Hood (TX);
Fort Lewis (WA);
Fort Riley (KS).
Military service: Navy[A] (6);
Initial pilot sites (3): National Naval Medical Center (MD);
Phase 1 expansion--fiscal year 2009 (18):
Camp Lejeune (NC);
Camp Pendleton (CA);
Naval Hospital Bremerton (WA);
Naval Medical Center San Diego (CA);
Phase 2 expansion--fiscal year 2010 (6): Naval Medical Center
Portsmouth (VA).
Total number of pilot sites: 27.
Source: DOD.
Note: Numbers in parentheses indicate numbers of IDES sites.
[A] Navy IDES pilot sites serve both Navy and Marine Corps
servicemembers, since the Marine Corps is within the Department of the
Navy.
[End of table]
Pilot Evaluation Results Are Promising, but the Degree of Improvement
Achieved Is Unknown:
DOD and VA's Evaluation Shows That the Pilot Is Achieving Some of Its
Goals:
In their planning documents for the IDES pilot, DOD and VA stated that
they were basing their evaluation of the effectiveness of the IDES
pilot on whether it has achieved three key goals relative to the
legacy process: increased servicemember satisfaction, improved case-
processing time, and a reduction in servicemember appeal rates. In
addition, they also examined IDES program costs. To determine whether
they have achieved their goals, the agencies surveyed servicemembers
in the IDES pilot and legacy systems and are using a data system--
called the Veterans Tracking Application (VTA)--that enables them to
track case processing time and appeals. They have been monitoring
their progress on these goals through weekly reports.
In August 2010, DOD and VA officials issued an interim report to
Congress summarizing their evaluation results to date. In this report,
the agencies concluded that servicemembers who went through the IDES
pilot were more satisfied than those who went through the legacy
system, and that the IDES process met the agencies' goals of
delivering VA benefits to active duty servicemembers within 295 days
and to reserve component servicemembers within 305 days. Specifically,
they reported that, as of February 2010, the IDES process took an
average of 274 days to complete for active duty servicemembers and 281
days for reserve component members who, according to the interim
report, comprise 15 percent of IDES participants. Furthermore, they
concluded that the IDES pilot has achieved a faster processing time
than the legacy system, which they estimated to be 540 days.[Footnote
11]
While overall results were promising, data presented in the report had
some limitations, and the report itself did not include certain
analyses. For example, DOD officials told us that the 540-day estimate
for the legacy process was based upon a review of a small and
nonrepresentative sample of legacy cases during the agencies' "table
top" planning exercise in August 2007.[Footnote 12] In addition,
although DOD officials told us that they planned to compare average
processing times of pilot cases with a broader sample of legacy cases,
and to determine whether fewer servicemembers are appealing the
findings of informal PEBs and formal PEBs in the pilot compared with
the legacy, the interim report did not include these comparisons. In
addition, in their planning documents for the IDES pilot, DOD and VA
indicated that they were establishing a goal to deliver VA benefits to
80 percent of members in the IDES pilot within the 295-and 305-day
time frames. However, their interim report did not discuss whether
this goal was met.
Our review of DOD and VA's data and weekly reports generally confirm
DOD and VA's findings, as of early 2010. However, while the agencies
have largely met their overall goal to increase servicemember
satisfaction and met their timeliness goal as of February 2010, since
that time, case processing times have been steadily increasing as the
caseload has increased. In addition, not all of the service branches
are achieving the same results.
* Servicemember satisfaction: Our review of the survey data that DOD
used for the interim report (as of February 2010), as well as a recent
weekly report, indicate that, on average, servicemembers in the IDES
process have had higher satisfaction levels than those who went
through the legacy process. In addition, a higher percentage of
servicemembers who went through the IDES process felt that the process
was fair compared with those who went through the legacy system.
However, servicemembers in the Air Force who went through the IDES
pilot indicated less satisfaction with the process than those who went
through the legacy system, though Air Force members represented a
small proportion of pilot cases--about 7 percent of those enrolled in
the pilot.[Footnote 13] We reviewed the agencies' survey methodology
and generally found their survey design and conclusions to be sound
(see appendix I for further information on our review).
* Average case processing times: The agencies have been meeting their
295-day and 305-day timeliness goals for much of the past 2 years, but
more recent weekly reports indicate case processing time has been
increasing and that they are now missing their goal for active duty
members.[Footnote 14] As of August 29, 2010, the agencies missed the
goal for active duty servicemembers by 1 day, while still meeting the
305-day goal for reserve component members by 7 days. Processing times
have increased as caseload has increased, from about 5,750 active
cases in February to about 9,650 cases in August 2010. We reviewed the
reliability of the VTA data upon which the agencies based their
analyses and generally found these data to be sufficiently reliable
for purposes of these analyses.[Footnote 15]
The increases in overall case processing time and caseloads mirror the
trends at individual sites. For each pilot site, case processing times
have generally increased as workloads have increased. For example,
figure 3 shows the case processing times 1 year or more after
implementation and in August 2010 for the first seven pilot sites.
Figure 3: Average Case Processing Times and Changes in Active Caseload
by Location at Least 1 Year After Implementation and in August 2010:
[Refer to PDF for image: horizontal bar graph]
Processing time:
Location: Andrews (Air Force);
About 1 year after implementation[A]: 292 days;
August 29, 2010[B]: 355 days;
Change in active caseload: Increased by 23 cases.
Location: Walter Reed (Army);
About 1 year after implementation[A]: 250 days;
August 29, 2010[B]: 324 days;
Change in active caseload: Decreased by 13 cases.
Location: Fort Belvoir (Army);
About 1 year after implementation[A]: 238 days;
August 29, 2010[B]: 298 days;
Change in active caseload: Increased by 44 cases.
Location: Fort Meade (Army);
About 1 year after implementation[A]: 257 days;
August 29, 2010[B]: 283 days;
Change in active caseload: Increased by 44 cases.
Location: Fort Stewart (Army);
About 1 year after implementation[A]: 203 days;
August 29, 2010[B]: 258 days;
Change in active caseload: Increased by 144 cases.
Location: Bethesda (Navy);
About 1 year after implementation[A]: 286 days;
August 29, 2010[B]: 380 days;
Change in active caseload: Increased by 135 cases.
Location: San Diego (Navy);
About 1 year after implementation[A]: 236 days;
August 29, 2010[B]: 316 days;
Change in active caseload: Increased by 413 cases.
Sources: GAO presentation of weekly report data from DOD and VA.
[A] For the oldest pilot locations--Walter Reed Army Medical Center,
Andrews Air Force Base, and Bethesda Naval Medical Center--the first
average case processing times shown were as of May 31, 2009, which is
more than 1 year after these sites began implementing the pilot in
November 2007 because this was the first month that the agencies
reported processing times by location. The first processing date for
all other sites comes from the weekly report closest to 1 year after
each site began implementing the pilot. (The implementation dates
were: October 1, 2008, for Fort Belvoir and Fort Meade; October 31,
2008, for Naval Medical Center San Diego; and November 30, 2008, for
Fort Stewart).
[B] The end date for the changes in active caseload is August 22,
2010, and differs by 1 week from the end date of August 29, 2010, used
for the average case processing time because the data used in these
two analyses are presented in different appendices to the weekly
reports that rotate each week.
[End of figure]
Of the four military services, only the Army and Navy were achieving
the 295-and 305-day goals on average, as of February 2010, and only
the Army was achieving these goals as of August 2010. Because the Army
comprises a large proportion of cases (approximately 60 percent of
IDES pilot cases that have completed the whole process), it has
lowered the overall average processing time to near or below the
established goals. Figure 4 shows the average case processing times
for active duty, by service, as of August 2010. (See appendix II for
reserve component.)
Figure 4: Active Duty IDES Case Processing Times by Service, as of
August 29, 2010:
[Refer to PDF for image: horizontal bar graph]
Service goal: 295 days.
Service: Air Force;
Elapsed time in days: 339.
Service: Army;
Elapsed time in days: 266.
Service: Navy;
Elapsed time in days: 340.
Service: Marine Corps;
Elapsed time in days: 334.
Service: All;
Elapsed time in days: 296.
Sources: GAO presentation of weekly report data from DOD and VA.
[End of figure]
As of February 2010, the agencies also had not met the goal of
processing 80 percent of all pilot cases within targeted time frames.
Specifically, about 60 percent of active duty pilot cases have been
completed within 295 days, according to our analysis of the agencies'
case data intended for their interim report. Further, none of the four
military services have achieved this goal, although the Army has had
the highest rate of cases (66 percent) meeting the goal, while only 42
percent of Air Force cases were processed within the time frame (see
figure 5 for active duty and appendix II for reserve component).
Figure 5: Percentage of IDES Active Duty Cases Completed in 295 Days
or Less by Service, as of February 2010:
[Refer to PDF for image: horizontal bar graph]
Service goal: 80%.
Service: Air Force;
Cases meeting goal: 42%.
Service: Army;
Cases meeting goal: 66%.
Service: Navy;
Cases meeting goal: 57%.
Service: Marine Corps;
Cases meeting goal: 53%.
Service: All;
Cases meeting goal: 60%.
Sources: GAO analysis of pilot case data from DOD and VA.
[End of figure]
Extent of Improvement Over the Legacy System Is Unknown Due to Gaps in
Legacy Data:
DOD and VA planned to compare the case processing times of
servicemembers in the IDES pilot and servicemembers who, between
fiscal years 2005 and 2009, were enrolled in the legacy system at
pilot sites prior to pilot implementation, but significant gaps in the
legacy case data preclude reliable comparisons. DOD compiled the
legacy case data from each of the military services and the VA, but
the military services each had slightly different disability
evaluation processes, used different data systems, and did not track
the same information. As a result, information needed to conduct a
comparison is not available for all services. For example, the Navy,
Marine Corps, and Air Force legacy data do not have information on
when the servicemember was referred into the disability evaluation
system and, as a result, case-processing time for the legacy system
DOD-wide cannot be known.[Footnote 16] DOD officials said they planned
to estimate legacy case processing time by approximating the dates
that servicemembers in the Navy, Marine Corps, and Air Force were
referred into the disability evaluation process, but their methodology
was based on a limited number of Army cases (see appendix I for
further information). In addition, for legacy cases across all
military services, VA was not able to provide data on the date VA
benefits were delivered, so total case processing time from referral
to delivery of VA benefits cannot be measured. However, while legacy
case data are not sufficiently reliable for comparison with the IDES
overall, the Army's legacy data appear to be reliable on some key
processing dates, making some limited comparisons possible. Our
analysis of Army legacy data suggests that, under the legacy process,
active duty Army cases took 369 days to complete the DOD legacy
process and reach the VA rating phase--though this figure does not
include time to complete the VA rating and provide the benefits to
servicemembers--compared with 266 days to deliver VA benefits to
servicemembers under the pilot, according to the agencies' August
weekly report.[Footnote 17] However, Army comparisons cannot be
generalized to the other services.
The agencies also planned to compare servicemembers' appeal rates in
the pilot and legacy systems, but similar gaps in the legacy data
preclude a comparison DOD-wide. For example, the legacy data that DOD
compiled did not contain data on appeals of informal PEB decisions to
the formal PEB in the Navy and Marines, and consequently the rate of
appeals across the military in the legacy system is unknown. While the
Army's appeals data appear to be more reliable, potentially making
some limited comparisons possible, the agencies' method for comparing
pilot appeals with legacy has limitations. DOD officials told us they
are planning to compare the proportion of informal PEB decisions that
were appealed to a formal PEB hearing in the pilot and legacy systems.
However, this will not take into account that, under the legacy
system, a servicemember could appeal the informal PEB's decision for
two reasons--because they were dissatisfied with the fitness decision
or the disability rating the PEB assigned, while in the IDES, they can
only appeal the informal PEB decision to a formal PEB if they are
dissatisfied with the fitness decision. Under the IDES, servicemembers
who disagree with the disability rating can appeal to VA for a rating
reconsideration. By not including appeals to VA for rating
reconsiderations, the agencies may overestimate the decrease in
appeals in the IDES pilot. For example, our analysis of data as of
early 2010 for the Army indicates that Army members in the pilot
appealed 7.5 percent of informal PEB decisions. However, when appeals
to VA are factored in, 13 percent of Army members in the pilot filed
an appeal, which is the same proportion as in the legacy system (see
figure 6).
Figure 6: Army Servicemember IDES and Legacy Appeal Rates, as of early
2010:
[Refer to PDF for image: horizontal bar graph]
Legacy[A]: Cases with an appeal;
Informal PEB appeals: 12.9%.
IDES pilot[B]: Cases with an appeal;
Informal PEB appeals: 7.5%;
VA rating reconsiderations: 5.6%;
Total: 13.1%.
Sources: GAO analysis of legacy data and pilot case data provided by
DOD and VA.
[A] Legacy data is as of January 2010 on servicemembers who were
referred to the disability evaluation system between fiscal years 2005
and 2009 at 21 military treatment facilities selected as IDES pilot
sites.
[B] Pilot case data is as of February 2010 for servicemembers who were
referred to the IDES beginning November 2007.
[End of figure]
In addition to evaluating the three goals, DOD and VA initially
planned a cost-benefit analysis of the IDES program but have only
completed an analysis of costs. According to data provided to us in
August 2010, DOD projects that costs directly associated with
implementing the IDES will be $63 million greater per year when
compared with the legacy system, after full expansion of the IDES.
[Footnote 18] In October 2010, VA reported to us total IDES cost
estimates of approximately $50 million for fiscal year 2011--about $33
million for VBA, which provides VA case managers and rating staff to
the IDES, and $17 million for the Veterans Health Administration
(VHA), which provides medical staff to perform the single exams.
[Footnote 19] These analyses did not quantify the value of potential
benefits created by the pilot, for example time savings from DOD
physicians no longer needing to perform disability examinations, which
allows them to perform other duties.
Pilot Sites Experienced Several Challenges:
As DOD and VA tested the IDES at different facilities and added
caseload to the pilot, they encountered several challenges that led to
delays in certain phases of the process. Among these were insufficient
staffing, challenges in conducting the single exams, logistical
challenges related to integrating VA staff, as well as housing and
managing servicemembers going through the IDES. DOD and VA were able
to address some, but not all, of these challenges as they arose.
DOD and VA Did Not Sufficiently Staff Many Key Positions in the IDES
Pilot:
DOD and VA have not provided sufficient numbers of staff in many of
the IDES locations, affecting their ability to complete certain phases
of the IDES process within the goals they established. Officials at
most of the 10 pilot sites we visited said they have experienced
staffing shortages to at least some extent, with a few sites--Fort
Carson and Fort Stewart, in particular--experiencing severe shortages.
VA or contract examiners: At three pilot sites we visited--Fort
Carson, Fort Polk, and Fort Stewart--local officials said that a lack
of VA or VA contractor staff who could perform the required single
medical exams led to bottlenecks in the process.[Footnote 20] For
example, as of August 2010, exams at Fort Carson have taken an average
of 140 days to complete for active duty servicemembers, according to
the agencies' data, far from achieving their goal to complete single
medical exams within 45 days (see figure 7; see also appendix II for
processing times for reserve component members). Across all pilot
sites, exams have taken 68 days to complete for active duty
servicemembers, on average, with 8 of the 27 pilot sites meeting the
45-day goal.[Footnote 21] The different sites we visited faced
shortages for different types of examiners. For instance, Fort
Carson's IDES process was particularly hampered by a lack of mental
health specialists; in contrast, VA officials serving the Fort Polk
pilot site said they had sufficient specialists to perform specialty
medical exams but did not have enough examiners to complete general
medical exams.
Figure 7: Single Exam Processing Time for Active Duty Servicemembers
at IDES Pilot Sites, as of August 29, 2010:
[Refer to PDF for image: vertical bar graph]
Service goal: 45 days;
Average for all sites: 68 days.
Air Force:
Site: Elmendorf;
Elapsed time in days: 74.
Site: Andrews;
Elapsed time in days: 58.
Site: Nellis;
Elapsed time in days: 57.
Site: Vance;
Elapsed time in days: 52.
Site: MacDill;
Elapsed time in days: 40.
Site: Travis;
Elapsed time in days: 33.
Army:
Site: Fort Carson;
Elapsed time in days: 140.
Site: Fort Stewart;
Elapsed time in days: 94.
Site: Fort Richardson;
Elapsed time in days: 81.
Site: Fort Wainwright;
Elapsed time in days: 80.
Site: Walter Reed;
Elapsed time in days: 73.
Site: Fort Sam Houston;
Elapsed time in days: 70.
Site: Fort Belvoir;
Elapsed time in days: 65.
Site: Fort Polk;
Elapsed time in days: 62.
Site: Fort Drum;
Elapsed time in days: 57.
Site: Fort Lewis;
Elapsed time in days: 56.
Site: Fort Benning;
Elapsed time in days: 44.
Site: Fort Hood;
Elapsed time in days: 39.
Site: Fort Meade;
Elapsed time in days: 38.
Site: Fort Riley;
Elapsed time in days: 38.
Site: Fort Bragg;
Elapsed time in days: 30.
Navy[A]:
Site: Bethesda;
Elapsed time in days: 57.
Site: Camp Lejeune;
Elapsed time in days: 49.
Site: Portsmouth;
Elapsed time in days: 48.
Site: San Diego;
Elapsed time in days: 46.
Site: Camp Pendleton;
Elapsed time in days: 45.
Site: Bremerton;
Elapsed time in days: 42.
Marine Corps:
Site: Camp Lejeune;
Elapsed time in days: 62.
Site: Camp Pendleton;
Elapsed time in days: 59.
Site: Bethesda;
Elapsed time in days: 58.
Site: Portsmouth;
Elapsed time in days: 50.
Site: San Diego;
Elapsed time in days: 47.
Site: Bremerton;
Elapsed time in days: 44.
Sources: GAO presentation of weekly report data from DOD and VA.
[A] This figure shows processing times separately for servicemembers
in the Navy and Marine Corps at the six Navy IDES pilot sites.
[End of figure]
Military physicians: At some of the pilot sites we visited, local DOD
officials felt there were not enough physicians to quickly complete
and document their determinations of whether servicemembers' medical
conditions may limit their ability to serve in the military. As a
result, the sites had difficulty achieving the agencies' goal to
complete the MEB determinations within 35 days. Across all sites, the
MEB determination has taken an average of 61 days to complete for
active duty servicemembers, with 8 of the 27 sites meeting the 35-day
goal, as of August 2010.[Footnote 22] A few sites we visited were far
from achieving the 35-day goal, such as Fort Belvoir, where MEB
determinations averaged 101 days to complete for active duty
servicemembers (see figure 8 and appendix II for processing times for
reserve component members). Only the Army, which has physicians
dedicated to disability evaluation, has established a caseload target
for MEB physicians--120 servicemembers per physician, but Army
officials were not able to provide us with data on the extent to which
pilot sites met this target. The Navy and Air Force have not
established caseload targets for their physicians; their MEB
determinations are prepared by physicians who perform other
responsibilities, such as clinical treatment or supervision.
Figure 8: MEB Processing Times for Active Duty Servicemembers at IDES
Pilot Sites, as of August 29, 2010:
[Refer to PDF for image: vertical bar graph]
Service goal: 35 days;
Average for all sites: 61 days.
Air Force:
Site: MacDill;
Elapsed time in days: 106.
Site: Andrews;
Elapsed time in days: 85.
Site: Nellis;
Elapsed time in days: 58.
Site: Travis;
Elapsed time in days: 43.
Site: Vance;
Elapsed time in days: 33.
Site: Elmendorf;
Elapsed time in days: 30.
Army:
Site: Fort Richardson;
Elapsed time in days: 109.
Site: Fort Meade;
Elapsed time in days: 100.
Site: Fort Belvoir;
Elapsed time in days: 101.
Site: Walter Reed;
Elapsed time in days: 76.
Site: Fort Stewart;
Elapsed time in days: 74.
Site: Fort Carson;
Elapsed time in days: 69.
Site: Fort Sam Houston;
Elapsed time in days: 65.
Site: Fort Lewis;
Elapsed time in days: 56.
Site: Fort Hood;
Elapsed time in days: 52.
Site: Fort Polk;
Elapsed time in days: 47.
Site: Fort Drum;
Elapsed time in days: 39.
Site: Fort Riley;
Elapsed time in days: 37.
Site: Fort Benning;
Elapsed time in days: 35.
Site: Fort Wainwright;
Elapsed time in days: 34.
Site: Fort Bragg;
Elapsed time in days: 33.
Navy[A]:
Site: Camp Lejeune;
Elapsed time in days: 95.
Site: Camp Pendleton;
Elapsed time in days: 73.
Site: Bethesda;
Elapsed time in days: 72.
Site: San Diego;
Elapsed time in days: 31.
Site: Portsmouth;
Elapsed time in days: 24.
Site: Bremerton;
Elapsed time in days: 20.
Marine Corps:
Site: Camp Lejeune;
Elapsed time in days: 89.
Site: Camp Pendleton;
Elapsed time in days: 66.
Site: Bethesda;
Elapsed time in days: 62.
Site: San Diego;
Elapsed time in days: 33.
Site: Portsmouth;
Elapsed time in days: 23.
Site: Bremerton;
Elapsed time in days: 14.
Sources: GAO presentation of weekly report data from DOD and VA.
[A] This figure shows processing times separately for servicemembers
in the Navy and Marine Corps at the six Navy IDES pilot sites.
[End of figure]
DOD PEB adjudicators: Officials with the Air Force and Navy PEBs, who
determine a servicemember's fitness for duty, also expressed concerns
about understaffing, though their concerns are not related to the IDES
alone since they are currently reviewing cases in both the legacy
system and the IDES pilot. Air Force PEB officials noted that they had
a substantial backlog of disability evaluation system cases awaiting a
fitness decision, though they recently added adjudicators to reduce
the backlog. Navy PEB officials also expressed concerns that lack of
sufficient staff has made it difficult to process cases in a timely
manner. At the time of our review, none of the services were meeting
the agencies' goal for informal PEBs to complete their fitness
decisions within 15 days, with the Air Force, Navy, and Marine Corps
far from reaching it (See figure 9 for processing times for active
duty servicemembers. See also appendix II for reserve component
processing times). At 23 days, the Army, with 3 PEBs, is slightly
short of the goal. However, we could not determine case processing
times at each Army PEB, since the agencies' weekly monitoring report
presents data by military services but not by individual PEB. In
addition, Air Force and Army PEB officials informed us that they had
prioritized IDES pilot cases over legacy cases at some point in time.
As a result, DOD's data for those services may underestimate the
amount of time the informal PEB would have taken if IDES cases had not
received priority.
Figure 9: Informal PEB Processing Times for Active Duty Servicemembers
in the IDES Pilot, by Military Service, as of August 29, 2010:
[Refer to PDF for image: horizontal bar graph]
Service goal: 15 days.
Service: Air Force;
Elapsed time in days: 64.
Service: Army;
Elapsed time in days: 23.
Service: Navy;
Elapsed time in days: 83.
Service: Marine Corps;
Elapsed time in days: 97.
Sources: GAO presentation of weekly report data from DOD and VA.
[A] The Navy PEB determines fitness decisions for servicemembers in
the Marine Corps.
[End of figure]
VA rating staff: Officials at the Baltimore rating office--one of the
two VA offices that conduct disability ratings for the IDES pilot--
expressed significant concerns that they were understaffed, in part
due to staff turnover. DOD and VA data show that, overall, the VA
rating offices are not meeting the agencies' goal to complete ratings
within 15 days, taking 39 days on average for active duty
servicemembers and 42 days for reserve component members.[Footnote 23]
We could not determine case processing times at each individual VA
rating office, since DOD and VA's weekly monitoring reports do not
provide processing times for the rating phase by office. The weekly
reports also do not provide data on caseloads at each office. Although
the Baltimore office currently has fewer rating staff than Seattle, VA
officials said that it has prepared ratings for the majority of IDES
pilot cases, based on the way in which VA has allocated cases between
the two offices. The Baltimore office handles cases for the Air Force,
Navy, Marines, and 5 of the 15 Army pilot sites, while the Seattle
office conducts ratings for the remaining 10 Army pilot sites.
[Footnote 24] VA officials said that to address staffing shortages in
Baltimore, they have assigned staff from other VA offices to assist
the Baltimore office.
VA case managers: DOD and VA have set a target for each VA case
manager to handle no more than 30 cases at a time, but two sites we
visited--Fort Carson and Fort Stewart--appeared to be far from these
targets. At Fort Carson, three VA case managers told us they were
handling about 900 cases when we visited in April 2010, for a caseload
ratio of roughly 1:300. At the time of our visit in June 2010, Fort
Stewart had over 750 active cases with two VA case managers, for a
caseload ratio of approximately 1:375. Although local officials we
spoke with at both sites told us that the numbers of VA case managers
were insufficient, an official at VA's central office told us that VA
bases staffing of case managers on the number of new (not pending)
cases each month, and the agencies' data indicates the average number
of new cases per VA case manager has been about 25 at each site. The
VA official said that the reason local case managers felt understaffed
was likely due to other process inefficiencies. In addition, the
official told us VA can reassign staff from other VA programs to
assist case managers at IDES pilot sites as needed. At some of the
other pilot sites we visited, local officials also told us they had
concerns at times about the numbers of VA case managers available to
handle the site's caseload, but VA was able to add staff. VA case
managers at two Air Force sites we visited--Travis and Vance Air Force
Bases--indicated that their caseloads were manageable. We were unable
to independently determine the extent to which VA is meeting its
caseload target because VA does not collect national data on actual
caseloads per case manager.
DOD board liaisons: At most of the sites we visited, local officials
expressed concerns about insufficient numbers of DOD board liaisons,
who serve as servicemembers' DOD case managers. DOD guidance has been
inconsistent on the caseload target for DOD board liaisons. While
DOD's operations manual for the IDES pilot sets a caseload target of
at most 30 cases per board liaison, guidance on the general disability
evaluation system sets the target at a maximum of 20 cases per
liaison. DOD and VA's documents related to planning for IDES expansion
indicate that DOD is striving for a 1:20 caseload target in the IDES.
However, 19 of the 27 pilot sites did not meet the 1:30 caseload
target, and 23 did not meet the 1:20 target (see figure 10).
Figure 10: Average Cases per DOD Board Liaison at IDES Pilot Sites:
[Refer to PDF for image: vertical bar graph]
Goals:
1:30 caseload;
1:20 caseload.
Air Force:
Site: Travis;
Cases per DOD board liaison: 49.
Site: Nellis;
Cases per DOD board liaison: 30.
Site: Elmendorf;
Cases per DOD board liaison: 26.
Site: MacDill;
Cases per DOD board liaison: 22.
Site: Andrews;
Cases per DOD board liaison: 14.
Site: Vance;
Cases per DOD board liaison: 5.
Army:
Site: Fort Lewis;
Cases per DOD board liaison: 152.
Site: Fort Bragg;
Cases per DOD board liaison: 84.
Site: Fort Meade;
Cases per DOD board liaison: 76.
Site: Fort Carson;
Cases per DOD board liaison: 70.
Site: Fort Polk;
Cases per DOD board liaison: 56.
Site: Fort Sam Houston;
Cases per DOD board liaison: 56.
Site: Fort Richardson;
Cases per DOD board liaison: 46.
Site: Fort Stewart;
Cases per DOD board liaison: 45.
Site: Fort Hood;
Cases per DOD board liaison: 44.
Site: Fort Belvoir;
Cases per DOD board liaison: 37.
Site: Fort Wainwright;
Cases per DOD board liaison: 35.
Site: Fort Drum;
Cases per DOD board liaison: 35.
Site: Fort Riley;
Cases per DOD board liaison: 35.
Site: Walter Reed;
Cases per DOD board liaison: 27.
Site: Fort Benning;
Cases per DOD board liaison: 10.
Navy[A]:
Site: Camp Lejeune;
Cases per DOD board liaison: 86.
Site: Camp Pendleton;
Cases per DOD board liaison: 60.
Site: Portsmouth;
Cases per DOD board liaison: 41.
Site: San Diego;
Cases per DOD board liaison: 38.
Site: Bremerton;
Cases per DOD board liaison: 35.
Site: Bethesda;
Cases per DOD board liaison: 12.
Sources: GAO presentation of data from the Departments of the Air
Force, second quarter, fiscal year 2010; Army, May 2010; and Navy,
October 2010.
[A] These Navy military treatment facilities also serve members in the
Marine Corps.
[End of figure]
Local DOD and VA officials attributed staffing shortages to higher
than anticipated caseloads and difficulty finding qualified staff in
rural areas. At several of the pilot sites we visited, officials said
that caseloads were higher than the initial estimates that they had
based staffing levels upon. DOD officials said that they had based
caseload estimates on a 1-year history of caseload at each site. While
some sites have added staff as caseloads increased, others, such as
Fort Polk, located in central Louisiana, have had difficulty finding
qualified staff, particularly physicians, in this rural area.[Footnote
25]
Two of the pilot sites we visited--Fort Carson and Fort Stewart--were
particularly challenged to provide staff in response to surges in
caseload, which occurred when Army units were preparing to deploy to
combat zones. Through the Army's predeployment medical assessment
process, large numbers of servicemembers were determined to be unable
to deploy due to a medical condition and were referred to the IDES
within a short period of time, overwhelming the staff.[Footnote 26]
These two sites were unable to quickly increase staffing levels,
particularly clinicians performing the single exam. The VA medical
center conducting the single medical exams for Fort Carson experienced
turnover among its examiners at the same time that the caseload
surged, while at Fort Stewart, the contractor performing the single
medical exams had difficulties finding qualified physicians in a rural
area of Georgia. To address caseload surges, examiners were reassigned
from other locations to the pilot sites. For example, VA officials
told us they assigned examiners from other VA medical centers to the
Fort Carson IDES and established a contract with a private-sector
provider to complete the exams that VA examiners would normally have
performed for veterans in the area claiming VA disability
compensation. At Fort Stewart, the contractor told us that they had
reassigned examiners from their Atlanta clinic to Fort Stewart.
Insufficiency of Exam Summaries and Disagreements about Medical
Diagnoses and Ratings Can Prolong Case Processing Time:
Issues related to the completeness and clarity of single exam
summaries were an additional cause of delays in the VA rating phase of
the IDES process. Officials from VA rating offices said that some exam
summaries did not contain information necessary to make a rating or
fitness decision, or were unclear as to the examiners' diagnoses and
conclusions. As a result, VA rating office staff must ask the examiner
to clarify the summary or add information and, in some cases, redo the
exam, adding time to the process. In addition, VA rating staff told us
that it is sometimes unclear who they should contact if they identify
insufficiencies in an exam summary and finding the appropriate person
also adds time. However, the extent to which insufficient exam
summaries caused delays in the IDES process is unknown because DOD and
VA's VTA system does not track whether an exam summary had to be
returned to the examiner or whether it was resolved. Due to these
limitations, VA officials told us that VA rating staff have created
logs of outstanding insufficient exams and sent them to VA examiners
to correct.
VA officials attributed the problems with exam summaries to several
factors, including the difficulty of conducting exams for IDES pilot
cases, which may entail evaluating many complex medical conditions and
may involve several physicians and specialists. In addition, VA
officials indicated that, at sites with exam backlogs, such as at Fort
Carson, it may be difficult for examiners to ensure quality when are
trying to complete exams quickly. Furthermore, VA staff noted that
some errors were common, such as missing information for
musculoskeletal conditions and traumatic brain injury, suggesting that
some examiners may not be aware of the information required for
certain types of medical conditions. Finally, while examiners are
supposed to receive the servicemember's complete medical records prior
to the date of the exam, some VA examiners also told us that they did
not receive the records in time for the exam in some cases, or the
records were not well-organized. As a result, they lacked key
information, such as the servicemember's medical history and results
of laboratory tests. According to the agencies' operations manual for
the IDES pilot, the DOD board liaison should compile the complete
medical records within 10 days of an active duty servicemember being
referred to the IDES, but some DOD officials we spoke with said that
it is sometimes difficult to obtain all of the records, particularly
when servicemembers have received treatment from private-sector
physicians.[Footnote 27]
In addition, while the single exam in the IDES eliminates duplicative
exams performed by DOD and VA in the legacy system, it raises the
potential for there to be disagreements about diagnoses of
servicemembers' conditions, with implications for their disability
ratings, as well as processing times. DOD officials we spoke with in
our interviews and site visits also said that their physicians
sometimes disagree with VA medical diagnoses, particularly for mental
health conditions, and this has extended processing times for some
cases. In addition, since medical diagnoses are a basis for VA's
disability ratings, DOD may subsequently disagree with the ratings VA
completed for determining DOD disability benefits. The number of cases
with disagreements about diagnoses and ratings, and the extent to
which they have increased processing time, are unknown because the VTA
system does not track when a case has had such disagreements. However,
officials at 4 of the 10 pilot sites we visited said that military
physicians have disagreed with VA diagnoses in at least some cases. In
addition, PEB officials in two of the three military services--the
Army and the Navy--said that they have sometimes disagreed with the
rating VA produced for determining DOD disability benefits.
An example can illustrate the implications of differences in
diagnoses. Officials at Army pilot sites informed us about cases in
which a military physician had treated members for a mental condition,
such as anxiety or depressive disorder. However, when the members went
to see the VA examiners for their single exam, the examiners diagnosed
them with posttraumatic stress disorder (PTSD). When such cases were
sent to the PEB, it returned them to the MEB because it was unclear to
the PEB which conditions should be the basis of their decision on the
servicemembers' fitness for duty. The cases then languished because
the military physicians experienced difficulties resolving the
discrepancy with the VA diagnosis.
To address such processing delays, the Army issued guidance in
February 2010 stating that MEB physicians should review all of the
medical records (including the results of the single exam) and
determine whether to revise their diagnoses. If after doing so the MEB
physician maintains that their original diagnosis is accurate, they
should write a memorandum summarizing the basis of their decision, and
the PEB should accept the MEB's diagnosis. Some Army officials we
spoke with believe that this guidance has been helpful for enabling
cases to move forward when there are differences in diagnoses. The
other services do not have written guidance on how to address
differences in diagnoses, though Navy officials told us that they have
provided verbal guidance to their physicians, and Air Force officials
said they have not had cases with significant disagreements about
diagnoses.
In some cases, due to the differences in diagnoses, DOD has also
disagreed with the rating that VA prepared for DOD disability
benefits, particularly in cases involving servicemembers with mental
health conditions.[Footnote 28] For example, Army and Navy officials
told us about cases in which the PEB found the servicemember unfit due
to a mental condition, such as major depression, and asked VA to
complete a rating for this condition. However, VA returned a rating
for occupational and social impairment caused by PTSD, since the
examiner had diagnosed the member with PTSD. DOD requires a rating for
only the conditions for which the member was found unfit for duty
because it can only provide disability benefits for those conditions.
However, according to VA regulations for rating mental disorders, VA
does not rate each mental health condition individually; rather, VA
bases its rating on the degree to which the combination of symptoms of
mental disorders cause occupational and social impairment.[Footnote
29] As such, when rating mental health conditions for IDES cases, VA
officials said that rating specialists would consider both the
symptoms of mental conditions diagnosed by DOD physicians and those
identified by the VA examiner. Both Army and Navy PEB officials said
that they generally accept VA ratings in these cases, even though the
rating is not for the unfitting conditions alone. However, they noted
that, if they feel the VA rating is in error, there is no guidance on
how disagreements about servicemembers' ratings should be resolved.
Army and Navy officials said that they may return the case to VA and
informally request that they reconsider the case, though Navy PEB
officials said that they are hesitant to do so because it may further
delay the case.
DOD and VA officials attributed disagreements about diagnoses to
several factors. They noted that VA examiners may not have received or
reviewed the servicemembers' medical records prior to the exam, and
therefore may not be aware of the medical conditions for which the
members had been previously diagnosed and treated. In addition, DOD
and VA identify conditions for different purposes in the disability
evaluation system. While DOD identifies conditions that make a
servicemember unable to perform their duties, VA identifies all
service-connected conditions. As such, VA examiners are likely to
identify a broader set of conditions than DOD's physicians. In
addition, local officials we spoke with in some of our site visits
said that servicemembers may be more willing to disclose all of their
medical conditions to VA than to DOD because VA could potentially
compensate them for all of the conditions. Furthermore, VA officials
noted that servicemembers' health conditions may have changed between
the time DOD physicians identified the conditions and VA performed the
exam. Finally, DOD and VA officials said that differences in opinions
about diagnoses are common among physicians, particularly in the
mental health field. For example, they noted that it be can be
difficult to distinguish PTSD from anxiety, depression, and other
mental health conditions.[Footnote 30]
Pilot Sites Faced Various Logistical Challenges Integrating VA Staff:
DOD and VA officials at several pilot sites said that they experienced
some logistical challenges integrating VA staff at the military
facilities. At a few sites, it took time for VA staff to receive
common access cards needed to access the military facilities and to
use the facilities' computer systems. During the time that VA staff
did not have access cards, they were unable to access VA computer
systems, such as those for establishing the VA claim, requesting
exams, and viewing exam results, via DOD's network.
In addition, DOD and VA staff noted several difficulties using the
agencies' multiple information technology (IT) systems to process
cases. While the agencies both use the VTA system to manage cases, VA
also has IT systems for completing certain tasks, and the military
services also have their own case tracking systems. This causes DOD
and VA staff to have to enter the same data multiple times into
different IT systems. In addition, some VA staff working on military
bases reported that using the military services' computer systems to
access VA systems has significantly slowed down computer processing
speeds. Finally, DOD and VA staff cannot directly access each others'
systems, making it more cumbersome for case managers to determine the
status of servicemembers' cases. For example, without access to VA's
system for managing exams, DOD board liaisons cannot readily provide
servicemembers with information on when or where their exams are
scheduled and must contact VA case managers to obtain the information.
A few sites we visited were able to address some IT issues. For
example, at Fort Polk, VA officials said they were adding a new
telecommunications line to provide faster computer processing speeds
for their staff.
In addition, VA physicians working at military facilities need to be
credentialed by DOD before they can begin working on base, which
involves verification of their education, license, and clinical
history. Some VA officials said that this process could take 1 month
or longer to complete.[Footnote 31]
Extended Periods in the Military Disability Evaluation Process Posed
Housing and Other Challenges at Some Pilot Sites:
Although many DOD and VA officials we interviewed at central offices
and pilot sites felt that the IDES process expedited the delivery of
VA benefits to servicemembers, several also indicated that it may
increase the amount of time servicemembers are in the military's
disability evaluation process. Data on legacy cases are not
sufficiently reliable to determine whether this is the case military-
wide, but Army data appear to be sufficiently reliable to allow for
some limited analysis. Our analysis of Army pilot and legacy data as
of early 2010 shows that compared with legacy cases, active duty cases
in the pilot took on average 39 more days to reach the end of the PEB
phase--the last step of the DOD disability evaluation process before
servicemembers begin transitioning from military service or, if found
fit, back to duty. For reserve component cases in the Army, IDES pilot
cases took on average 17 more days to reach the end of the PEB phase,
compared with legacy cases. It was not possible to conduct this
analysis for the other military services because their legacy data
lacked information on when servicemembers were referred into the
disability evaluation system.
Some DOD officials noted that the increased time that servicemembers
are in the military's disability evaluation process means that they
must be cared for and managed for a longer period. Officials in our
site visits and interviews said that some pilot sites have had
challenges housing servicemembers in the IDES, in part due to
servicemembers being in the process longer. For some servicemembers in
the disability evaluation system, the military services may move them
to temporary medical units or, for those needing longer-term medical
care or complex case management, to special medical units such as a
Warrior Transition Unit in the Army or Wounded Warrior Regiment in the
Marine Corps.[Footnote 32] However, these units were full at a few
pilot sites we visited, or members in the IDES did not meet the
criteria for entering the special medical units. Where servicemembers
remain with their units while going through the disability evaluation
system, the units cannot replace them with able-bodied members.
Officials at Fort Carson said that this created a challenge for combat
units. Because most servicemembers in the IDES did not meet the
criteria for entering Warrior Transition Units, combat units had to
find another organizational unit to take charge of members in the IDES
so they could replace them with soldiers ready and able to deploy to
combat areas. In addition, officials at Naval Medical Center San Diego
and Fort Carson said that some members are not gainfully employed by
their units and, left idle while waiting to complete their disability
evaluation process, are more likely to engage in negative behavior,
potentially resulting in their being discharged due to misconduct and
a forfeiture of disability benefits.[Footnote 33] We were unable to
assess the extent or cause of this problem because the VTA system that
tracks servicemembers in the IDES does not capture sufficient detail
on reasons for servicemembers dropping out of the IDES, or which
organizational unit(s) the servicemember was assigned to while in the
IDES. DOD officials also noted that servicemembers benefit from
continuing to receive their salaries and benefits while their case
undergoes scrutiny by two agencies, though some also acknowledged that
these additional salaries and benefits create costs for DOD.
DOD and VA Expansion Plans Address Some Though Not All Challenges:
DOD and VA Have Incorporated Many Lessons Learned into Their Planning
for Worldwide Expansion of the IDES but Lack Concrete Plans for
Addressing Some Challenges:
DOD and VA plan to expand the IDES to sites worldwide on an ambitious
timetable--to 113 sites during fiscal year 2011, a pace of about 1
site every 3 days. Expansion is scheduled to occur in four stages,
beginning with 28 sites in the southeastern and western United States
by the end of December 2010.[Footnote 34]
DOD and VA have many efforts under way to prepare for IDES expansion.
At each site, local DOD and VA officials are expected to work together
to prepare for implementation. This includes completing a site
assessment matrix--a checklist of information DOD and VA officials at
each site should obtain and preparations they should make. While most
pilot sites had used a site assessment matrix to prepare for IDES
implementation, the agencies completed a significant revision of the
matrix in August 2010, and they now request additional information and
documentation to address areas where prior IDES sites had experienced
challenges. In addition, while during the pilot phase local DOD and VA
officials were encouraged to develop written agreements on IDES
procedures, the matrix now requests that a written agreement be
completed prior to implementing the IDES. Finally, senior-level local
DOD and VA officials will be expected to sign the site assessment
matrix to certify that a site is ready for IDES implementation. This
differs from the pilot phase where, according to DOD and VA officials,
some sites implemented the IDES without having been fully prepared. In
addition, in September 2010, the military services and VA held
preimplementation training conferences for local DOD and VA staff. At
the time of our review, the first 28 expansion sites were completing
their site assessment matrices.
Through the new site assessment matrix and other initiatives under
way, DOD and VA are addressing several of the challenges identified in
the pilot phase. These include ensuring sufficient exam and case
management staff, being prepared to deal with surges in caseloads,
addressing exam sufficiency issues, and making adequate logistical
arrangements.
Ensuring sufficient exam resources: The matrix asks whether a site can
complete single exams within the IDES' 45-day time frame and within
DOD's TRICARE access standards.[Footnote 35] The matrix asks for
detailed information, such as who will conduct the exams (VA, VA
contractor, or military providers), where the exams will be conducted,
and VA's anticipated overall volume of disability compensation and
pension exams in the area. In addition to the matrix, VA has several
initiatives under way to increase resources and expedite exams. VA
plans to award a new contract under which it can acquire examiners for
sites that do not have sufficient staff to perform exams, such as
sites located where VA does not have medical facilities or in rural
areas where VA has had difficulty hiring staff. VA has also recently
changed its exam policy so that exams performed by nurse practitioners
or physician assistants certified to perform disability exams no
longer have to be cosigned by a physician, which is expected to
expedite completion of more exam reports.
Ensuring sufficient VA rating staff: VA officials said that they have
hired new staff to replace those that recently left the Baltimore
rating office and anticipate hiring a small number of additional
staff. Based on caseload projections, they expect that, once the
additional staff are hired, the Baltimore office will be close to
having sufficient rating staff. Although VA officials said that the
Baltimore office conducted ratings for a majority of cases during the
IDES pilot phase, they have projected that the workload will be
divided almost evenly between the Baltimore and Seattle offices once
the IDES is fully expanded worldwide.
Ensuring sufficient DOD PEB adjudicators: Air Force officials informed
us they added adjudicators for the informal PEB and have since
eliminated their case backlog. They are currently adding adjudicators
for the formal PEB. Navy PEB officials also said that they are adding
adjudicators through activation of reserve component personnel for
special work and expected that they would be in place by November 2010.
Ensuring sufficient case management staffing: The site assessment
matrix also asks whether local facilities will have sufficient trained
DOD board liaison staff to meet a 1:20 caseload ratio and sufficient
VA case managers to meet a 1:30 caseload ratio. In addition, according
to DOD officials, each of the military services is increasing its
board liaison staffing levels to achieve 1:20 caseload ratios. VA
officials said that they plan to hire an additional 73 case managers.
Coping with caseload surges: The matrix asks sites to provide a longer
and more detailed caseload history--a 2-year, month-by-month history--
as opposed to the 1-year history that DOD based its caseload
projections on during the pilot phase. In addition, the matrix asks
sites to anticipate any surges in caseloads, such as those due to
seasonal trends. Sites are also expected to provide a written
contingency plan for dealing with caseload surges. In addition, the
matrix asks sites to develop a system for communicating updates, such
as information on expected caseload surges, to stakeholders. VA
officials also said that the Army has agreed to keep them better
informed of deployments that could result in caseload surges. Further,
VA officials noted that they are developing a plan for addressing the
additional need for examiners during surges, through which VA offices
with lower demand for disability exams would send examiners to an IDES
site experiencing a surge in exam workloads.
Ensuring the sufficiency of single exams: The site assessment matrix
asks sites whether all staff who will conduct exams are trained to VA
standards and certified by VA to conduct disability compensation and
pension exams. In addition, VA has begun the process of revising its
exam templates, to better ensure that examiners include the
information needed for a VA disability rating decision and enable them
to complete their exam reports in less time. Finally, a VA official
stated that VA is examining whether it can add capabilities to the VTA
system that would enable staff to identify where problems with exams
have occurred and track the progress of their resolution. For sites
that choose to have military physicians perform the single exams, VA
officials said that they have provided materials to DOD from their
national training program, and DOD has made these materials accessible
on its Web site. To help improve the ability of DOD board liaisons to
obtain servicemembers' medical and personnel records prior to the
exam, DOD officials said that they are revising their policies to
require reserve component units to provide the records when a reserve
member is referred to the IDES.
Ensuring adequate logistics at IDES sites: The site assessment matrix
asks sites whether they have the logistical arrangements needed to
implement the IDES, including necessary facilities, IT, and
transportation for servicemembers to exam locations. For example, the
matrix asks whether the military treatment facility will address the
needs of VA staff for access cards, identification badges, and
security clearances, and whether all VA medical providers will be
credentialed and privileged to practice at the DOD facility. In terms
of IT, the matrix asks whether DOD sites will enable VA staff access
to VA information systems needed to perform their duties. The matrix
also asks sites to identify IT contacts from both VA and DOD so that
they may work together to resolve IT problems. Furthermore, DOD and VA
are developing a general memorandum of agreement on IDES information
sharing. This agreement is intended to enable DOD and VA staff access
to each other's IT systems, for example, to allow DOD staff to track
the status of VA exams. DOD officials also said that they are
developing two new IT solutions. According to officials, one system
currently being tested would help military treatment facilities better
manage their cases. Another IT solution, still at a preliminary stage
of development, would integrate the VTA with the services' case
tracking systems so as to reduce multiple data entry.
However, in some areas, DOD and VA's efforts to prepare for IDES
expansion do not fully address some challenges or are not yet complete.
Ensuring sufficient military physician staffing: While DOD and VA are
taking steps to address shortages of examiners, case managers, and
adjudicators, they do not yet have strategies or plans to address
potential shortages of military physicians for completing MEB
determinations. For example, the site assessment matrix does not
include a question about the sufficiency of military providers to
handle expected numbers of MEB cases at the site, or ask sites to
identify strategies for ensuring sufficient military physicians if
there is a caseload surge or staff turnover.
Ensuring sufficient housing and organizational oversight for IDES
participants: Although the site assessment matrix asks sites whether
they will have sufficient temporary housing available for
servicemembers going through the IDES, the matrix requires only a yes
or no response and does not ensure that sites will have conducted a
thorough review of their housing capacity prior to implementing the
IDES. For example, sites are not asked about the capacity of their
medical hold units or special units for wounded servicemembers, or to
identify other options if their existing units do not have sufficient
capacity for their projected IDES caseload. In addition, the site
assessment matrix does not address whether sites have plans for
ensuring that IDES participants are gainfully employed or sufficiently
supported by their organizational units.
Addressing differences in diagnoses: According to a DOD official, as
part of its revision of its IDES operations manual, DOD is currently
developing guidance on how staff should address differences in
diagnoses between military physicians and VA examiners, and between
military PEBs and VA disability rating staff. DOD anticipated issuing
the new guidance in September 2010, but at the time of our review had
not yet done so. In addition, a VA official stated that VA is
developing new procedures for identifying cases with potential for
multiple mental health diagnoses and will ask VA examiners to review
the servicemembers' medical records and reconcile differing diagnoses.
However, since the new guidance and procedures are still being
developed, we cannot determine whether they will resolve discrepancies
or disagreements. Significantly, DOD and VA do not have a mechanism
for tracking disagreements about diagnoses and ratings, and
consequently, may not be able to determine whether the guidance
sufficiently addresses the discrepancies or whether it requires
further revision.
DOD and VA Lack a Mechanism for Monitoring Problems That May Emerge
with Full Implementation:
As DOD and VA move quickly to implement the IDES worldwide, they have
some mechanisms in place to monitor challenges that may arise in the
IDES. DOD officials said that they expect to continue holding
postimplementation "hotwash" meetings, in which they review individual
sites' implementation. In addition, DOD and VA will continue to
regularly collect and report data on caseloads, processing times, and
servicemember satisfaction. Furthermore, the new site assessment
matrix asks sites to develop plans for VA and DOD local staff to meet
weekly for the first 60 to 90 days after implementing the IDES, then
no less than monthly to address any identified challenges. VA
officials also said that they will continue to prepare a report on an
annual basis on challenges in the IDES. To prepare this report, they
will obtain input and data from local DOD and VA officials.
However, DOD and VA do not have a system-wide monitoring mechanism to
help ensure that steps they took to address challenges are sufficient
and to identify problems in a more timely basis. For example, they do
not collect data centrally on staffing levels relative to caseload.
Consequently, despite efforts to acquire additional staff, as local
sites experience staffing turnover in the future, DOD and VA central
offices may not become aware that a site is short-staffed until their
monitoring reports show lengthy processing times. As a result, DOD and
VA may be delayed in taking corrective action, since it takes time to
assess what types of staff are needed at a site and to hire or
reassign staff. In addition, without information on when or how often
other problems occur, such as insufficient exam summaries or
disagreements about diagnoses, DOD and VA managers may not be able to
target additional training or guidance where needed. Furthermore,
while DOD and VA report data on processing times by phase of the
process, military treatment facility, and military service, their
monitoring reports do not show processing times or caseloads for each
VA rating office and each of the five PEBs (three Army and one each
for the Navy and Air Force), limiting their ability to identify if
specific rating or PEB offices are experiencing challenges.
DOD and VA also lack mechanisms or forums for systematically sharing
information on challenges as well as best practices. For example,
while the site assessment matrix indicates that sites are expected to
hold periodic meetings to identify local challenges, DOD and VA have
not established a process for local sites to systematically report
those challenges to DOD and VA management and for lessons learned to
be systematically shared system-wide. During the pilot phase, VA
surveyed pilot sites on a monthly basis about challenges they faced in
completing single exams. Such a practice has the potential to provide
useful feedback if extended to other IDES challenges.
Conclusions:
By merging two duplicative disability evaluation systems, the IDES
shows promise for expediting the delivery of VA benefits to
servicemembers leaving the military due to a disability.
Servicemembers who proceed through the process are able to leave the
military with greater financial security, since they receive
disability benefits from both agencies shortly after discharge.
Further, having both DOD and VA personnel involved in reviewing each
disability evaluation may result in a more thorough scrutiny of cases
and informed decisions on behalf of servicemembers.
However, piloting of the system at 27 sites has revealed several
significant challenges that require careful management attention and
oversight before DOD and VA expand the system military-wide. DOD and
VA are currently taking steps to address many of these challenges, and
the agencies have developed a site implementation process that
encourages local DOD and VA officials to identify and resolve local
challenges prior to transitioning to the new system. However, given
the agencies' ambitious implementation schedule--more than 100 sites
in a year--it is unclear whether all of these challenges will be fully
dealt with before DOD and VA deploy the integrated system to
additional military facilities. For example, it is unclear whether
sites will have sufficient military physicians to complete key steps
of the process in a timely manner. Insufficient staffing of any one
part of the process is likely to lead to bottlenecks, delaying not
only servicemembers' receipt of disability benefits, but also their
separation from the military and reentry into civilian life. In
addition, DOD's preparations of sites for the IDES do not ensure that
military facilities have adequate capacity or plans for housing and
providing organizational oversight over servicemembers in the IDES,
who potentially could remain at the locations for extended periods of
time. Furthermore, while integrating VA medical exams into DOD's
disability evaluation system eliminates duplicative exams, it raises
the potential for there to be disagreements about diagnoses of
servicemembers' conditions, with implications for servicemembers'
disability ratings and their DOD disability compensation. While DOD is
developing guidance to address such disagreements, it is important
that the agencies have a thorough understanding of how often and why
these disagreements occur and continually review whether their new
guidance adequately addresses this issue so as to be able to make
improvements where needed.
Successful implementation of any program requires effective
monitoring. DOD and VA currently have mechanisms to track numbers of
cases processed, timeliness, and servicemember satisfaction, but they
do not routinely monitor factors--such as staffing levels relative to
caseload, disagreements about diagnoses, and insufficient exam
summaries--that can delay the process. In addition, they do not
monitor timeliness and caseloads for some of the key IDES offices,
namely each VA rating office and each PEB. Ultimately, the success or
failure of the IDES will depend on DOD and VA's ability to
sufficiently staff local sites, the VA rating offices, and the PEBs,
and to resolve other challenges not only at the initiation of the
transition to IDES but also on an ongoing, long-term basis. By not
monitoring staffing and other risk factors, DOD and VA may not be able
to ensure that their efforts to address these factors are sufficient
or to identify problems as they emerge and take immediate steps to
address them before they become major problems.
Recommendations for Executive Action:
To ensure that the IDES is sufficiently staffed and that military
treatment facilities are prepared to house personnel in the IDES, we
recommend that the Secretary of Defense direct the military services
to conduct thorough assessments prior to each site's implementation of
the IDES of the following three issues:
* the adequacy of staffing of military physicians for completing MEB
determinations at military treatment facilities; contingency plans
should be developed to address potential staffing shortfalls, for
example, due to staff turnover or caseload surges;
* the availability of housing for servicemembers in the IDES at
military facilities; alternative housing options should be identified
if sites do not have adequate capacity; and:
* the capacity of organizational units to absorb servicemembers
undergoing the disability evaluation; plans should be in place to
ensure servicemembers are appropriately and constructively engaged.
To improve their agencies' ability to resolve differences about
diagnoses of servicemembers' conditions, and to determine whether
their new guidance sufficiently addresses these disagreements, we
recommend that the Secretaries of Defense and Veterans Affairs take
the following two actions:
* conduct a study to assess the prevalence and causes of such
disagreements; and:
* establish a mechanism to continuously monitor disagreements about
diagnoses between military physicians and VA examiners and between
PEBs and VA rating offices.
To enable their agencies to take early action on problems at IDES
sites postimplementation, we recommend that the Secretaries of Defense
and Veterans Affairs develop a system-wide monitoring mechanism to
identify challenges as they arise in all DOD and VA facilities and
offices involved in the IDES. This system could include:
* continuous collection and analysis of data on DOD and VA staffing
levels, sufficiency of exam summaries, and diagnostic disagreements;
* monitoring of available data on caseloads and case processing time
by individual VA rating office and PEB; and:
* a formal mechanism for agency officials at local DOD and VA
facilities to communicate challenges and best practices to DOD and VA
headquarters offices.
Agency Comments and Our Evaluation:
We provided a draft of this report to DOD and VA for review and
comment. The agencies provided written comments, which are reproduced
in appendixes III and IV. DOD and VA generally concurred with our
recommendations. Each agency also provided technical comments, which
we incorporated as appropriate.
DOD concurred with our recommendation to ensure that, before the IDES
is implemented at each new site, a thorough assessment be done of the
site's staffing adequacy, the availability of housing for
servicemembers in the IDES, and the capacity of organizational units
to appropriately and constructively engage servicemembers in the IDES.
However, DOD stated that the IDES site assessment matrix addresses
plans to ensure that servicemembers are gainfully employed while in
the IDES. We changed our report to more clearly indicate that the site
assessment matrix does not, in fact, address such plans. We believe
that specifically identifying this in the matrix could help local DOD
officials, including servicemembers' unit commanders, focus on
ensuring gainful employment or other support.
DOD concurred, and VA concurred in principle, with our recommendation
to study and establish mechanisms to monitor diagnostic differences.
VA identified a plan to study the prevalence and causes of diagnostic
differences and determine by July 1, 2011, whether mechanisms are
needed. DOD stated that it expects, as diagnostic differences are
monitored and studied, that the agencies will address and resolve many
of the issues identified in our report. We agree that the planned
study could yield valuable insights on how to resolve diagnostic
differences but emphasize that continuous monitoring of such
differences over a period of time may be needed to assess the extent
and nature of such differences, as well as the success of any actions
to address them.
Both agencies concurred with our recommendation to develop monitoring
mechanisms to help them take early actions on problems that may arise
at IDES sites postimplementation. VA stated that the VTA system
currently has data that can be monitored by PEB and VA rating site,
and DOD said its weekly monitoring report could be modified to present
these data. Also, VHA plans to monitor the IDES exam workload,
including numbers of exam requests compared with forecasts, exam
timeliness, and insufficient exams. Implementation is scheduled for
December 31, 2010. In terms of identifying site implementation
problems for quick resolution, DOD stated that the military services
bring sites' challenges and best practices to the Disability Advisory
Council, a DOD body that includes VA representatives, which is being
re-chartered as part of the Benefits Executive Council, a subgroup of
the VA-DOD Joint Executive Council. VA and DOD's plans sound promising
and consistent with our recommendations provided that they allow for
ongoing monitoring of site staffing levels and create a systematic way
for local DOD and VA staff to communicate their challenges or best
practices, enabling the agencies to identify and address problems at
an early stage.
We are sending copies of this report to the appropriate congressional
committees, the Secretary of Defense, the Secretary of Veterans
Affairs, and other interested parties. The report is also available at
no charge on the GAO Web site at [hyperlink, http://www.gao.gov].
If you or your staff members have any questions about this report,
please contact me at (202) 512-7215 or at bertonid@gao.gov. Contact
points for our Offices of Congressional Relations and Public Affairs
may be found on the last page of this report. Staff members who made
key contributions in this report are listed in appendix V.
Signed by:
Daniel Bertoni:
Director, Education, Workforce, and Income Security Issues:
List of Committees:
The Honorable Carl Levin:
Chairman:
The Honorable John McCain:
Ranking Member:
Committee on Armed Services:
United States Senate:
The Honorable Daniel Akaka:
Chairman:
The Honorable Richard Burr:
Ranking Member:
Committee on Veterans' Affairs:
United States Senate:
The Honorable Daniel Inouye:
Chairman:
The Honorable Thad Cochran:
Ranking Member:
Subcommittee on Defense:
Committee on Appropriations:
United States Senate:
The Honorable Tim Johnson:
Chairman:
The Honorable Kay Bailey Hutchison:
Ranking Member:
Subcommittee on Military Construction, Veterans Affairs, and Related
Agencies:
Committee on Appropriations:
United States Senate:
The Honorable Ike Skelton:
Chairman:
The Honorable Howard P. "Buck" McKeon:
Ranking Member:
Committee on Armed Services:
House of Representatives:
The Honorable Bob Filner:
Chairman:
The Honorable Steve Buyer:
Ranking Member:
Committee on Veterans' Affairs:
House of Representatives:
The Honorable Norman Dicks:
Chairman:
The Honorable C. W. Bill Young:
Ranking Member:
Subcommittee on Defense:
Committee on Appropriations:
House of Representatives:
The Honorable Chet Edwards:
Chairman:
The Honorable Zach Wamp:
Ranking Member:
Subcommittee on Military Construction, Veterans Affairs, and Related
Agencies:
Committee on Appropriations:
House of Representatives:
[End of section]
Appendix I: Objectives, Scope, and Methodology:
In conducting our review of the integrated disability evaluation
system (IDES) piloted by the Departments of Defense (DOD) and Veterans
Affairs (VA), our objectives were to examine (1) the results of DOD
and VA's evaluation of the IDES pilot, (2) challenges in implementing
the piloted system to date, and (3) DOD and VA plans to expand the
piloted system and whether those plans adequately address potential
challenges. We conducted this performance audit from November 2009 to
December 2010, in accordance with generally accepted government
auditing standards. Those standards require that we plan and perform
the audit to obtain sufficient, appropriate evidence to provide a
reasonable basis for our findings and conclusions based on our audit
objectives. We believe that the evidence obtained provides a
reasonable basis for our findings and conclusions based on our audit
objectives.
Review of DOD and VA's Evaluation of the IDES Pilot:
To address objective 1, we reviewed DOD and VA policy guidance,
reports, and analysis plans to determine how the agencies are
evaluating the pilot's effectiveness and to obtain information on
their results. We also reviewed the relevant requirements of the
National Defense Authorization Act of 2008 as it pertains to this
review. In addition, we interviewed officials responsible for the
evaluation at DOD's Office of the Deputy Under Secretary of Defense
for Wounded Warrior Care & Transition Policy (WWCTP), DOD's Defense
Manpower Data Center, and two organizations that DOD has contracted
with to perform the evaluation--Booz Allen Hamilton and Westat. We
then tested the reliability of the data the agencies are using for
their evaluation--data from surveys of servicemembers, IDES case data
from the Veterans Tracking Application (VTA) system, and legacy case
data that DOD's WWCTP obtained from the military services. Finally, we
conducted some analyses of IDES and legacy case data for the Army to
compare the two systems on timeliness and appeal rates, using elements
of the data that we found to be reliable, but these comparisons have
limitations and are not generalizable to other military services. The
sections below describe our data reliability work and our analysis of
Army data in further detail.
Review of Satisfaction Survey Data Reliability:
DOD and VA have been surveying servicemembers going through the IDES
pilot, and a comparison group of veterans who went through the
standard "legacy" disability evaluation system, to determine whether
the IDES pilot has improved servicemember satisfaction. The agencies
survey all servicemembers in the IDES pilot at three points in time--
following their completion of the medical evaluation board (MEB) of
the disability evaluation process, completion of the physical
evaluation board (PEB), and during the transition phase. To create a
comparison group, the agencies sampled veterans who have been through
the legacy system at current pilot sites. Their sampling methods were
designed to ensure that the pilot and legacy groups were of comparable
size and had similar proportions of servicemembers found unfit for
duty. DOD and VA are analyzing the differences between the pilot and
legacy groups' average responses on four "survey composites," or
general categories composed of several survey questions: overall
experience, fairness, DOD board liaison officer customer service, and
VA case manager customer service.
We reviewed the reliability of surveys DOD and VA are using to obtain
information on satisfaction levels by examining their survey design
and analysis. To do so, we interviewed officials at DOD's Defense
Manpower Data Center and Westat responsible for implementing the
survey, as well as officials at WWCTP and Booz Allen Hamilton
responsible for designing the survey and analyzing the survey data. We
also reviewed the survey instruments, response rates, data analysis
plans, analysis results, and survey data as of February 28, 2010. We
found DOD's survey methodology--and the data derived using that
methodology--to be reliable for purposes of comparing servicemembers'
satisfaction levels in the IDES and legacy disability evaluation
systems.
Pilot and Legacy Case Data Reliability Tests:
DOD and VA are collecting data on IDES pilot cases through the VTA and
are using these data to conduct ongoing monitoring of case processing
times and appeal rates, with the results presented in weekly reports.
VA manages VTA, but evaluation of the data is primarily conducted by
staff at DOD's WWCTP and Booz Allen Hamilton.
For their August 2010 interim report to Congress, DOD staff created a
data set used to compare pilot and legacy processing times and appeal
rates. This data set included IDES pilot cases as of February 28,
2010, with the earliest case started in November 2007. The data set
also included data, as of January 31, 2010, on legacy cases started
between fiscal years 2005 and 2009 at the first 21 sites operating the
IDES pilot, prior to pilot implementation. The agencies also matched
legacy case data from each of the military services with VA data, in
order to capture additional processing time it took for servicemembers
to navigate the VA disability claims process. Because the data set was
created from February 2010 pilot data, it only included about one-
third of the IDES pilot cases that were completed as of August 29,
2010. The February 2010 data set included cases from 17 of the 27
current pilot sites, and 7 of the 17 sites--including some of the
pilot sites with the largest caseloads such as Fort Carson and Camp
Lejeune--had fewer than 20 completed cases each when the data set was
created.
To assess whether the data DOD and VA are using for their monitoring
and evaluation are reliable, we obtained the early 2010 data set that
the agencies' planned to use for their evaluation report to Congress.
We restricted our reliability assessments to the specific variables
that the agencies used in their analyses. Following steps detailed
below, we found that the IDES pilot case data were sufficiently
reliable for our analyses, but that the legacy case data were
incomplete with respect to data elements key to measuring case
processing time and appeal rates.
To assess the reliability of the agencies' IDES pilot data, we
interviewed VA database managers responsible for VTA, reviewed VTA
manuals and guidance, conducted electronic tests of the data and, for
a small, random sample of cases, checked the data against case files.
* Through our interviews and document reviews, we concluded that the
agencies have sufficient internal controls to give reasonable
assurance that the data are complete.
* Our electronic testing of the data generally found low rates of
missing data and errors in completed IDES cases. In these tests, we
considered a data element to be sufficiently reliable for purposes of
using in our report if 15 percent or less of the data were missing or
had errors. Using this standard, we determined that one data element
for IDES cases--the date that servicemembers separated from the
military--was not reliable, because: (1) it was missing in 19 percent
of completed cases and (2) in cases where the date was present, more
than 30 percent appeared to have errors (for example, the date was
before a step of the process that it should have followed).
* We also conducted a trace-to-file process to determine whether date
fields in the VTA system were an accurate reflection of the
information in the IDES case files. Specifically, we compared 12 date
fields in the VTA against a random sample of paper files for 54
completed cases: 24 from the three Army PEBs, 10 from the Air Force
PEB, and 20 from the Navy PEB (10 Navy cases and 10 Marine Corps).
[Footnote 36] In comparing these dates, we allowed for a 10 percent
discrepancy in dates--i.e., a difference of 2 to 10 days, depending on
the date and phase of the process[Footnote 37]--to allow for the
possibility that dates may have been entered into the database after
an event took place. The trace-to-file process resulted in an overall
accuracy rate of 84 percent. For five data elements key to DOD and
VA's evaluation of the IDES pilot, we found that VTA dates reflected
dates in the case files 85 percent of the time or better. For six key
data elements--i.e., the end dates of the exam and MEB phases, the
start of the PEB phase, the date a VA rating request was made, the
date of the final disposition, and the date servicemembers received VA
benefits--the VTA dates matched case file dates between 70 to 85
percent of the time. Although we considered these dates sufficiently
reliable to include in this report, these dates should be interpreted
with more caution. The separation date was accurate less than 70
percent of the time and did not meet our standards of reliability.
To assess the reliability of the legacy data that the agencies planned
to compare the IDES pilot against, we tested the data electronically,
and found that data for key dates and appeals indicators had
significant gaps because the services did not collect the same
information for legacy cases that were collected for pilot cases (see
table 2). For example, only Army cases had information on when
servicemembers were referred to the MEB process. In addition, the
legacy data did not include the date on when servicemembers received
VA benefits--which is necessary for measuring the full length of the
legacy process. Without sufficient data on the beginning (when
servicemembers were referred into the system) or end of the process
(when they received VA benefits), we concluded that the full case
processing time in the legacy system cannot be known. We also
concluded that comparisons could not be made between the legacy and
IDES pilot on appeal rates because only Army and Air Force cases had
information on whether servicemembers appealed the informal PEB
decisions.
Table 2: Percentage of Legacy Cases with Referral and Appeal Dates, by
Military Service:
Key data elements: Date of referral;
Army: 100.0%;
Navy: 0.0%;
Marine Corps: 0.0%;
Air Force: 0.0%;
All: 62.8%.
Key data elements: Informal PEB appeal;
Army: 89.2%;
Navy: 0.0%;
Marine Corps: 0.0%;
Air Force: 80.3%;
All: 62.4%.
Source: GAO analysis of DOD legacy case data.
[End of table]
GAO's Review of the Agencies' Comparison of Pilot and Legacy Data:
In addition to reviewing the reliability of the IDES pilot and legacy
data, we reviewed how DOD and VA are using the data for their
comparisons of the two disability evaluation systems. Through
interviews with officials at DOD's WWCTP and Booz Allen Hamilton and
documents they provided us, we understand that DOD planned to address
gaps in the legacy data by: (1) approximating the referral dates in
Air Force, Marine Corps, and Navy cases using Army data and (2) using
dates when cases were ready to be rated by VA to approximate the end
of the process. Specifically, to approximate referral dates, they said
they would use the average time for Army cases between when the
servicemember was referred and when the MEB documentation identifying
the servicemember's potentially unfitting medical conditions (i.e.,
the narrative summary) was completed, which they calculated to be 60
days. For Navy and Marine Corps cases, they then subtracted 60 days
from the date of the narrative summary to estimate a referral date
and, for Air Force cases, they did so from the date of the MEB
decision. However, because only 11 percent of Army legacy cases had a
narrative summary date, the estimate of 60 days is based on a small
number of cases (see table 3). To address the lack of data on the date
VA benefits were delivered, DOD planned to use the date that VA
determined a case was ready to be rated to approximate the end of the
process, though this would underestimate the length of time it took to
deliver VA benefits in the legacy process.
Table 3: Percentage of Legacy Cases with Data Used for DOD
Comparisons, by Military Service:
Key data elements: Narrative summary date;
Army: 10.5%;
Navy: 99.9%;
Marine Corps: 100.0%;
Air Force: 0.0%;
All: 35.9%.
Key data elements: Date VA ready to rate;
Army: 88.8%;
Navy: 87.5%;
Marine Corps: 86.7%;
Air Force: 87.6%;
All: 88.2%.
Source: GAO analysis of DOD and VA legacy case data.
[End of table]
GAO Analysis of IDES Case Data:
For objective 1, we presented information on average processing time
in the IDES, both overall and by military service, using information
presented by DOD and VA in their weekly monitoring reports. Where
information was not available in the weekly reports, we conducted our
own analysis using the early 2010 data set that DOD and VA intended to
use for their report to Congress. Specifically, we used these data to
determine the proportion of pilot cases meeting the 295-day goal for
active duty servicemembers and the 305-day goal for reserve
servicemembers.
In addition, although limitations in the legacy data preclude reliable
comparisons between the IDES pilot and legacy systems for all the
military services, the Army legacy data on when servicemembers were
referred into the IDES were sufficiently complete to make some limited
comparisons. Specifically, we analyzed Army legacy data to determine
how long the legacy process took, on average, between when
servicemembers were referred to the process and when VA was ready to
conduct the disability rating. We limited our analysis to cases in
which a VA claim was filed between 2006 and 2009 because data on when
VA was ready to conduct the rating was missing for a substantial
number of cases where the VA claim was filed in 2005 and 2010. We
compared this legacy average with the total pilot case processing time
through to delivery of VA benefits, but we noted that the legacy
average does not account for time for VA to complete the rating and
deliver the benefits. We also analyzed Army data on appeals in order
to illustrate the limitations of DOD's plan to compare only appeals to
the informal PEB in the pilot and legacy systems and not take into
account appeals of rating decisions to VA. We conducted this analysis
using the legacy data and pilot case data as of early 2010, since DOD
and VA's weekly reports do not contain information on appeals to VA.
Identifying Challenges in Implementing the IDES at Pilot Sites:
To identify challenges in implementing the IDES during the pilot
phase, we visited 10 of the 27 military treatment facilities
participating in the pilot. At the site visits, we interviewed
officials involved in implementing the IDES from both DOD and VA,
including military facility commanders and administrators, DOD board
liaisons, military physicians involved in MEB determinations, DOD
legal staff, VA case workers, VA or contract examiners, and
administrators at VA medical clinics and VA regional offices. We
selected the 10 facilities to obtain perspectives from sites in
different military services and geographical regions and that varied
in terms of disability evaluation caseloads and how their single exams
were conducted (by DOD, VA, or a VA contractor) (see table 4).
Table 4: Selected Characteristics of IDES Pilot Sites Visited:
Military treatment facility: 71st Medical Group, Vance Air Force Base;
Military service: Air Force;
Geographic region: Central;
IDES caseload[A]: 21;
Entity performing single exam: VA contractor.
Military treatment facility: David Grant Medical Center, Travis Air
Force Base;
Military service: Air Force;
Geographic region: West;
IDES caseload[A]: 112;
Entity performing single exam: VA.
Military treatment facility: Bayne Jones Army Community Hospital, Fort
Polk;
Military service: Army;
Geographic region: South;
IDES caseload[A]: 518;
Entity performing single exam: VA.
Military treatment facility: Dewitt Army Community Hospital, Fort
Belvoir;
Military service: Army;
Geographic region: East;
IDES caseload[A]: 268;
Entity performing single exam: VA.
Military treatment facility: Evans Army Community Hospital, Fort
Carson;
Military service: Army;
Geographic region: Central;
IDES caseload[A]: 1,341;
Entity performing single exam: VA.
Military treatment facility: Walter Reed Army Medical Center;
Military service: Army;
Geographic region: East;
IDES caseload[A]: 936;
Entity performing single exam: VA.
Military treatment facility: Winn Army Community Hospital, Fort
Stewart;
Military service: Army;
Geographic region: South;
IDES caseload[A]: 1,209;
Entity performing single exam: VA contractor.
Military treatment facility: Naval Hospital Camp Lejeune;
Military service: Navy;
Geographic region: South;
IDES caseload[A]: 1,214;
Entity performing single exam: VA and VA contractor.
Military treatment facility: Naval Hospital Camp Pendleton;
Military service: Navy;
Geographic region: West;
IDES caseload[A]: 537;
Entity performing single exam: VA contractor.
Military treatment facility: Naval Medical Center San Diego;
Military service: Navy;
Geographic region: West;
IDES caseload[A]: 1,447;
Entity performing single exam: VA.
Sources: GAO interviews and data from DOD and VA.
[A] Caseload size as of August 22, 2010.
[End of table]
We also interviewed various offices at DOD and VA involved in
implementing the IDES pilot. At DOD, this included WWCTP; Office of
the Assistant Secretary of Defense for Health Affairs; Office of the
Assistant Secretary of Defense for Reserve Affairs; Air Force Physical
Disability Division; Army Physical Disability Agency; Navy Physical
Evaluation Board; Office of the Air Force Surgeon General; Army
Medical Command; and Navy Bureau of Medicine and Surgery. At VA, we
interviewed officials in the Veterans Benefits Administration,
Veterans Health Administration, and VA/DOD Collaboration Service.
Furthermore, we reviewed relevant documents, including DOD and VA
policies and guidance and records of "hotwash" meetings, which DOD and
VA held shortly after implementing the IDES at pilot sites to identify
implementation successes and challenges. We also reviewed data on
processing times for the single exams, MEB determinations, informal
PEB decisions, and VA ratings, as reported in the agencies' weekly
monitoring reports. In addition, we reviewed relevant federal laws and
regulations.
To determine whether the IDES process extended the time that
servicemembers remained in military service, we analyzed the legacy
and pilot case data from the early 2010 data set, but we identified
several limitations with the data. As noted earlier, the date
servicemembers separated from the military was missing for 19 percent
of completed IDES pilot cases. Further, as shown in table 5, only Air
Force cases contained data on the separation date in the legacy data.
Also noted earlier, only the Army legacy data contained information on
when servicemembers were referred into the legacy process. As a
result, for Army cases, we compared the average length of time it took
cases to reach a final PEB decision in the legacy and pilot, since
this date was sufficiently complete in both the legacy and pilot data.
The PEB decision is the last phase of the disability evaluation
process before a servicemember either begins to transition from
military service, or if they are found fit, returns to their unit.
Table 5: Percentage of Legacy Cases with Data Used for Comparison of
Time in Active Duty, by Military Service:
Key data elements: Date of separation;
Army: 0.0%;
Navy: 0.0%;
Marine Corps: 0.0%;
Air Force: 96.5%;
All: 7.6%.
Key data elements: Date of final disposition;
Army: 89.2%;
Navy: 99.9%;
Marine Corps: 100.0%;
Air Force: 100.0%;
All: 93.2%.
Source: GAO analysis of DOD and VA legacy case data.
[End of table]
Examining DOD and VA's Plans for Expanding the IDES:
To identify the agencies' preparations for worldwide expansion of the
IDES, we reviewed documents on DOD and VA's expansion strategy, their
site assessment matrix, and weekly monitoring reports which, beginning
in July 2010, tracked key implementation time frames, both nationally
and at individual military treatment facilities. Our interviews with
officials involved in the pilot at DOD, VA, and each of the military
services also provided us with information on the agencies' expansion
plans. We also reviewed relevant federal laws and regulations.
We determined the adequacy of the agencies' planning efforts by
assessing whether their plans addressed the challenges we had
identified in objective 2. We also determined whether the plans
incorporated internal controls described in GAO's Standards for
Internal Control in the Federal Government and best practices for
program implementation identified in academic literature.[Footnote 38]
[End of section]
Appendix II: IDES Pilot Processing Times for Reserve Component
Servicemembers:
The figures below show case processing times in the IDES pilot for
reserve component servicemembers. Figure 11 shows the average number
of days it took to complete the process--i.e., to deliver VA benefits
to reserve component servicemembers, as of August 2010. Figure 12
shows the percentage of cases that met the DOD and VA goal to deliver
VA benefits within 305 days, as of February 2010. Figures 13-15 show
the average length of time it took, as of August 2010, to complete
phases of the IDES process--i.e., the single exam, the MEB
documentation, and the informal PEB decision, respectively--each of
which have taken longer, on average, than the goals established by DOD
and VA.
Figure 11: Average Number of Days to Deliver VA Benefits for Reserve
Component Servicemembers, by Military Service, as of August 29, 2010:
[Refer to PDF for image: horizontal bar graph]
Service goal: 305 days.
Service: Air Force;
Elapsed time in days: 376.
Service: Army;
Elapsed time in days: 285.
Service: Navy;
Elapsed time in days: 321.
Service: Marine Corps;
Elapsed time in days: 368.
Service: All;
Elapsed time in days: 298.
Sources: GAO presentation of weekly report data from DOD and VA.
[End of figure]
Figure 12: Percentage of Cases Meeting 305-Day Goal for Delivery of VA
Benefits to Reserve Component Servicemembers, by Military Service, as
of February 2010:
[Refer to PDF for image: horizontal bar graph]
Service goal: 80%.
Service: Air Force;
Percentage of cases meeting goal: 33%.
Service: Army;
Percentage of cases meeting goal: 67%.
Service: Navy;
Percentage of cases meeting goal: 71%.
Service: Marine Corps;
Percentage of cases meeting goal: 52%.
Service: All;
Percentage of cases meeting goal: 65%.
Sources: GAO analysis of pilot case data from DOD and VA.
[End of figure]
Figure 13: Average Number of Days to Complete Single Exams for Reserve
Component Servicemembers, by IDES Pilot Site, as of August 29, 2010:
[Refer to PDF for image: vertical bar graph]
Average for all sites: 64 days:
Service goal: 45 days.
Air Force:
Site: Andrews;
Elapsed tame in days: 61.
Site: Elmendorf;
Elapsed tame in days: 59.
Site: Nellis;
Elapsed tame in days: 57.
Site: MacDill;
Elapsed tame in days: 44.
Site: Travis;
Elapsed tame in days: 36.
Army:
Site: Fort Wainwright;
Elapsed tame in days: 136.
Site: Fort Carson;
Elapsed tame in days: 109.
Site: Fort Stewart;
Elapsed tame in days: 93.
Site: Fort Richardson;
Elapsed tame in days: 87.
Site: Walter Reed;
Elapsed tame in days: 70.
Site: Fort Sam Houston;
Elapsed tame in days: 67.
Site: Fort Belvoir;
Elapsed tame in days: 65.
Site: Fort Drum;
Elapsed tame in days: 63.
Site: Fort Lewis;
Elapsed tame in days: 62.
Site: Fort Polk;
Elapsed tame in days: 59.
Site: Fort Benning;
Elapsed tame in days: 46.
Site: Fort Riley;
Elapsed tame in days: 45.
Site: Fort Meade;
Elapsed tame in days: 39.
Site: Fort Bragg;
Elapsed tame in days: 32.
Site: Fort Hood;
Elapsed tame in days: 31.
Site: Camp Pendleton;
Elapsed tame in days: 88.
Navy[A]:
Site: Bethesda;
Elapsed tame in days: 71.
Site: Portsmouth;
Elapsed tame in days: 57.
Site: San Diego;
Elapsed tame in days: 53.
Site: Bremerton;
Elapsed tame in days: 47.
Site: Camp Lejeune;
Elapsed tame in days: 26.
Marine Corps:
Site: Camp Pendleton;
Elapsed tame in days: 64.
Site: Camp Lejeune;
Elapsed tame in days: 60.
Site: Bethesda;
Elapsed tame in days: 57.
Site: San Diego;
Elapsed tame in days: 46.
Site: Bremerton;
Elapsed tame in days: 29.
Sources: GAO presentation of weekly report data from DOD and VA.
[A] This figure shows processing times separately for servicemembers
in the Navy and Marine Corps at the six Navy IDES pilot sites. DOD and
VA's data indicate that, as of August 2010, there had not yet been any
Marine Corps reserve component servicemembers who completed the single
exam in the IDES pilot at Naval Medical Center Portsmouth.
[End of figure]
Figure 14: Average Number of Days to Complete MEB Documentation for
Reserve Component Servicemembers, by IDES Pilot Site, as of August 29,
2010:
[Refer to PDF for image: vertical bar graph]
Average for all sites: 76 days.
Service goal: 35 days.
Air Force:
Site: MacDill;
Elapsed time in days: 177.
Site: Andrews;
Elapsed time in days: 92.
Site: Elmendorf;
Elapsed time in days: 55.
Site: Travis;
Elapsed time in days: 53.
Site: Nellis;
Elapsed time in days: 51.
Army:
Site: Fort Richardson;
Elapsed time in days: 124.
Site: Fort Belvoir;
Elapsed time in days: 109.
Site: Fort Meade;
Elapsed time in days: 100.
Site: Walter Reed;
Elapsed time in days: 90.
Site: Fort Sam Houston;
Elapsed time in days: 69.
Site: Fort Polk;
Elapsed time in days: 66.
Site: Fort Stewart;
Elapsed time in days: 63.
Site: Fort Hood;
Elapsed time in days: 58.
Site: Fort Carson;
Elapsed time in days: 53.
Site: Fort Lewis;
Elapsed time in days: 44.
Site: Fort Benning;
Elapsed time in days: 38.
Site: Fort Bragg;
Elapsed time in days: 33.
Site: Fort Drum;
Elapsed time in days: 31.
Site: Fort Wainwright;
Elapsed time in days: 28.
Navy[A]:
Site: Camp Lejeune;
Elapsed time in days: 79.
Site: Bethesda;
Elapsed time in days: 78.
Site: Camp Pendleton;
Elapsed time in days: 47.
Site: San Diego;
Elapsed time in days: 23.
Site: Bremerton;
Elapsed time in days: 22.
Marine Corps:
Site: Camp Lejeune;
Elapsed time in days: 111.
Site: Bethesda;
Elapsed time in days: 67.
Site: Camp Pendleton;
Elapsed time in days: 60.
Site: San Diego;
Elapsed time in days: 34.
Site: Bremerton;
Elapsed time in days: 12.
Sources: GAO presentation of weekly report data from DOD and VA.
[A] This figure shows processing times separately for servicemembers
in the Navy and Marine Corps at the six Navy IDES pilot sites. DOD and
VA's data indicate that, as of August 2010, there had not yet been any
Marine Corps reserve component servicemembers who completed the MEB
phase in the IDES pilot at Naval Medical Center Portsmouth.
[End of figure]
Figure 15: Average Number of Days to Complete the Informal PEB for
Reserve Component Servicemembers, by Military Service, as of August
29, 2010:
[Refer to PDF for image: horizontal bar graph]
Service goal: 15 days.
Service: Air Force;
Elapsed time in days: 76.
Service: Army;
Elapsed time in days: 26.
Service: Navy;
Elapsed time in days: 80.
Service: Marine Corps;
Elapsed time in days: 106.
Sources: GAO presentation of weekly report data from DOD and VA.
[A] The Navy PEB determines fitness decisions for servicemembers in
the Marine Corps.
[End of figure]
[End of section]
Appendix III: Comments from the Department of Defense:
Office Of The Under Secretary Of Defense:
Personnel And Readiness:
4000 Defense Pentagon:
Washington, D.C. 2030-4000:
November 17, 2010:
Mr. Daniel Bertoni:
Director, Education, Workforce, and Income Security:
U.S. Government Accountability Office:
441 G Street, N.W.
Washington, DC 20548:
Dear Mr. Bertoni,
This is the Department of Defense (DoD) response to the GAO Draft
Report, GAO-11-69, "Military And Veterans Disability System: Pilot Has
Achieved Some Goals, but Further Planning and Monitoring Needed,"
dated October 22, 2010 (GAO Code 130971).
The Department appreciates the opportunity to collaborate with the GAO
in identifying areas within the administration of the Military and
Veterans Disability Evaluation System for emphasis to better support
our wounded, ill, or injured Service members as they recover and
return to duty or prepare to leave military service.
Each Military Department has processes and organizations in place to
support the needs of Service members proceeding through the Disability
Evaluation System.
The Department concurs with the recommendations contained in the draft
report except as noted. Specific comments are provided in the
attachment to this letter.
Sincerely,
Signed by:
John R. Campbell:
Deputy Under Secretary of Defense:
Wounded Warrior Care and Transition Policy:
Attachments: As stated:
[End of letter]
GAO Draft Report Dated December 2010:
GAO-11-69 (GAO Code 130971):
"Military And Veterans Disability System: Pilot Has Achieved Some
Goals, But Further Planning And Monitoring Needed"
Department Of Defense Comments To The GAO Recommendations:
Recommendation 1:
To ensure that the IDES is sufficiently staffed and that military
treatment facilities are prepared to house personnel in the IDES, we
recommend that the Secretary of Defense direct the military services
to conduct a thorough assessment prior to each site's implementation
of the IDES of:
* the adequacy of staffing of MEB physicians at military treatment
facilities; contingency plans should be developed to address potential
staffing shortfalls, for example, due to staff turnover or caseload
surges.
* the availability of housing for Service members in the IDES at
military facilities; alternate housing options should be identified if
sites do not have adequate capacity.
* the capacity of organizational units to absorb Service members
undergoing the disability evaluation; plans should be in place to
ensure Service members are appropriately and constructively engaged.
DoD Response: Concur with comments/clarification of staffing
terminology.
* The Department has concern about the use of the term "MEE.
physician." MEB physician is not a recognized clinical specialty.
Physicians who participate in the disposition of a medical evaluation
board may be considered a MEB physician. However, the only specialty
provider required on a medical evaluation board is a psychiatrist, if
the case involves a review of a mental condition. Thus, any assessment
of adequacy of staffing should include availability of all qualified
providers available to review cases as part of a medical evaluation
board. The availability of psychiatrists should be assessed separately.
* The Department concurs with requiring the military services to
identify alternative housing options should more space for IDES
participants be required.
* The Department concurs with the draft recommendation that plans
should be in place to ensure Service members are appropriately and
constructively engaged. As noted in the draft report, the site
assessment matrix does address plans for ensuring that IDES
participants are gainfully employed by their organizational units, it
is the units responsibility to follow the requirements of the site
assessment matrix.
Recommendation 2:
To improve their agencies' ability to resolve differences about
diagnoses of Service members' conditions, and to determine whether
their new guidance sufficiently addresses these disagreements, we
recommend that the Secretaries of Defense and Veterans Affairs:
* conduct a study to assess the prevalence and causes or such
disagreements; and;
* establish a mechanism to continuously monitor disagreements about
diagnoses between MEB physicians and VA examiners and between PEBs and
VA rating offices.
DoD Response: Concur with comments.
* The Department concurs with the draft GAO recommendation to conduct
a study to assess the prevalence and cause of disagreements between
the Military Department physicians and the Department of Veterans
Affairs physicians.
* The Department concurs with the draft GAO recommendation to
establish a mechanism to continuously monitor disagreements about
diagnoses between Military Department physicians and the Department of
Veterans Affairs physicians. As noted in the comments to
Recommendation 1, the term MEB physician is not a recognized clinical
specialty, as such, the Department prefers Military Department
physician. The Department and the Department of Veterans Affairs both
consult the Veterans Affairs rating schedule when making a
determination of disability. As the two departments study and monitor
disagreements we will address and resolve many of the issues outlined
in the report.
Recommendation 3:
To enable their agencies to take early action on problems at IDES
sites post-implementation, we recommend that the Secretaries of
Defense and Veterans Affairs develop a system-wide monitoring
mechanism to identify challenges as they arise in all DoD and VA
facilities and offices involved in the IDES_ This system could include:
* continuous collection and analysis of data on DoD and VA staffing
levels, sufficiency of exam summaries, and diagnostic disagreements;
* monitoring of available data on caseloads and case processing time
by individual VA rating office and PEB; and;
* a formal mechanism for agency officials at local DoD and VA
facilities to communicate challenges and best practices to DoD and VA
headquarters offices.
DoD Response: Concur with comments.
* The Department concurs with the draft GAO recommendation to
continuously collect and analyze data on staffing levels, sufficiency
of exam summaries, and diagnostic disagreements.
* The Department concurs with the draft GAO recommendation to monitor
available data on caseloads and case processing time by individual
rating office and PEB. Currently, the Department tracks caseloads and
processing times through the Veterans Tracking Application (VTA), and
a weekly report is provided to stakeholders. The report allows for
continuous monitoring and can be modified to enable tracking by rating
office and PEB.
* The Department concurs with the draft GAO recommendation for a
formal mechanism for agency officials at local DoD and VA facilities
to communicate challenges and best practices to DoD and VA
headquarters offices. The Department and the Department of Veterans
Affairs jointly participate in the Disability Advisory Council (DAC).
One of the objectives of the DAC is the identify best practices,
address inconsistencies in policy, address problems and issues in the
administration of the IDES and to provide a forum for developing,
planning and implementing future improvements. Military Department
representatives on the DAC bring the challenges and best practices
from local DoD and VA facilities to the DAC. The DAC is being re-
chartered as the Disability Evaluation System Benefits Executive
Council Working Group under the auspices of the Benefits Executive
Council (BEC).
[End of section]
Appendix IV: Comments from the Department of Veterans Affairs:
Department Of Veterans Affairs:
Washington DC 20420:
November 18, 2010:
Mr. Daniel Bertoni:
Director, Education, Workforce, and Income Security Issues:
U.S. Government Accountability Office:
441 G Street, NW:
Washington, DC 20548:
Dear Mr. Bertoni:
The Department of Veterans Affairs (VA) has reviewed the Government
Accountability Office's (GAO) draft report, Military And Veterans
Disability System: Pilot has Achieved Some Goals but Further Planning
and Monitoring Needed (GAO-11-69) and generally agrees with GAO's
conclusions and concurs with one GAO recommendation and concurs in
principle with one GAO recommendation.
The enclosure specifically addresses each of GAO's recommendations and
provides comments on the draft report. VA appreciates the opportunity
to comment on you draft report.
Sincerely,
Signed by:
John R. Gingrich:
Chief of Staff:
Enclosure:
[End of letter]
Enclosure:
Department of Veterans Affairs (VA) Comments to Government
Accountability Office (GAO) Draft Report: Military And Veterans
Disability System: Pilot has Achieved Some Goals but Further Planning
and Monitoring Needed (GAO-11-69).
GAO Recommendation 2: To improve their agencies' ability to resolve
differences about diagnoses of servicemembers' conditions, and to
determine whether their new guidance sufficiently addresses these
disagreements, we recommend that the Secretaries of Defense and
Veterans Affairs:
* Conduct a study to assess the prevalence and causes of such
disagreements; and;
* Establish a mechanism to continuously monitor disagreements about
diagnoses between MEB physicians and VA examiners and between PEBs and
VA rating offices.
VA Comment: Concur in principle. The Department of Veterans Affairs
(VA) will study the prevalence and causes of the variations. Based on
the results of this study, a determination will be made, no later than
July 1, 2011, as to what, if any, mechanisms need to be put in place.
GAO Recommendation 3: To enable their agencies to take early action on
problems at IDES sites post-implementation, we recommend that the
Secretaries of Defense and Veterans Affairs develop a system-wide
monitoring mechanism to identify challenges as they arise in all DOD
and VA facilities and offices involved in the IDES. This system could
include:
* Continuous collection and analysis of data on DoD and VA staffing
levels, sufficiency of exam summaries, and diagnostic disagreements;
* Monitoring of available data on caseloads and case processing time
by individual VA rating office and PEB; and;
* A formal mechanism for agency officials at local DoD and VA
facilities to communicate challenges and best practices to DoD and VA
headquarters offices.
VA Comment: Concur. The Veterans Health Administration (VHA) has
developed a new, focused monitoring of performance at sites that has
been implemented at IDES. Additionally, VHA has introduced system
changes and workload-recording practices that will make it
significantly easier to more closely monitor DES examination
activities, distinct from other compensation and pension examination
workload. In particular, VHA will monitor requests (versus forecast),
examination timeliness, examination insufficiencies, and examination
termination reason (e.g., no-show, incorrect examination, etc.). VHA
will additionally closely monitor the effect the IDES examination
workload has on all C&P examination workload. This will be implemented
by December 31, 2010.
VA and DoD currently track caseloads and processing times through the
Veterans Tracking Application (VTA), and a weekly report is provided
to stakeholders. Through this reporting mechanism, workload will
continue to be monitored and Military Services Coordinator staffing
levels are adjusted as caseload fluctuates. VA Regional Offices are
required to have a written contingency plan in place to address
unexpected spikes or projected increases in caseload.
Data specific to each Physical Evaluation Board and Rating Office are
currently available in VTA these data are monitored to identify trends
and outliers. VA will establish additional workload controls that can
be monitored through the VETSNET Operation Reports. The controls will
be distinct for the preliminary rating and the final rating. This
provides a system of management of the sub-phases and provides more
accurate reporting on timeliness. By March 31, 2011, VTA will be
enhanced with new functionality to identify cases that require
additional development, including cases involving insufficient exam
summaries.
Collaborative processes are being established between VA and DoD that
will facilitate the establishment of best practices for the expanded
program.
[End of section]
Appendix V: GAO Contact and Staff Acknowledgments:
GAO Contact:
Daniel Bertoni, (202) 512-7215, bertonid@gao.gov:
Staff Acknowledgments:
Michele Grgich (Assistant Director), Yunsian Tai (Analyst-in-Charge),
Jeremy Conley, and Greg Whitney made significant contributions to this
report. Walter Vance and Vanessa Taylor provided assistance with
research methodology and data analysis. Bonnie Anderson, Rebecca
Beale, Mark Bird, Brenda Farrell, Valerie Melvin, Patricia Owens, and
Randall Williamson provided subject matter expertise. Susan Bernstein
and Kathleen van Gelder provided writing assistance. James Bennett
provided graphics assistance. Roger Thomas provided legal counsel.
[End of section]
Footnotes:
[1] These studies include Independent Review Group, Rebuilding the
Trust: Report on Rehabilitative Care and Administrative Processes at
Walter Reed Army Medical Center and National Naval Medical Center
(Arlington, Va.: April 2007); Task Force Report to the President:
Returning Global War on Terror Heroes (April 2007); President's
Commission on Care for America's Returning Wounded Warriors, Serve,
Support, Simplify (July 2007); Department of the Army, Office of the
Inspector General, Report on the Army Physical Disability Evaluation
System (Washington, D.C.: Mar. 6, 2007); GAO, Military Disability
System: Increased Supports for Servicemembers and Better Pilot
Planning Could Improve the Disability Evaluation Process, [hyperlink,
http://www.gao.gov/products/GAO-08-1137] (Washington, D.C.: Sept. 24,
2008).
[2] Pub. L. No. 110-181, §1601-1676, 430, 122 Stat. 3.
[3] Pub. L. No. 110-181, § 1615(d), 122 Stat. 3, 447. We previously
reported that DOD and VA have completed the requirements established
in the NDAA 2008 for developing policy to improve the medical and
physical disability evaluation of recovering servicemembers. GAO,
Recovering Servicemembers: DOD and VA Have Jointly Developed the
Majority of Required Policies but Challenges Remain, [hyperlink,
http://www.gao.gov/products/GAO-09-728] (Washington, D.C.: July 8,
2009).
[4] The data we received for the legacy disability evaluation system
is as of January 31, 2010. The data we received for the IDES pilot is
as of February 28, 2010. The survey data we received on participants
who went through the legacy system and those who went through the IDES
pilot was as of February 28, 2010.
[5] The IDES pilot sites we visited were: (1) Bayne Jones Army
Community Hospital, Fort Polk, Louisiana; (2) David Grant Medical
Center, Travis Air Force Base, California; (3) Dewitt Army Community
Hospital, Fort Belvoir, Virginia; (4) Evans Army Community Hospital,
Fort Carson, Colorado; (5) Naval Hospital Camp Lejeune, North
Carolina; (6) Naval Hospital Camp Pendleton, California; (7) Naval
Medical Center San Diego, California; (8) Walter Reed Army Medical
Center, Washington, D.C.; (9) Winn Army Community Hospital, Fort
Stewart, Georgia; and (10) Vance Air Force Base, Oklahoma.
[6] Pub. L. No. 110-181, § 1615(d)(1), 122 Stat. 3.
[7] A physician is required to identify a condition that may cause the
member to fall below retention standards after the member has received
the maximum benefit of medical care.
[8] Servicemembers may receive monthly disability retirement benefits
if they have at least 20 years of active duty or equivalent service,
or if they have less than 20 years of active duty or equivalent
service and a 30 percent or higher disability rating. Servicemembers
may receive lump sum disability severance if they have fewer than 20
years of active duty or equivalent service, and they have a
compensable disability rated at 20 percent or lower. Servicemembers
who separate from the military with a DOD disability rating of 30
percent or higher receive health care benefits for life, regardless of
their years of military service. Servicemembers may also be found to
have an unstable disability, in which case they may be placed on the
Temporary Disability Retired List.
[9] For more detailed descriptions of the disability evaluation
system, see GAO, Military Disability System: Improved Oversight Needed
to Ensure Consistent and Timely Outcomes for Reserve and Active Duty
Service Members, [hyperlink, http://www.gao.gov/products/GAO-06-362]
(Washington, D.C.: Mar. 31, 2006) and [hyperlink,
http://www.gao.gov/products/GAO-08-1137].
[10] The Army Reserve, the National Guard, the Air Force Reserve, the
Air National Guard, the Navy Reserve, and the Marine Corps Reserve
constitute DOD's reserve component.
[11] DOD and VA also concluded in their interim report that disability
ratings in IDES pilot cases have been higher than in legacy cases, and
more servicemembers in the pilot were eligible for monthly disability
benefits rather than lump sum severance, compared to the legacy, but
they noted that these changes were primarily due to the enactment of
NDAA 2008, rather than the IDES pilot. NDAA 2008 required DOD to apply
VA's standards when rating disabilities.
[12] During the table top exercise, a sample of complete legacy cases
was used in a simulation exercise to test the relative merits of four
pilot options. For further information on the table top exercise, see
GAO, DOD and VA: Preliminary Observations on Efforts to Improve Care
Management and Disability Evaluations for Servicemembers, [hyperlink,
http://www.gao.gov/products/GAO-08-514T] (Washington, D.C.: Feb. 27,
2008).
[13] Weekly monitoring reports from February 2010 (the cutoff date for
survey data analyzed for DOD and VA's interim report) and August 2010
show lower satisfaction levels among Air Force servicemembers.
[14] The weekly monitoring reports present cumulative case processing
times, i.e., average case processing times for all cases completed as
of that given week.
[15] Our data reliability assessment included interviews regarding
internal controls, electronic testing, and a trace-to-file process,
where we matched a small number of randomly sampled case file dates
against the dates that had been entered into the VTA. For the trace-to-
file process, the overall accuracy rate was 84 percent, and all but
one date were 70 percent accurate or better and deemed sufficiently
reliable for reporting purposes. See appendix I for details on our
data reliability assessment.
[16] DOD officials stated that, under the legacy system, the Navy,
Marine Corps, and Air Force considered a case to be referred into the
disability evaluation system when a physician documented the
conditions that may render a servicemember unable to perform their
duties. Under the IDES process, the servicemember is formally referred
into the disability evaluation system before the documentation is
prepared.
[17] Reserve component Army cases took 389 days to reach the VA rating
phase under the legacy process, compared with 285 days to deliver VA
benefits under the pilot. Reserve component cases made up 48 percent
of legacy cases and 23 percent of pilot cases.
[18] As part of their analysis of costs, DOD estimated that costs of
servicemembers' disability benefits will increase by approximately
$960 million per year. However, they noted that these additional costs
are due to requirements in the National Defense Authorization Act of
2008 mandating the use of VA's rating standards in the disability
evaluation system, which tend to result in higher benefits than the
rating standards that DOD had previously used. DOD stated that these
increased costs would be realized under the legacy system as well.
[19] VHA estimated costs of about $33 million, but anticipates being
reimbursed by DOD for about half of these costs through a cost-sharing
agreement.
[20] At Fort Stewart, a private-sector provider performs the single
exams through a contract with VA. At Fort Carson and Fort Polk, the
exams are conducted by VA medical staff. A VA contractor also conducts
single exams at Camp Lejeune (NC), Camp Pendleton (CA), Fort Lewis
(WA), Naval Hospital Bremerton (WA), and Vance Air Force Base (OK).
[21] The 8 pilot sites that met the 45-day goal for completing single
exams include 2 Air Force sites, 5 Army sites, and 1 Navy site that
met the 45-day goal for servicemembers in both the Navy and Marine
Corps. One additional site (Camp Pendleton) met the 45-day goal for
Navy members but did not meet it for Marine Corps members.
[22] These 8 sites include 2 Air Force sites, 3 Army sites, and 3 Navy
sites that met the 35-day goal for both servicemembers in the Navy and
Marine Corps.
[23] A VA official said that these averages may not include all cases
completed as of August 2010, due to system design issues with the VTA
system. In our review of the VTA data as of February 2010, we found
that in the approximately 1,100 cases that had completed the full IDES
process up to that date, about 10 percent of the cases were missing
the date of the VA rating determination. However, the VA official
estimated that, as of October 2010, data may be missing for about one-
third of the 6,000 cases for which the VA rating offices have
completed ratings. According to the VA official, VTA was updated in
September 2010 to address these issues.
[24] The rating offices are aligned with DOD's PEBs. The Baltimore
rating office rates cases adjudicated by the Air Force PEB, Navy PEB,
and the Army's PEB at Walter Reed Army Medical Center, Washington,
D.C. The Seattle rating office rates cases adjudicated by the Army's
PEBs at Fort Sam Houston, TX, and Fort Lewis, WA.
[25] VA officials told us that they have recently engaged a contractor
to perform exams for Fort Polk.
[26] In prior work on the Army's predeployment medical assessment
process, GAO recommended that the Army develop an enforcement
mechanism to ensure that soldiers are properly referred to and
complete the MEB prior to deployment, move forward with plans for an
electronic processing system, and provide servicemembers and their
families with an independent ombudsman. See GAO, Military Personnel:
Army Needs to Better Enforce Requirements and Improve Record Keeping
for Soldiers Whose Medical Conditions May Call for Significant Duty
Limitations, [hyperlink, http://www.gao.gov/products/GAO-08-546]
(Washington, D.C.: June 10, 2008). At the time of our review, these
recommendations were still in process.
[27] For reserve component servicemembers, the IDES operations manual
states that the DOD board liaison should compile the complete medical
records within 30 days of their referral to the IDES.
[28] In our interviews, DOD officials also mentioned cases in which
DOD's PEB disagreed about VA's rating for fibromyalgia and sleep apnea.
[29] For example, VA would rate mental health conditions that cause
occasional decrease in work efficiency at 30 percent, while it would
rate conditions that cause deficiencies in most areas (such as work,
school, family relations, judgment, thinking, or mood) at 70 percent.
See 38 C.F.R. 4.125-4.130.
[30] Some DOD and VA officials also indicated that diagnostic
disagreements reflect a greater level of scrutiny on behalf of
servicemembers.
[31] In its comments on a draft of our report, VA informed us that VHA
is starting discussions with DOD and The Joint Commission (a nonprofit
organization that evaluates and accredits health care organizations)
on streamlining certain processes, including simplifying the
credentialing process.
[32] The Air Force and Navy do not have comparable special medical
units, although they have temporary medical hold units. For further
information on the Army's Warrior Transition Units, see GAO, Army
Health Care: Progress Made in Staffing and Monitoring Units that
Provide Outpatient Case Management, but Additional Steps Needed,
[hyperlink, http://www.gao.gov/products/GAO-09-357] (Washington, D.C.:
Apr. 20, 2009).
[33] Officials at Naval Medical Center San Diego were particularly
concerned about the length of the process for recruits in basic
training. Under the legacy system, there had been an expedited
disability evaluation process for military recruits injured during
basic training. At IDES pilot sites, recruits went through the longer
IDES process. DOD is currently developing an expedited IDES process
for recruits.
[34] DOD and VA had originally planned for 34 sites to implement the
IDES by the end of December 2010. However, the Army postponed
implementation at 6 sites.
[35] DOD's TRICARE Prime access standards are based on the minimum
time a beneficiary should have to wait for an appointment, and the
provider's distance from the beneficiary's residence. For example, the
standard for routine care is an appointment within 7 calendar days,
and a provider not more than 30 minutes' travel time from the
beneficiary's residence.
[36] We had originally requested files for 30 Army cases, 10 from each
Army PEB. However, one PEB had only completed 4 IDES cases at that
time, so they provided us with those 4 cases.
[37] Specifically, we allowed for a 10 percent discrepancy in dates,
which fluctuated depending on the length of the process phase. For
example, for the Final Disposition date in the Transition phase, we
allowed for a discrepancy of 5 days which is 10 percent of the 45 day
goal for that stage of the process, rounded up.
[38] GAO, Standards for Internal Control in the Federal Government,
[hyperlink, http://www.gao.gov/products/GAO/AIMD-00.21.3.1]
(Washington, D.C.: November 1999); Dennis P. Slevin and Jeffrey K.
Pinto, "Balancing Strategy and Tactics in Project Implementation,"
Sloan Management Review 33 (fall 1987).
[End of section]
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