VA Disability Benefits
Routine Monitoring of Disability Decisions Could Improve Consistency Gao ID: GAO-06-120T October 20, 2005The House Subcommittee on Disability Assistance and Memorial Affairs asked GAO to discuss its work on the consistency of disability compensation claims decisions of the Department of Veterans Affairs (VA). GAO has reported wide state-to-state variations in average compensation payments per disabled veteran, raising questions about decisional consistency. In 2003, GAO designated VA's disability programs, along with other federal disability programs, as high risk, in part because of concerns about decisional consistency. Illustrating this issue, GAO reported that inadequate information from VA medical centers on joint and spine impairments contributed to inconsistent regional office disability decisions.
GAO's November 2004 report explained that adjudicators in the Department of Veterans Affairs often must use judgment in making disability compensation claims decisions. As a result, it is crucial for VA to have a system for routinely identifying the effect of judgment on decisional variations among its 57 regional offices to determine if the variations are reasonable and, if not, how to correct them. In 2002, GAO reported that state-to-state variations of as much as 63 percent in average compensation payments per disabled veteran indicated potential inconsistency. The nature of the criteria that adjudicators must apply in evaluating the degree of impairment due to mental disorders provides an example of the extent of judgment required. GAO's October 2005 report on decisions for joint and spine disabilities showed one important way to improve consistency. Specifically, regional offices often rely on VA's 157 medical centers to examine claimants and provide medical information needed to decide the claims. However, VA has found inconsistency among its medical centers in the adequacy of their joint and spine disability exam reports that regional offices need to decide these claims. As of May 2005, the percentage of exam reports containing the required information varied across the medical centers from a low of 57 percent to a high of 92 percent. This could adversely affect the consistency of disability claims decisions involving joint and spine impairments. Although VA has made substantial progress, more remains to be done to improve the level of consistency in the disability exam reports.
GAO-06-120T, VA Disability Benefits: Routine Monitoring of Disability Decisions Could Improve Consistency
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United States Government Accountability Office:
GAO:
Testimony before the Subcommittee on Disability Assistance and Memorial
Affairs, Committee on Veterans' Affairs,
House of Representatives:
For Release on Delivery:
Expected at 10:30 a.m. EDT Thursday, October 20, 2005:
VA Disability Benefits:
Routine Monitoring of Disability Decisions Could Improve Consistency:
Statement of Cynthia A. Bascetta, Director:
Education, Workforce, and Income Security Issues:
GAO-06-120T:
GAO Highlights:
Highlights of GAO-06-120T, a testimony before the Subcommittee on
Disability Assistance and Memorial Affairs, House Committee on
Veterans' Affairs:
Why GAO Did This Study:
The House Subcommittee on Disability Assistance and Memorial Affairs
asked GAO to discuss its work on the consistency of disability
compensation claims decisions of the Department of Veterans Affairs
(VA). GAO has reported wide state-to-state variations in average
compensation payments per disabled veteran, raising questions about
decisional consistency. In 2003, GAO designated VA‘s disability
programs, along with other federal disability programs, as high risk,
in part because of concerns about decisional consistency. Illustrating
this issue, GAO reported that inadequate information from VA medical
centers on joint and spine impairments contributed to inconsistent
regional office disability decisions.
What GAO Found:
GAO‘s November 2004 report explained that adjudicators in the
Department of Veterans Affairs often must use judgment in making
disability compensation claims decisions. As a result, it is crucial
for VA to have a system for routinely identifying the effect of
judgment on decisional variations among its 57 regional offices to
determine if the variations are reasonable and, if not, how to correct
them. In 2002, GAO reported that state-to-state variations of as much
as 63 percent in average compensation payments per disabled veteran
indicated potential inconsistency. The nature of the criteria that
adjudicators must apply in evaluating the degree of impairment due to
mental disorders provides an example of the extent of judgment
required.
VA‘s Medical Criteria for Evaluating the Degree of Impairment Due to
Mental Disorders:
[See Table 1]
GAO‘s October 2005 report on decisions for joint and spine disabilities
showed one important way to improve consistency. Specifically, regional
offices often rely on VA‘s 157 medical centers to examine claimants and
provide medical information needed to decide the claims. However, VA
has found inconsistency among its medical centers in the adequacy of
their joint and spine disability exam reports that regional offices
need to decide these claims. As of May 2005, the percentage of exam
reports containing the required information varied across the medical
centers from a low of 57 percent to a high of 92 percent. This could
adversely affect the consistency of disability claims decisions
involving joint and spine impairments. Although VA has made substantial
progress, more remains to be done to improve the level of consistency
in the disability exam reports.
What GAO Recommends:
In 2004, GAO recommended that VA develop a plan to use data from a new
administrative data system to identify indications of inconsistent
decision making that need to be studied. VA concurred but has not yet
developed such a plan. In October 2005, GAO recommended that VA develop
a strategy for improving consistency of disability examination reports
needed by regional offices to make proper decisions across the nation
on claims involving joint and spine impairments. VA concurred.
www.gao.gov/cgi-bin/getrpt?GAO-06-120T.
To view the full product, including the scope and methodology, click on
the link above. For more information, contact Cynthia A. Bascetta at
(202) 512-7101.
[End of section]
Mr. Chairman and Members of the Subcommittee:
Thank you for inviting me to discuss our work on the consistency of
decisions that the Department of Veterans Affairs (VA) makes on
veterans' disability compensation claims. Ensuring that VA's disability
decisions are consistent across the nation is vital to ensuring the
integrity of VA's disability program. In 2002, we reported that wide
variations existed across the nation in the average compensation
payments per disabled veteran, and we recommended that VA study such
indications of inconsistency in the decision making of its 57 regional
offices.[Footnote 1] As you know, in January 2003, GAO designated VA's
disability program, along with other federal disability programs, as
high risk, in part because of concerns about the consistency of
decision making.[Footnote 2]
In December 2004, the media published data showing that the average
compensation payment per disabled veteran varied from a low of $6,710
in Ohio to a high of $10,851 in New Mexico. In response, the Secretary
asked the Office of Inspector General in December 2004 to study the
reasons for the wide variations in average payments, and in May 2005,
the Inspector General reported its findings and made recommendations
for improvement.[Footnote 3] As the Inspector General found, much needs
to be done to ensure that VA renders consistent decisions across the
nation.
As you requested, my remarks today will draw upon two GAO reports. The
first, issued in November 2004, addressed VA's need for a systematic
approach to identifying consistency issues that need to be studied in
detail.[Footnote 4] The second report, issued on October 12, 2005,
examined VA's efforts to achieve consistency among its medical centers
in the quality of the medical information they provide to regional
offices in order to make decisions on disability claims involving
impairments of joints and the spine.[Footnote 5] Improving the quality
of the medical information for these impairments could improve VA's
decisional consistency.
In summary, as we reported in November 2004, VA's adjudicators often
must use judgment in making disability decisions. As a result,
variation is an inherent factor in the decision-making process. This
makes it crucial that VA have a system for routinely identifying
variations among its 57 regional offices so that such variations can be
studied to determine if they are within the bounds of reasonableness
and, if not, how to correct the problem. Also, as we reported in
October 2005, to achieve consistency, VA must deal with issues
involving not only its regional offices but also its 157 medical
centers which conduct most of the disability examinations that regional
offices rely on to provide the medical information they need to make
disability decisions. As we reported, VA has found inconsistency among
its medical centers in the extent to which they provide regional
offices with exam reports containing all the medical information needed
to ensure that regional offices make decisions awarding the appropriate
level of benefits to veterans with joint and spine impairments. Some
medical centers consistently provide high-quality exam reports, while
others do not, which means the benefits awarded to veterans with
similar joint and spine impairments could differ, depending on which
medical center examined them. Although VA has made substantial progress
in correcting this problem, more remains to be done to ensure that all
medical centers provide exam reports containing adequate information
for regional offices to make proper decisions.
Background:
Regardless of a veteran's employment status or level of earnings, VA's
disability compensation program pays monthly cash benefits to eligible
veterans who have service-connected disabilities resulting from
injuries or diseases incurred or aggravated while on active military
duty. A veteran starts the disability claims process by submitting a
claim to one of the 57 regional offices administered by the Veterans
Benefits Administration (VBA). In the average compensation claim, the
veteran claims about five disabilities for which the regional office
must develop the evidence required by law and federal regulations, such
as military records and medical evidence. To obtain the required
medical evidence, VBA's regional offices often arrange medical
examinations for claimants. For example, in fiscal year 2004, VBA's 57
regional offices asked the 157 medical centers administered by the
Veterans Health Administration (VHA) to examine about 500,000 claimants
and provide examination reports containing the medical information
needed to decide the claim.
On the basis of the evidence developed by the regional office, an
adjudicator determines whether each disability claimed by the veteran
is connected to the veteran's military service. Then, by applying
medical criteria contained in VA's Rating Schedule, the adjudicator
evaluates the degree of disability caused by each service-connected
disability in order to determine the veteran's overall degree of
service-connected disability. The degree of disability is expressed as
a percentage, in increments of 10 percentage points--for example, 10
percent, 20 percent, 30 percent, and so on, up to 100 percent
disability. The higher the percentage of disability, the higher the
benefit payment received by the veteran.
If a veteran disagrees with the regional office adjudicator's decision
on whether a disability is service-connected or on the appropriate
percentage of disability, the veteran may file a Notice of
Disagreement. The regional office then provides a further written
explanation of the decision, and if the veteran still disagrees, the
veteran may appeal to VA's Board of Veterans' Appeals. Before appealing
to the board, a veteran may ask for a review by a regional office
Decision Review Officer, who is authorized to grant the contested
benefits based on the same case record that the original adjudicator
relied on to make the initial decision.
After appealing to the board, if a veteran disagrees with the board's
decision, the veteran may appeal to the U.S. Court of Appeals for
Veterans Claims, which has the authority to render decisions
establishing criteria that are binding on future decisions made by VA's
regional offices as well the board. For example, in DeLuca v. Brown, 8
Vet. App. 202 (1995), the court held that when federal regulations
define joint and spine impairment severity in terms of limits on range
of motion, VA claims adjudicators must consider whether range of motion
is further limited by factors such as pain and fatigue during "flare-
ups" or following repetitive use of the impaired joint or spine.
Previous to this decision, VA had not explicitly considered whether
such additional limitations existed because VA contended that its
Rating Schedule incorporated such considerations.
VA Needs A System For Routinely Monitoring Variations Inherent In
Deciding Disability Claims:
Because adjudicators often must use judgment when deciding disability
compensation claims, variations in decision making are an inherent
possibility. While some claims are relatively straightforward, many
require judgment, particularly when the adjudicator must evaluate (1)
the credibility of different sources of evidence; (2) how much weight
to assign different sources of evidence; or (3) disabilities, such as
mental disorders, for which the disability standards are not entirely
objective and require the use of professional judgment. Without
measuring the effect of judgment on decisions, VA cannot provide
reasonable assurance that consistency is acceptable. At the same time,
it would be unreasonable to expect that no decision-making variations
would occur.
Consider, for example, a disability claim that has two conflicting
medical opinions, one provided by a medical specialist who reviewed the
claim file but did not examine the veteran, and a second opinion
provided by a medical generalist who reviewed the file and examined the
veteran. One adjudicator could assign more weight to the specialist's
opinion, while another could assign more weight to the opinion of the
generalist who examined the veteran. Depending on which medical opinion
is given more weight, one adjudicator could grant the claim and the
other could deny it. Yet a third adjudicator might conclude that the
competing evidence provided an approximate balance between the evidence
for and the evidence against the veteran's claim, which would require
that the adjudicator apply VA's "benefit-of-the-doubt" rule and decide
in favor of the veteran.
An example involving mental disorders also demonstrates how
adjudicators sometimes must make judgments about the degree of severity
of a disability. The disability criteria in VA's Rating Schedule
provide a formula for rating the severity of a veteran's occupational
and social impairment due to a variety of mental disorders. This
formula is a nonquantitative, behaviorally oriented framework for
guiding adjudicators in choosing which of the degrees of severity shown
in table 1 best describes the claimant's occupational and social
impairment.
Table 1: VA's Medical Criteria for Evaluating the Degree of
Occupational and Social Impairment Due to Mental Disorders:
Degree of occupational and social impairment as characterized in VA's
medical criteria: Totally impaired;
Disability rating (in percent): 100.
Degree of occupational and social impairment as characterized in VA's
medical criteria: Deficient in most areas such as work, school, family
relations, judgment, thinking, or mood;
Disability rating (in percent): 70.
Degree of occupational and social impairment as characterized in VA's
medical criteria: Reduced reliability and productivity;
Disability rating (in percent): 50.
Degree of occupational and social impairment as characterized in VA's
medical criteria: Occasional decrease in work efficiency and
intermittent periods of inability to perform occupational tasks;
Disability rating (in percent): 30.
Degree of occupational and social impairment as characterized in VA's
medical criteria: Mild or transient symptoms that decrease work
efficiency and ability to perform occupational tasks only during
periods of significant stress, or symptoms can be controlled by
continuous medication;
Disability rating (in percent): 10.
Degree of occupational and social impairment as characterized in VA's
medical criteria: Not severe enough to interfere with occupational or
social functioning or to require continuous medication;
Disability rating (in percent): 0.
Source: VA's Schedule for Rating Disabilities.
Note: The Veterans' Disability Benefits Commission is currently
reviewing the appropriateness of VA's Rating Schedule, including the
criteria for mental disorders.
[End of table]
Similarly, VA does not have objective criteria for rating the degree to
which certain spinal impairments limit a claimant's motion. Instead,
the adjudicator must assess the evidence and decide whether the
limitation of motion is "slight, moderate, or severe." To assess the
severity of incomplete paralysis, the adjudicator must decide whether
the veteran's paralysis is "mild, moderate, or severe." The decision on
which severity classification to assign to a claimant's condition could
vary in the minds of different adjudicators, depending on how they
weigh the evidence and how they interpret the meaning of the different
severity classifications.
Despite the inherent variation, however, it is reasonable to expect the
extent of variation to be confined within a range that knowledgeable
professionals could agree is reasonable, recognizing that disability
criteria are more objective for some disabilities than for others. For
example, if two adjudicators were to review the same claim file for a
veteran who has suffered the anatomical loss of both hands, VA's
disability criteria state unequivocally that the veteran is to be given
a 100 percent disability rating. Therefore, no variation would be
expected. However, if two adjudicators were to review the same claim
file for a veteran with a mental disability, knowledgeable
professionals might agree that it would not be out of the bounds of
reasonableness for these adjudicators to diverge by 30 percentage
points but that wider divergences would be outside the bounds of
reasonableness.
The fact that two adjudicators might make differing, but reasonable,
judgments on the meaning of the same evidence is recognized in the
design of the system that VBA uses to assess the accuracy of disability
decisions made by regional office adjudicators. VBA instructs the staff
who review the accuracy of decisions to refrain from charging the
original adjudicator with an error merely because they would have made
a different decision than the one made by the original adjudicator. VBA
instructs the reviewers not to substitute their own judgment in place
of the original adjudicator's judgment as long as the original
adjudicator's decision is adequately supported and reasonable.
Because of the inherent possibility that different adjudicators could
make differing decisions based on the same information pertaining to a
specific impairment, we recommended in November 2004 that the Secretary
of Veterans Affairs develop a plan containing a detailed description of
how VA would (1) use data from a newly implemented administrative
information system--known as Rating Board Automation 2000--to identify
indications of decision-making inconsistencies among the regional
offices for specific impairments and (2) conduct systematic studies of
the impairments for which the data reveal possible inconsistencies
among regional offices. VA concurred with our recommendation but has
not yet developed such a plan. At this point, VA has now collected 1
full year of data using the new administrative data system, which
should be sufficient to begin identifying variations and then assessing
whether such variations are within the bounds of reasonableness.
Inconsistent Quality Of Disability Examination Reports Underscores Need
To Monitor Consistency Of Decisions:
Because the existing medical records of disability claimants often do
not provide VBA regional offices with sufficient evidence to decide
claims properly, the regional offices often ask VHA medical centers to
examine the claimants and provide exam reports containing the medical
information needed to make a decision. Exams for joint and spine
impairments are among the exams that regional offices most frequently
request.[Footnote 6]
To comply with the DeLuca decision's requirements for joint and spine
disability exam reports, VHA instructs its medical center clinicians to
make not only an initial measurement of the range of motion in the
impaired joint or spine but also to measure range of motion after
having the claimant flex the impaired joint or spine several times.
This is done to determine the extent to which repeated motion may
result in pain or fatigue that further degrades the functioning of the
impaired joint or spine. In addition, the clinician also is instructed
to determine if the claimant experiences flare-ups from time to time,
and if so, how often such flare-ups occur and the extent to which they
limit the functioning of the impaired joint or spine. However, in a
baseline study conducted in 2002, VA found that 61 percent of the exam
reports on joint and spine impairments did not provide sufficient
information on the effects of repetitive movement or flare-ups to
comply with the DeLuca criteria.
We reported earlier this month on the progress VA had made since 2002
in ensuring that its medical centers consistently prepare joint and
spine exam reports containing the information required by DeLuca. We
found that, as of May 2005, the percentage of joint and spine exam
reports not meeting the DeLuca criteria had declined substantially from
61 percent to 22 percent. Much of this progress appeared attributable
to a performance measure for exam report quality established by VHA in
fiscal year 2004 after both VHA and VBA had taken a number of steps to
build a foundation for improvement. This included creating the
Compensation and Pension Examination Project Office, a national office
established in 2001 to improve the disability exam process, and
providing extensive training to VHA and VBA personnel.
While VA made substantial progress in ensuring that its medical
centers' exam reports adequately address the DeLuca criteria, a 22
percent deficiency rate indicated that many joint and spine exam
reports still did not comply with DeLuca. Moreover, in relation to the
issue of consistency, the percentage of exam reports satisfying the
DeLuca criteria varied widely across the 21 health care networks that
manage VHA's 157 medical centers--from a low of 57 percent compliance
to a high of 92 percent. It should be noted that the degree of
variation is likely even greater than indicated by these percentages
because, within any given health care network, an individual medical
center's performance in meeting the DeLuca criteria may be lower or
higher than the combined average performance for all the medical
centers in that specific network. Therefore, in the network that had 57
percent of its joint and spine exams meeting DeLuca criteria, an
individual medical center within that network may have had less than 57
percent meeting the DeLuca criteria. Conversely, in the network that
had 92 percent of the exams meeting the DeLuca criteria, an individual
medical center within that network may have had more than 92 percent
satisfying DeLuca. Unless medical centers across the nation
consistently provide the information required by DeLuca, veterans
claiming joint and spine impairments may not receive consistent
disability decisions.
Further, VA has found deficiencies in a substantial portion of the
requests that VBA's regional offices send to VHA's medical centers,
asking them to perform disability exams. For example, VA found in early
2005 that nearly one-third of the regional office requests for spine
exams contained errors such as not identifying the pertinent medical
condition or not requesting the appropriate exam. However, VBA had not
yet established a performance measure for the quality of the exam
requests that regional offices submit to medical centers.
To help ensure continued progress in satisfying the DeLuca criteria, we
recommended that the Secretary of Veterans Affairs direct the Under
Secretary for Health to develop a strategy for improving consistency
among VHA's health care networks in meeting the DeLuca criteria. For
example, if performance in satisfying the DeLuca criteria continues to
vary widely among the networks during fiscal year 2006, VHA may want to
consider establishing a new performance measure specifically for joint
and spine exams or requiring that medical centers use automated
templates developed for joint and spine exams, provided an in-progress
study of the costs and benefits of the automated exam templates
supports their use. We also recommended that the Secretary direct the
Under Secretary for Benefits to develop a performance measure for the
quality of exam requests that regional offices send to medical centers.
Conclusions:
As a national program, VA's disability compensation program must ensure
that veterans receive fair and equitable decisions on their disability
claims no matter where they live across the nation. Given the inherent
risk of variation in disability decisions, it is incumbent on VA to
ensure program integrity by having a credible system for identifying
indications of inconsistency among its regional offices and then
remedying any inconsistencies found to be unreasonable. Until
assessments of consistency become a routine part of VA's oversight of
decisions made by its regional offices, veterans may not consistently
get the benefits they deserve for disabilities connected to their
military service, and taxpayers may not trust the effectiveness and
fairness of the disability compensation program.
Mr. Chairman, this concludes my remarks. I would be happy to answer any
questions you or the members of the subcommittee may have.
Contact and Acknowledgments:
For further information, please contact Cynthia A. Bascetta at (202)
512-7101. Also contributing to this statement were Irene Chu and Ira
Spears.
FOOTNOTES
[1] GAO, Veterans' Benefits: Quality Assurance for Disability Claims
and Appeals Processing Can Be Further Improved, GAO-02-806 (Washington,
D.C.: Aug. 16, 2002).
[2] GAO, High-Risk Series: An Update, GAO-03-119 (Washington, D.C.:
January 2003).
[3] VA Office of Inspector General, Review of State Variances in VA
Disability Compensation Payments, Report No. 05-00765-137 (Washington,
D.C.: May 19, 2005).
[4] GAO, Veterans Benefits: VA Needs Plan for Assessing Consistency of
Decisions, GAO-05-99 (Washington, D.C.: Nov. 19, 2004).
[5] GAO, Veterans' Disability Benefits: VA Could Enhance Its Progress
in Complying with Court Decision on Disability Criteria, GAO-06-46
(Washington, D.C.: Oct. 12, 2005).
[6] Because of workload issues at some VHA medical centers, 10 of VBA's
57 regional offices request most of their disability exams from a
private contractor, QTC Medical Services. These 10 regional offices are
San Diego, California; Los Angeles, California; Salt Lake City, Utah;
Seattle, Washington; Atlanta, Georgia; Winston-Salem, North Carolina;
Boston, Massachusetts; Roanoke, Virginia; Houston, Texas; and Muskogee,
Oklahoma. To assess the quality of QTC exam reports, VBA uses a review
system separate from the system for reviewing the quality of VHA
medical center exam reports. According to VBA officials responsible for
reviewing QTC exam report quality, VBA deemed about 95 percent of QTC's
exam reports to be adequate during the quarter ending October 31, 2004.
However, the method used to select the review sample does not provide
statistically reliable results for any specific type of impairment,
such as joint or spine impairments.
