DOD and VA
Preliminary Observations on Efforts to Improve Care Management and Disability Evaluations for Servicemembers Gao ID: GAO-08-514T February 27, 2008In February 2007, a series of Washington Post articles about conditions at Walter Reed Army Medical Center highlighted problems in the Army's case management of injured servicemembers and in the military's disability evaluation system. These deficiencies included a confusing disability evaluation process and servicemembers in outpatient status for months and sometimes years without a clear understanding about their plan of care. These reported problems prompted various reviews and commissions to examine the care and services to servicemembers. In response to problems at Walter Reed and subsequent recommendations, the Army took a number of actions and DOD formed a joint DOD-VA Senior Oversight Committee. This statement updates GAO's September 2007 testimony and is based on ongoing work to (1) assess actions taken by the Army to help ill and injured soldiers obtain health care and navigate its disability evaluation process; and to (2) describe the status, plans, and challenges of DOD and VA efforts to implement a joint disability evaluation system. GAO's observations are based largely on documents obtained from and interviews with Army, DOD, and VA officials. The facts contained in this statement were discussed with representatives from the Army, DOD, and VA.
Over the past year, the Army significantly increased support for servicemembers undergoing medical treatment and disability evaluations, but challenges remain. To provide a more integrated continuum of care for servicemembers, the Army created a new organizational structure--the Warrior Transition Unit--in which servicemembers are assigned key staff to help manage their recovery. Although the Army has made significant progress in staffing these units, several challenges remain, including hiring medical staff in a competitive market, replacing temporarily borrowed personnel with permanent staff, and getting eligible servicemembers into the units. To help servicemembers navigate the disability evaluation process, the Army is increasing staff in several areas, but gaps and challenges remain. For example, the Army expanded hiring of board liaisons to meet its goal of 30 servicemembers per liaison, but as of February 2008, the Army did not meet this goal at 11 locations that support about half of servicemembers in the process. The Army faces challenges hiring enough liaisons to meet its goals and enough legal personnel to help servicemembers earlier in the process. To address more systemic issues, DOD and VA promptly designed and are now piloting a streamlined disability evaluation process. In August 2007, DOD and VA conducted an intensive 5-day exercise that simulated alternative pilot approaches using previously-decided cases. This exercise yielded data quickly, but there were trade-offs in the nature and extent of data that could be obtained in that time frame. The pilot began with "live" cases at three treatment facilities in the Washington, D.C. area in November 2007, and DOD and VA may consider expanding the pilot to additional sites around July 2008. However, DOD and VA have not finalized their criteria for expanding the pilot beyond the original sites and may have limited pilot results at that time. Significantly, current evaluation plans lack key elements, such as an approach for measuring the performance of the pilot--in terms of timeliness and accuracy of decisions--against the current process, which would help planners manage for success of further expansion.
GAO-08-514T, DOD and VA: Preliminary Observations on Efforts to Improve Care Management and Disability Evaluations for Servicemembers
This is the accessible text file for GAO report number GAO-08-514T
entitled 'DOD and VA: Preliminary Observations on Efforts to Improve
Care Management and Disability Evaluations for Servicemembers' which
was released on February 27, 2008.
This text file was formatted by the U.S. Government Accountability
Office (GAO) to be accessible to users with visual impairments, as part
of a longer term project to improve GAO products' accessibility. Every
attempt has been made to maintain the structural and data integrity of
the original printed product. Accessibility features, such as text
descriptions of tables, consecutively numbered footnotes placed at the
end of the file, and the text of agency comment letters, are provided
but may not exactly duplicate the presentation or format of the printed
version. The portable document format (PDF) file is an exact electronic
replica of the printed version. We welcome your feedback. Please E-mail
your comments regarding the contents or accessibility features of this
document to Webmaster@gao.gov.
This is a work of the U.S. government and is not subject to copyright
protection in the United States. It may be reproduced and distributed
in its entirety without further permission from GAO. Because this work
may contain copyrighted images or other material, permission from the
copyright holder may be necessary if you wish to reproduce this
material separately.
Testimony:
Before the Subcommittee on National Security and Foreign Affairs, Committee
on Oversight and Government Reform, House of Representatives:
United States Government Accountability Office:
GAO:
For Release on Delivery:
Expected 2:00 p.m. EST:
Wednesday, February 27, 2008:
DOD and VA:
Preliminary Observations on Efforts to Improve Care Management and
Disability Evaluations for Servicemembers:
Statement of Daniel Bertoni, Director:
Education, Workforce, and Income Security:
Statement of John H. Pendleton, Acting Director: Health Care:
GAO-08-514T:
GAO Highlights:
Highlights of GAO-08-514T, a testimony before the Subcommittee on
National Security and Foreign Affairs, Committee on Oversight and
Government Reform, House of Representatives.
Why GAO Did This Study:
In February 2007, a series of Washington Post articles about conditions
at Walter Reed Army Medical Center highlighted problems in the Army‘s
case management of injured servicemembers and in the military‘s
disability evaluation system. These deficiencies included a confusing
disability evaluation process and servicemembers in outpatient status
for months and sometimes years without a clear understanding about
their plan of care. These reported problems prompted various reviews
and commissions to examine the care and services to servicemembers. In
response to problems at Walter Reed and subsequent recommendations, the
Army took a number of actions and DOD formed a joint DOD-VA Senior
Oversight Committee.
This statement updates GAO‘s September 2007 testimony and is based on
ongoing work to (1) assess actions taken by the Army to help ill and
injured soldiers obtain health care and navigate its disability
evaluation process; and to (2) describe the status, plans, and
challenges of DOD and VA efforts to implement a joint disability
evaluation system. GAO‘s observations are based largely on documents
obtained from and interviews with Army, DOD, and VA officials. The
facts contained in this statement were discussed with representatives
from the Army, DOD, and VA.
What GAO Found:
Over the past year, the Army significantly increased support for
servicemembers undergoing medical treatment and disability evaluations,
but challenges remain. To provide a more integrated continuum of care
for servicemembers, the Army created a new organizational structure”the
Warrior Transition Unit”in which servicemembers are assigned key staff
to help manage their recovery. Although the Army has made significant
progress in staffing these units, several challenges remain, including
hiring medical staff in a competitive market, replacing temporarily
borrowed personnel with permanent staff, and getting eligible
servicemembers into the units. To help servicemembers navigate the
disability evaluation process, the Army is increasing staff in several
areas, but gaps and challenges remain. For example, the Army expanded
hiring of board liaisons to meet its goal of 30 servicemembers per
liaison, but as of February 2008, the Army did not meet this goal at 11
locations that support about half of servicemembers in the process. The
Army faces challenges hiring enough liaisons to meet its goals and
enough legal personnel to help servicemembers earlier in the process.
To address more systemic issues, DOD and VA promptly designed and are
now piloting a streamlined disability evaluation process. In August
2007, DOD and VA conducted an intensive 5-day exercise that simulated
alternative pilot approaches using previously-decided cases. This
exercise yielded data quickly, but there were trade-offs in the nature
and extent of data that could be obtained in that time frame. The pilot
began with ’live“ cases at three treatment facilities in the
Washington, D.C. area in November 2007, and DOD and VA may consider
expanding the pilot to additional sites around July 2008. However, DOD
and VA have not finalized their criteria for expanding the pilot beyond
the original sites and may have limited pilot results at that time.
Significantly, current evaluation plans lack key elements, such as an
approach for measuring the performance of the pilot”in terms of
timeliness and accuracy of decisions”against the current process, which
would help planners manage for success of further expansion.
Figure: Major Differences between Current and Pilot Military Disability
Evaluation Processes:
[See PDF for image]
Current process:
Servicemember:
Board liaison provides support;
Medical Evaluation Board (MEB): Physical performed by military
department; Physical Evaluation Board (PEB): Military department
determines disability rating for computing DOD disability benefits.
Current process, after separation:
Veteran:
Receives DOD disability benefits and develops claim for VA disability
benefits;
* Comprehensive physical performed to VA standards;
* VA determines disability rating.
Pilot process:
Servicemember:
Board liaison and VA staff provide support; Medical Evaluation Board
(MEB): Comprehensive physical performed to VA standards; Physical
Evaluation Board (PEB): VA determines disability rating sued for
computing DOD disability benefits.
Pilot process, after separation:
Receives DOD disability benefits and received VA disability benefits
shortly after leaving military.
Source: GAO analysis of DOD documents.
[End of figure]
To view the full product, including the scope and methodology, click on
[hyperlink, http://www.GAO-08-514T]. For more information, contact
Daniel Bertoni at (202) 512-7215 or bertonid@gao.gov; or John H.
Pendleton at (202) 512-7114 or pendletonj@gao.gov.
[End of section]
Mr. Chairman and Members of the Subcommittee:
We are pleased to be here today as you examine issues related to
meeting the critical needs of returning wounded warriors. At present,
over 30,000 servicemembers have been wounded in Operations Enduring
Freedom and Iraqi Freedom.[Footnote 1] Due to improved battlefield
medicine, those who might have died in past conflicts are now
surviving, many with multiple serious injuries such as amputations,
traumatic brain injury (TBI), and post-traumatic stress disorder
(PTSD). Beyond adjusting to their injuries, returning servicemembers
can face additional challenges within the military. In February 2007, a
series of Washington Post articles about conditions at Walter Reed Army
Medical Center highlighted problems in the Army's management of care
for injured servicemembers and in the military's disability evaluation
system.
Since that time, various reviews and high-level commissions have
identified substantial weaknesses in the care that servicemembers
receive and the disability evaluation systems that they must navigate.
For example, in March 2007, the Army Inspector General identified
numerous issues with the Army's disability evaluation system and
related care,[Footnote 2] including a failure to meet timeliness
standards for determinations, inadequate training of staff, and the
lack of standardized operations and structure to care for returning
servicemembers. Similarly, reports from several commissions highlighted
long delays and confusion that ill or injured servicemembers experience
as they navigate the military disability evaluation system, and their
distrust of a process perceived to be adversarial.[Footnote 3] The
commissions referred to prior GAO work, including a March 2006 report
in which GAO found that the services were not meeting Department of
Defense (DOD) timeliness goals for processing disability cases and that
neither DOD nor the services systematically evaluated the consistency
of disability decisions.[Footnote 4] In October 2007, the Veterans'
Disability Benefits Commission reported significant differences in
disability ratings between DOD and the Department of Veterans Affairs
(VA)--with VA often assigning higher ratings than DOD.[Footnote 5]
In response to the deficiencies reported by the media, the Army took
several actions including, most notably, initiating the development of
the Army Medical Action Plan in March 2007. The plan, designed to help
the Army become more patient-focused, includes tasks for establishing a
continuum of care and service, automating portions of the disability
evaluation system, and maximizing coordination of efforts with VA.
In May 2007, DOD established the Wounded, Ill, and Injured Senior
Oversight Committee (Senior Oversight Committee) to bring high-level
attention to addressing the problems associated with the care and
treatment of returning servicemembers. The committee is co-chaired by
the Deputy Secretaries of Defense and Veterans Affairs and also
includes the military service secretaries and other high-ranking
officials within DOD and VA. To conduct its work, the Senior Oversight
Committee established workgroups that have focused on specific areas
including the disability evaluation system. In particular, under the
direction of the Senior Oversight Committee, DOD and VA are piloting a
joint disability evaluation system.
In September 2007, we testified before this subcommittee on our
preliminary observations with respect to Army, DOD, and VA efforts to
improve health care and disability evaluations for servicemembers.
[Footnote 6] Our testimony today provides an update on these efforts
and focuses on our ongoing work to (1) assess actions taken by the Army
to help ill and injured soldiers obtain health care and navigate its
disability evaluation process, and (2) describe the status, plans, and
challenges of DOD's and VA's efforts to implement a joint disability
evaluation system. Our testimony is based on documents obtained from
and interviews with Army, DOD, and VA officials. Specifically, we
reviewed staffing data related to case management and disability
evaluation initiatives established in the Army Medical Action Plan. We
did not verify the accuracy of these data; however, we interviewed
agency officials knowledgeable about the data, and we determined that
they were sufficiently reliable for the purposes of this statement. We
visited several Army sites--Walter Reed Army Medical Center
(Washington, D.C.), Forts Sam Houston and Hood (Texas), Fort Lewis
(Washington), and Forts Benning and Gordon (Georgia)--to talk with Army
officials about efforts to improve the health care and the disability
evaluation system for servicemembers and obtain views from
servicemembers about how these efforts are affecting them. In addition,
we reviewed the results of Army efforts to obtain servicemembers'
opinions about the Warrior Transition Unit and the disability
evaluation process. We also spoke with officials from DOD and VA to
learn about their plans for implementing and evaluating the disability
evaluation pilot. Our findings are preliminary. It was beyond the scope
of our work for this statement to review the efforts underway in other
military services. We discussed the facts contained in this statement
with Army officials, and we incorporated their comments where
appropriate. Our work, which began in July 2007, is being conducted 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.
In summary, the Army continues to increase support to servicemembers
undergoing medical treatment and disability evaluations, but faces
challenges reaching or maintaining its goals. To provide a more
integrated continuum of care for servicemembers, the Army has developed
a new organizational structure called Warrior Transition Units. Within
each unit, a servicemember is assigned to a team of three key staff--a
primary care manager, a nurse case manager, and a squad leader--who
manage the servicemember's care. Since September 2007, the Army has
made considerable progress in staffing this structure, increasing the
number of staff assigned to key positions by almost 75 percent.
However, shortfalls continue to exist in some areas--11 of the 32 U.S.
Warrior Transition Units had less than 90 percent of needed staff for
one or more key positions. In addition, the Army is facing other
challenges, which include replacing borrowed staff in key positions
with permanently assigned staff without disrupting the continuity of
care for servicemembers and moving additional eligible servicemembers
into the units without exacerbating existing staff shortfalls in some
locations. Furthermore, another emerging challenge is the Army's
ability to gather reliable and objective data on how well the units are
meeting servicemembers' needs.
Some servicemembers may not recover sufficiently to return to duty. To
support servicemembers who must undergo a fitness for duty assessment
and disability evaluation, the Army is reducing caseloads and expanding
hiring of key staff responsible for helping servicemembers navigate the
process. For example, for evaluation board liaisons who help
servicemembers track the process, the Army established an average
caseload goal of 30 servicemembers per board liaison and hired more
board liaisons to help meet this goal. However, almost one-third of
treatment locations--which support about half of servicemembers in the
disability evaluation process--have not met this goal. In addition, the
Army assigned 18 additional legal staff to support the disability
evaluation process in June 2007; however, current staffing levels are
still insufficient for widespread legal support early in the process.
The Army has other efforts underway to improve servicemembers' ability
to navigate the disability process, such as conducting standardized
briefings about the evaluation process, but reliable data on the
effectiveness of these and other efforts are not yet available.
To address issues with both DOD and VA disability evaluations,
including untimely and inconsistent decisions and servicemember
frustration, the agencies have designed, and are piloting, a
streamlined disability evaluation process. DOD and VA moved quickly to
design and implement the pilot for eventual expansion to all
servicemembers. To obtain the data for determining the pilot design and
supporting the implementation decision, DOD and VA conducted an
intensive 5-day exercise that simulated four alternative pilot
approaches using previously-decided cases. While the simulation was a
formal exercise and yielded useful information, the short time frames
necessitated trade-offs between moving quickly and doing a more
thorough evaluation, such as using a small number of cases instead of a
larger number that better represented the relative workloads of the
military services. DOD and VA began "live" implementation of the pilot-
-using actual cases--at three treatment facilities in the Washington,
D.C. area in November 2007. DOD and VA may consider expanding the pilot
to a few sites outside the Washington, D.C. area around July 2008, but
have yet to finalize their criteria for expanding implementation beyond
the original sites. Further, some key metrics, such as the timeliness
and accuracy of final DOD and VA decisions, might lag behind expansion
time frames and dates for reporting on pilot progress to Congress. To
date, DOD's and VA's pilot evaluation plan lacks key elements, such as
an approach for measuring the performance of the pilot--for example, in
terms of timeliness, accuracy, and consistency of decisions--against
the current process, and for surveying and measuring satisfaction of
pilot participants.
Background:
DOD and VA offer health care benefits to active duty servicemembers and
veterans, among others. Under DOD's health care system, eligible
beneficiaries may receive care from military treatment facilities or
from civilian providers. Military treatment facilities are individually
managed by each of the military services--the Army, the Navy,[Footnote
7] and the Air Force. Under VA, eligible beneficiaries may obtain care
through VA's integrated health care system of hospitals, ambulatory
clinics, nursing homes, residential rehabilitation treatment programs,
and readjustment counseling centers. VA has organized its health care
facilities into a polytrauma system of care[Footnote 8] that helps
address the medical needs of returning servicemembers and veterans, in
particular those who have an injury to more than one part of the body
or organ system that results in functional disability and physical,
cognitive, psychosocial, or psychological impairment. Persons with
polytraumatic injuries may have injuries or conditions such as TBI,
amputations, fractures, and burns.
Over the past 6 years, DOD has designated over 30,000 servicemembers
involved in Operations Iraqi Freedom and Enduring Freedom as wounded in
action. Servicemembers injured in these conflicts are surviving
injuries that would have been fatal in past conflicts, due, in part, to
advanced protective equipment and medical treatment. The severity of
their injuries can result in a lengthy transition from patient back to
duty, or to veteran status. Initially, most seriously injured
servicemembers from these conflicts, including activated National Guard
and Reserve members, are evacuated to Landstuhl Regional Medical Center
in Germany for treatment. From there, they are usually transported to
military treatment facilities in the United States, with most of the
seriously injured admitted to Walter Reed Army Medical Center or the
National Naval Medical Center. According to DOD officials, once they
are stabilized and discharged from the hospital, servicemembers may
relocate closer to their homes or military bases and are treated as
outpatients by the closest military or VA facility.
As part of the Army's Medical Action Plan, the Army has developed a new
organizational structure--Warrior Transition Units--for providing an
integrated continuum of care for servicemembers who generally require
at least 6 months of treatment, among other factors. Within each unit,
the servicemember is assigned to a team of three key staff and this
team is responsible for overseeing the continuum of care for the
servicemember.[Footnote 9] The Army refers to this team as a "Triad,"
which consists of a (1) primary care manager--usually a physician who
provides primary oversight and continuity of health care and ensures
the quality of the servicemember's care; (2) nurse case manager--
usually a registered nurse who plans, implements, coordinates,
monitors, and evaluates options and services to meet the
servicemember's needs; and (3) squad leader--a noncommissioned officer
who links the servicemember to the chain of command, builds a
relationship with the servicemember, and works along side the other
parts of the Triad to ensure the needs of the servicemember and his or
her family are met. The Army established 32 Warrior Transition Units,
to provide a unit in every medical treatment facility that has 35 or
more eligible servicemembers.[Footnote 10] The Army's goal is to fill
the Triad positions according to the following ratios: 1:200 for
primary care managers; 1:18 for nurse case managers at Army medical
centers that normally see servicemembers with more acute conditions and
1:36 for other types of Army medical treatment facilities; and 1:12 for
squad leaders.
Returning injured servicemembers must potentially navigate two
different disability evaluation systems that generally rely on the same
criteria but for different purposes. DOD's system serves a personnel
management purpose by identifying servicemembers who are no longer
medically fit for duty. The military's process starts with
identification of a medical condition that could render the
servicemember unfit for duty, a process that could take months to
complete. The servicemember is evaluated by a medical evaluation board
(MEB) to identify any medical conditions that may render the
servicemember unfit. The member is then evaluated by a physical
evaluation board (PEB) to make a determination of fitness or unfitness
for duty. If found unfit, and the unfit conditions were incurred in the
line of duty, the PEB assigns the servicemember a combined percentage
rating for those unfit conditions using VA's rating system as a
guideline, and the servicemember is discharged from duty. This
disability rating, along with years of service and other factors,
determines subsequent disability and health care benefits from
DOD.[Footnote 11] For servicemembers meeting the minimum rating and
years of duty thresholds, monthly disability retirement payments are
provided; for those not meeting these thresholds, a lump-sum severance
payment is provided.
As servicemembers in the Army navigate DOD's disability evaluation
system, they interface with staff who play a key role in supporting
them through the process. MEB physicians play a fundamental role as
they are responsible for documenting the medical conditions of
servicemembers for the disability evaluation case file. In addition,
MEB physicians may require that servicemembers obtain additional
medical evidence from specialty physicians such as a psychiatrist.
Throughout the MEB and PEB process, a physical evaluation board liaison
officer serves a key role by explaining the process to servicemembers,
and ensuring that the servicemembers' case files are complete before
they are forwarded for adjudication. The board liaison officer informs
servicemembers of board results and of deadlines at key decision points
in the process. The military also provides legal counsel to
servicemembers in the disability evaluation process. The Army, for
example, provides them with legal representation at formal board
hearings. The Army will provide military counsel, or servicemembers may
retain their own representative at their own expense.
In addition to receiving benefits from DOD, veterans may receive
compensation from VA for lost earning capacity due to service-connected
disabilities. 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 will evaluate all claimed conditions, whether they
were evaluated previously by the military service's evaluation process
or not. If the VA finds that a veteran has one or more service-
connected disabilities with a combined rating of at least 10
percent,[Footnote 12] VA will pay monthly compensation. The veteran can
claim additional benefits over time, for example, if a service-
connected disability worsens.
To improve the timeliness and resource utilization of DOD's and VA's
separate disability evaluation systems, the agencies embarked on a
planning effort of a joint disability evaluation system that would
enable servicemembers to receive VA disability benefits shortly after
leaving the military without going through both DOD's and VA's
processes. A key part of this planning effort included a "table top"
exercise whereby the planners simulated the outcomes of cases using
four potential options that incorporated variations of following three
elements: (1) a single, comprehensive medical examination to be used by
both DOD and VA in their disability evaluations; (2) a single
disability rating performed by VA; and (3) incorporating a DOD-level
evaluation board for adjudicating servicemembers' fitness for duty.
Based on the results of this exercise, DOD and VA implemented the
selected pilot design using live cases at three Washington, D.C.-area
military treatment facilities including Walter Reed Army Medical Center
in November 2007.[Footnote 13] Key features of the pilot include (see
fig. 1):
* a single physical examination conducted to VA standards as part of
the medical evaluation board;[Footnote 14]
* disability ratings prepared by VA, for use by both DOD and VA in
determining disability benefits; and:
* additional outreach and non-clinical case management provided by VA
staff at the DOD pilot locations to explain VA results and processes to
servicemembers.
Figure 1: Major Differences between Current and Pilot Military
Disability Evaluation Processes:
[See PDF for image]
Current process:
Servicemember:
Board liaison provides support;
Medical Evaluation Board (MEB): Physical performed by military
department; Physical Evaluation Board (PEB): Military department
determines disability rating for computing DOD disability benefits.
Current process, after separation:
Veteran:
Receives DOD disability benefits and develops claim for VA disability
benefits;
* Comprehensive physical performed to VA standards;
* VA determines disability rating.
Pilot process:
Servicemember:
Board liaison and VA staff provide support; Medical Evaluation Board
(MEB): Comprehensive physical performed to VA standards; Physical
Evaluation Board (PEB): VA determines disability rating sued for
computing DOD disability benefits.
Pilot process, after separation:
Receives DOD disability benefits and received VA disability benefits
shortly after leaving military.
Source: GAO analysis of DOD documents.
[End of figure]
The Army Continues to Increase Support to Servicemembers Undergoing
Medical Treatment and Disability Evaluation, but Faces Challenges
Reaching Stated Goals:
The Army has made strides increasing key staff positions in support of
servicemembers undergoing medical treatment as well as disability
evaluation, but faces a number of challenges to achieving or
maintaining stated goals. Although the Army has made significant
progress in staffing its Warrior Transition Units, several challenges
remain, including hiring medical staff in a competitive market,
replacing temporarily borrowed personnel with permanent staff, and
getting eligible servicemembers into the units. With respect to
supporting servicemembers as they navigate the disability evaluation
process, the Army has reduced caseloads of key support staff, but has
not yet reached its goals and faces challenges with both hiring and
meeting current demands of servicemembers in the process.
Army Has Made Considerable Progress in Staffing Its Warrior Transition
Units, but Faces Shortfalls and Other Challenges:
Since September 2007, the Army has made considerable progress in
staffing its Warrior Transition Units, increasing the number of staff
assigned to Triad positions by almost 75 percent. As of February 6,
2008, the Army had about 2,300 personnel staffing its Warrior
Transition Units. In February 2008, the Army reported that its Warrior
Transition Units had achieved "full operational capability," which was
the goal established in the Army's Medical Action Plan. The Warrior
Transition Units reported that they had met this goal even though some
units had staffing shortages or faced other challenges.[Footnote 15]
Although encouraging, the Army is facing several challenges in fully
staffing the Warrior Transition Units and ensuring all eligible
servicemembers can benefit from the care provided in these units. For
example, the Army established a goal of having at least 90 percent of
Triad staff positions filled to meet the staff-to-servicemember ratios
that the Army had established for its Warrior Transition
Units.[Footnote 16] As of February 6, 2008, the Army had surpassed this
goal for 21 of the 32 units. However, the remaining 11 Warrior
Transition Units had less than 90 percent of needed staff for one or
more Triad positions--representing a total shortfall of 10 primary care
managers, 44 nurse case managers, and 10 squad leaders. (See table 1.)
Although most of these locations were missing only 1 or 2 staff, a few
locations had more significant shortfalls. For example, Fort Hood
needed almost 30 nurse case managers to meet the Army's 90 percent
goal. Army officials cited challenges in staffing Triad positions,
including difficulties in hiring physicians and other medical personnel
at certain locations because salary levels do not provide the necessary
incentives in a competitive market:
Table 1: Locations Where Warrior Transition Units Had Less Than 90
Percent of Staff in Place in One or More Triad Positions, as of
February 6, 2008.
Location (size of Warrior Transition Unit population): Fort Hood, Texas
(957);
Additional Triad staff needed[A]: Primary care managers: 2;
Additional Triad staff needed[A]: Nurse case managers: 28;
Additional Triad staff needed[A]: Squad leaders: 2.
Location (size of Warrior Transition Unit population): Walter Reed Army
Medical Center, Washington, D.C. (674);
Additional Triad staff needed[A]: Primary care managers: 1;
Additional Triad staff needed[A]: Nurse case managers: [Empty];
Additional Triad staff needed[A]: Squad leaders: [Empty].
Location (size of Warrior Transition Unit population): Fort Lewis,
Washington (613);
Additional Triad staff needed[A]: Primary care managers: 3;
Additional Triad staff needed[A]: Nurse case managers: 10;
Additional Triad staff needed[A]: Squad leaders: [Empty].
Location (size of Warrior Transition Unit population): Fort Campbell,
Kentucky (596);
Additional Triad staff needed[A]: Primary care managers: 1;
Additional Triad staff needed[A]: Nurse case managers: 1;
Additional Triad staff needed[A]: Squad leaders: [Empty].
Location (size of Warrior Transition Unit population): Fort Drum, New
York (395);
Additional Triad staff needed[A]: Primary care managers: 1;
Additional Triad staff needed[A]: Nurse case managers: 1;
Additional Triad staff needed[A]: Squad leaders: 5.
Location (size of Warrior Transition Unit population): Fort Polk,
Louisiana (248);
Additional Triad staff needed[A]: Primary care managers: 1;
Additional Triad staff needed[A]: Nurse case managers: [Empty];
Additional Triad staff needed[A]: Squad leaders: [Empty].
Location (size of Warrior Transition Unit population): Fort Knox,
Kentucky (243);
Additional Triad staff needed[A]: Primary care managers: 1;
Additional Triad staff needed[A]: Nurse case managers: [Empty];
Additional Triad staff needed[A]: Squad leaders: [Empty].
Location (size of Warrior Transition Unit population): Fort Irwin &
Balboa, California (89);
Additional Triad staff needed[A]: Primary care managers: [Empty];
Additional Triad staff needed[A]: Nurse case managers: 2;
Additional Triad staff needed[A]: Squad leaders: 1.
Location (size of Warrior Transition Unit population): Fort Belvoir,
Virginia (43);
Additional Triad staff needed[A]: Primary care managers: [Empty];
Additional Triad staff needed[A]: Nurse case managers: 1;
Additional Triad staff needed[A]: Squad leaders: 1.
Location (size of Warrior Transition Unit population): Fort Huachuca,
Arizona (41);
Additional Triad staff needed[A]: Primary care managers: [Empty];
Additional Triad staff needed[A]: Nurse case managers: 1;
Additional Triad staff needed[A]: Squad leaders: [Empty].
Location (size of Warrior Transition Unit population): Redstone
Arsenal, Alabama (17);
Additional Triad staff needed[A]: Primary care managers: [Empty];
Additional Triad staff needed[A]: Nurse case managers: [Empty];
Additional Triad staff needed[A]: Squad leaders: 1.
Total Staff Needed:
Additional Triad staff needed[A]: Primary care managers: 10;
Additional Triad staff needed[A]: Nurse case managers: 44;
Additional Triad staff needed[A]: Squad leaders: 10.
Source: GAO analysis of Army data.
Note: The staffing needed is based on the number of servicemembers in
each Warrior Transition Unit, as of February 6, 2008.
[A] The number of additional staff needed to achieve the Army's goal of
filling 90 percent of Triad positions at each location.
[End of table]
The Army is confronting other challenges, as well, including replacing
borrowed staff in Triad positions with permanently assigned staff
without disrupting the continuity of care for servicemembers. We
previously reported in September 2007 that many units were relying on
borrowed staff to fill positions--about 20 percent overall. This
practice has continued; in February 2008, about 20 percent of Warrior
Transition Unit staff continued to be borrowed from other
positions.[Footnote 17] Army officials told us that using borrowed
staff was necessary to get the Warrior Transition Units implemented
quickly and has been essential in staffing units that have experienced
sudden increases in servicemembers needing care. Army officials told us
that using borrowed staff is a temporary solution for staffing the
units, and these staff will be transitioned out of the positions when
permanent staff are available. Replacing the temporary staff will
result in turnover among Warrior Transition Unit staff, which can
disrupt the continuity of care provided to servicemembers.
Another lingering challenge facing the Army is getting eligible
servicemembers into the Warrior Transition Units. In developing its
approach, the Army envisioned that servicemembers meeting specific
criteria, such as requiring more than 6 months of treatment or having a
condition that requires going through the Medical Evaluation Board
process, would be assigned to the Warrior Transition Units. Since
September 2007, the Warrior Transition Unit population has increased by
about 80 percent--from about 4,350 to about 7,900 servicemembers.
However, although the percentage of eligible servicemembers going
through the Medical Evaluation Board process who were not in a Warrior
Transition Unit has been cut almost in half since September 2007, more
than 2,500 eligible servicemembers were not in units, as of February 6,
2008. About 1,700 of these servicemembers (about 70 percent) are
concentrated in ten locations. (See table 2.)
Table 2: Locations with 100 or More Eligible Servicemembers Not in a
Warrior Transition Unit, as of February 6, 2008:
Location: Fort Hood, Texas;
Total number of servicemembers eligible for a Warrior Transition Unit:
1,331;
Number of eligible servicemembers not in a Warrior Transition Unit:
374;
Percentage of total eligible servicemembers not in a Warrior Transition
Unit: 28.
Location: Fort Carson, Colorado;
Total number of servicemembers eligible for a Warrior Transition Unit:
603;
Number of eligible servicemembers not in a Warrior Transition Unit:
240;
Percentage of total eligible servicemembers not in a Warrior Transition
Unit: 40.
Location: Fort Bragg, North Carolina;
Total number of servicemembers eligible for a Warrior Transition Unit:
666;
Number of eligible servicemembers not in a Warrior Transition Unit:
199;
Percentage of total eligible servicemembers not in a Warrior Transition
Unit: 30.
Location: Fort Gordon, Georgia;
Total number of servicemembers eligible for a Warrior Transition Unit:
437;
Number of eligible servicemembers not in a Warrior Transition Unit:
183;
Percentage of total eligible servicemembers not in a Warrior Transition
Unit: 42.
Location: Fort Lewis, Washington;
Total number of servicemembers eligible for a Warrior Transition Unit:
783;
Number of eligible servicemembers not in a Warrior Transition Unit:
170;
Percentage of total eligible servicemembers not in a Warrior Transition
Unit: 22.
Location: Fort Knox, Kentucky;
Total number of servicemembers eligible for a Warrior Transition Unit:
359;
Number of eligible servicemembers not in a Warrior Transition Unit:
116;
Percentage of total eligible servicemembers not in a Warrior Transition
Unit: 32.
Location: Fort Campbell, Kentucky;
Total number of servicemembers eligible for a Warrior Transition Unit:
711;
Number of eligible servicemembers not in a Warrior Transition Unit:
115;
Percentage of total eligible servicemembers not in a Warrior Transition
Unit: 16.
Location: Fort Drum, New York;
Total number of servicemembers eligible for a Warrior Transition Unit:
500;
Number of eligible servicemembers not in a Warrior Transition Unit:
105;
Percentage of total eligible servicemembers not in a Warrior Transition
Unit: 21.
Location: West Point, New York;
Total number of servicemembers eligible for a Warrior Transition Unit:
164;
Number of eligible servicemembers not in a Warrior Transition Unit:
105;
Percentage of total eligible servicemembers not in a Warrior Transition
Unit: 64.
Location: Tripler Army Medical Center, Hawaii; Total number of
servicemembers eligible for a Warrior Transition Unit: 283; Number of
eligible servicemembers not in a Warrior Transition Unit: 101;
Percentage of total eligible servicemembers not in a Warrior Transition
Unit: 36.
Location: Total;
Total number of servicemembers eligible for a Warrior Transition Unit:
5,837;
Number of eligible servicemembers not in a Warrior Transition Unit:
1,708;
Percentage of total eligible servicemembers not in a Warrior Transition
Unit: 29.
Source: GAO analysis of Army data.
[End of table]
Warrior Transition Unit commanders conduct risk assessments of eligible
servicemembers to determine if their care can be appropriately managed
outside of the Warrior Transition Unit. These assessments are to be
conducted within 30 days of determining that the servicemember meets
eligibility criteria. For example, a servicemember's knee injury may
require a Medical Evaluation Board review--a criterion for being placed
in a Warrior Transition Unit--but the person's unit commander can
determine that the person can perform a desk job while undergoing the
medical evaluation process. According to Army guidance, servicemembers
eligible for the Warrior Transition Unit will generally be moved into
the units, that it will be the exception, not the rule, for a
servicemember to not be transferred to a Warrior Transition Unit. Army
officials told us that the population of 2,500 servicemembers who had
not been moved into a Warrior Transition Unit consisted of both
servicemembers who had just recently been identified as eligible for a
unit but had not yet been evaluated and servicemembers whose risk
assessment determined that their care could be managed outside of a
unit. Officials told us that servicemembers who needed their care
managed more intensively through Warrior Transition Units had been
identified through the risk assessment process and had been moved into
such units. As eligible personnel are brought into the Warrior
Transition Units, however, it could exacerbate staffing shortfalls in
some units. To minimize future staffing shortfalls, Army officials told
us that they are identifying areas where they anticipate future
increases in the number of servicemembers needing care in a Warrior
Transition Unit and would use this information to determine appropriate
future staffing needs of the units.
Another emerging challenge is gathering reliable and objective data to
measure progress. A central goal of the Army's efforts is to make the
system more servicemember-and family-focused and the Army has initiated
efforts to determine how well the units are meeting servicemembers'
needs. To its credit, the Army has developed a wide range of methods to
monitor its units, among them a program to place independent ombudsmen
throughout the system as well as town hall meetings and a telephone
hotline for servicemembers to convey concerns about the Warrior
Transition Units. Additionally, through its Warrior Transition Program
Satisfaction Survey, the Army has been gathering and analyzing
information on servicemembers' opinions about their nurse case manager
and the overall Warrior Transition Unit. However, initial response
rates have been low, which has limited the Army's ability to reliably
assess satisfaction. In February 2008, the Army started following up
with nonrespondents, and officials told us that these efforts have
begun to improve response rates. To obtain feedback from a larger
percentage of servicemembers in the Warrior Transition Units, the Army
administered another satisfaction survey in January 2008. This survey,
which also solicited servicemembers' opinions about components of the
Triad and overall satisfaction with the Warrior Transition Units,
garnered a more than 90 percent response rate from the population
surveyed.[Footnote 18] While responses to the survey were largely
positive, the survey is limited in its ability to accurately gauge the
Army's progress in improving servicemember satisfaction with the
Warrior Transition Unit, because it was not intended to be a
methodologically rigorous evaluation. For example, the units were not
given specific instructions on how to administer the survey, and as a
result, it is not clear the extent to which servicemembers were
provided anonymity in responding to the survey. Units were instructed
to reach as many servicemembers as possible within a 24-hour period in
order to provide the Army with immediate feedback on servicemembers'
overall impressions of the care they were receiving.
Despite Hiring Efforts, Army Faces Challenges Providing Sufficient
Staff to Help Servicemembers Navigate the Disability Evaluation
Process:
Injured and ill servicemembers who must undergo a fitness for duty
assessment and disability evaluation rely on the expertise and support
of several key staff--board liaisons, legal personnel, and board
physicians--to help them navigate the process. Board liaisons explain
the disability process to servicemembers and are responsible for
ensuring that their disability case files are complete. Legal staff and
medical evaluation board physicians can substantially influence the
outcome of servicemembers' disability evaluations because legal
personnel provide important counsel to servicemembers during the
disability evaluation process, and evaluation board physicians evaluate
and document servicemembers' medical conditions for the disability
evaluation case file.[Footnote 19]
With respect to board liaisons, the Army has expanded hiring efforts
and met its goals for reducing caseloads at most treatment facilities,
but not at some of the facilities with the most servicemembers in the
process. In August 2007, the Army established an average caseload
target of 30 servicemembers per board liaison. As of February 2008, the
Army had expanded the number of board liaisons by about 22 percent.
According to the Army, average caseloads per liaison have declined from
54 servicemembers at the end of June 2007 to 46 at the end of December
2007. However, 11 of 35 treatment facilities continue to have shortages
of board liaisons and about half of all servicemembers in the
disability evaluation process are located at these 11 treatment
facilities. (See fig. 2.) Due to their caseloads, liaisons we spoke
with at one location had difficulty making appointments with
servicemembers, which has challenged their ability to provide timely
and comprehensive support.
Figure 2: Average Number of Servicemembers per Board Liaison at
Treatment Facilities, February 6, 2008:
[See PDF for image]
This figure contains both a pie-chart and a vertical bar graph. The pie-
chart depicts the following data:
Percentage of servicemembers represented by facilities that are meeting
and not meeting the Army's goal:
11 facilities not meeting Army's goal: 52%;
24 facilities meeting Army's goal: 48%.
The bar graph depicts the average number of service members per board
liaison at various treatment facilities. The Army's goal is to have 30
servicemembers per board liaison. The following approximated data is
depicted in the graph:
Treatment facility: Fort Wainwright, Alaska;
Average number of service members per board liaison: 80.
Treatment facility: Bavaria, Germany;
Average number of service members per board liaison: 78.
Treatment facility: Fort Hood, Texas;
Average number of service members per board liaison: 74.
Treatment facility: Fort Jackson, South Carolina;
Average number of service members per board liaison: 46.
Treatment facility: Fort Leonard Wood, Missouri;
Average number of service members per board liaison: 42.
Treatment facility: Fort Gordon, Georgia;
Average number of service members per board liaison: 41.
Treatment facility: Fort Drum, New York;
Average number of service members per board liaison: 34.
Treatment facility: Landstuhl, Germany;
Average number of service members per board liaison: 33;
Treatment facility: Fort Polk, Louisiana;
Average number of service members per board liaison: 33.
Treatment facility: Fort Campbell, Kentucky;
Average number of service members per board liaison: 32.
Treatment facility: Fort Lewis, Washington;
Average number of service members per board liaison: 29.
Treatment facility: Fort Bragg, North Carolina;
Average number of service members per board liaison: 28.
Treatment facility: Fort Richardson, Alaska;
Average number of service members per board liaison: 27.
Treatment facility: Fort Irwin and Balboa, California;
Average number of service members per board liaison: 27.
Treatment facility: Fort Huachuca, Arizona;
Average number of service members per board liaison: 26.
Treatment facility: Fort Sam Houston, Texas;
Average number of service members per board liaison: 25.
Treatment facility: Fort Eustis, Virginia;
Average number of service members per board liaison: 23.
Treatment facility: Tripler, Hawaii;
Average number of service members per board liaison: 20.
Treatment facility: Fort Sill, Oklahoma;
Average number of service members per board liaison: 17;
Treatment facility: Fort Belvoir; Virginia;
Average number of service members per board liaison: 17.
Treatment facility: Fort Benning, Georgia;
Average number of service members per board liaison: 16.
Treatment facility: Fort Stewart, Georgia;
Average number of service members per board liaison: 16.
Treatment facility: Fort Know, Kentucky;
Average number of service members per board liaison: 16.
Treatment facility: Fort Bliss, Texas;
Average number of service members per board liaison: 16.
Treatment facility: West Point, New York;
Average number of service members per board liaison: 15.
Treatment facility: Fort Lee, Virginia;
Average number of service members per board liaison: 15.
Treatment facility: Heidelberg, Germany;
Average number of service members per board liaison: 12.
Treatment facility: Walter Reed, Washington, DC;
Average number of service members per board liaison: 10.
Treatment facility: Fort Meade, Maryland;
Average number of service members per board liaison: 7.
Treatment facility: Fort Rucker, Alabama;
Average number of service members per board liaison: 7.
Treatment facility: Fort Leavenworth, Kansas;
Average number of service members per board liaison: 5.
Treatment facility: Fort Dix, New Jersey;
Average number of service members per board liaison: 3.
Treatment facility: Redstone Arsenal, Alabama;
Average number of service members per board liaison: 3.
Source: GAO analysis based on Army data.
[End of figure]
The Army plans to hire additional board liaisons, but faces challenges
in keeping up with increased demand. According to an Army official
responsible for staff planning, the Army reviews the number of liaisons
at each treatment facility weekly and reviews Army policy for the
target number of servicemembers per liaison every 90 days. The official
also identified several challenges in keeping up with increased demand
for board liaisons, including the increase in the number of injured and
ill servicemembers in the medical evaluation board process overall, and
the difficulty of attracting and retaining liaisons at some locations.
According to Army data, the total number of servicemembers completing
the medical evaluation board process increased about 19 percent from
the end of 2006 to the end of 2007.
In addition to gaps in board liaisons, according to Army documents,
staffing of dedicated legal personnel who provide counsel to injured
and ill servicemembers throughout the disability evaluation processes
is currently insufficient. Ideally, according to the Army,
servicemembers should receive legal assistance during both the medical
and physical evaluation board processes. While servicemembers may seek
legal assistance at any time, the Office of the Judge Advocate
General's policy is to assign dedicated legal staff to servicemembers
when their case goes before a formal physical evaluation board. In June
2007, the Army assigned 18 additional legal staff--12 Reserve attorneys
and 6 Reserve paralegals--to help meet increasing demands for legal
support throughout the process. As of January 2008, the Army had 27
legal personnel--20 attorneys and 7 paralegals--located at 5 of 35 Army
treatment facilities who were dedicated to supporting servicemembers
primarily with the physical evaluation board process.[Footnote 20]
However, the Office of the Judge Advocate General has acknowledged that
these current levels are insufficient for providing support during the
medical evaluation board process, and proposed hiring an additional 57
attorneys and paralegals to provide legal support to servicemembers
during the medical evaluation board process. The proposed 57 attorneys
and paralegals include 19 active-duty military attorneys, 19 civilian
attorneys, and 19 civilian paralegals. On February 21, 2008, Army
officials told us that 30 civilian positions were approved, consisting
of 15 attorneys and 15 paralegals.
While the Army has plans to address gaps in legal support for
servicemembers, challenges with hiring and staff turnover could limit
their efforts. According to Army officials, even if the plan to hire
additional personnel is approved soon, hiring of civilian attorneys and
paralegals may be slow due to the time it takes to hire qualified
individuals under government policies. Additionally, 19 of the 57 Army
attorneys who would be staffed under the plan would likely only serve
in their positions for a period of 12 to 18 months.[Footnote 21]
According to a Disabled American Veterans representative with extensive
experience counseling servicemembers during the evaluation process,
frequent rotations and turnover of Army attorneys working on disability
cases limits their effectiveness in representing servicemembers due to
the complexity of disability evaluation regulations.
With respect to medical evaluation board physicians, who are
responsible for documenting servicemembers medical conditions, the Army
has mostly met its goal for the average number of servicemembers per
physician at each treatment facility. In August 2007, the Army
established a goal of one medical evaluation board physician for every
200 servicemembers.[Footnote 22] As with the staffing ratio for board
liaisons, the ratio for physicians is reviewed every 90 days by the
Army and the ratio at each treatment facility is reviewed weekly,
according to an Army official. As of February 2008, the Army had met
the goal of 200 servicemembers per physician at 29 of 35 treatment
facilities and almost met the goal at two others.[Footnote 23]
Despite having mostly met its goal for medical evaluation board
physicians, according to Army officials, the Army continues to face
challenges in this area. For example, according to an Army official,
physicians are having difficulty managing their caseload even at
locations where they have met or are close to the Army's goal of 1
physician for 200 servicemembers due not only to the volume of cases
but also their complexity. According to Army officials, disability
cases often involve multiple conditions and may include complex
conditions such as TBI and PTSD. Some Army physicians told us that the
ratio of servicemembers per physician allows little buffer when there
is a surge in caseloads at a treatment facility. For this reason, some
physicians told us that the Army could provide better service to
servicemembers if the number of servicemembers per physician was
reduced from 200 to 100 or 150.
In addition to increasing the number of staff who support this process,
the Army has reported other progress and efforts underway that could
further ease the disability evaluation process. For example, the Army
has reported improving outreach to servicemembers by establishing and
conducting standardized briefings about the process. The Army has also
improved guidance to servicemembers by developing and issuing a
handbook on the disability evaluation process, and creating a web site
for each servicemember to track his or her progress through the medical
evaluation board. Finally, the Army told us that efforts are underway
to further streamline the process for servicemembers and improve
supporting information technology. For example, the Army established a
goal to eliminate 50 percent of the forms required by the current
process. While we are still assessing the scope, status, and potential
impact of these efforts, a few questions have been raised about some of
them. For example, according to Army officials, servicemembers' usage
of the medical evaluation board web site has been low. In addition,
some servicemembers with whom we spoke believe the information
presented on the web site was not helpful in meeting their needs.
One measure of how well the disability evaluation system is working
does not indicate that improvements have occurred. The Army collects
data and regularly reports on the timeliness of the medical evaluation
board process. While we have previously reported that the Army has few
internal controls to ensure that these data were complete and accurate,
the Army recently told us that they are taking steps to improve the
reliability of these data.[Footnote 24] We have not yet substantiated
these assertions. Assuming current data are reliable, the Army has
reported not meeting a key target for medical evaluation board
timeliness and has even reported a negative trend in the last year.
Specifically, the Army's target is for 80 percent of the medical
evaluation board cases to be completed in 90 days or less, but the
percent that met the standard declined from 70 percent in October
through December 2006, to 63 percent in October through December 2007.
Another potential indicator of how well the disability evaluation
process is working is under development. Since June 2007, the Army has
used the Warrior Transition Program Satisfaction Survey to ask
servicemembers about their experience with the disability evaluation
process and board liaisons. However, according to Army officials in
charge of the survey, response rates to survey questions related to the
disability process were particularly low because most surveyed
servicemembers had not yet begun the disability evaluation process. The
Army is in the process of developing satisfaction surveys that are
separate from the Warrior Transition Unit survey to gauge
servicemembers' perceptions of the medical and physical evaluation
board processes.
DOD-VA Joint Disability Evaluation Process Pilot Geared Toward Quick
Implementation, but Pilot Evaluation Plans Lack Key Elements:
DOD and VA have joined together to quickly pilot a streamlined
disability evaluation process, but evaluation plans currently lack key
elements. In August 2007, DOD and VA conducted an intensive 5-day
"table top" exercise to evaluate the relative merits of four potential
pilot alternatives. Though the exercise yielded data quickly, there
were trade-offs in the nature and extent of data that could be obtained
in that time frame. In November 2007, DOD and VA jointly initiated a 1-
year pilot in the Washington, D.C. area using live cases, although DOD
and VA officials told us they may consider expanding the pilot to other
locations beyond the current sites around July 2008. However, pilot
results may be limited at that and other critical junctures, and pilot
evaluation plans currently lack key elements, such as criteria for
expanding the pilot.
Selection of Pilot Design Based on Formal but Quick 5-day Exercise:
Prior to implementing the pilot in November 2007, the agencies
conducted a 5-day "table top" exercise that involved a simulation of
cases intended to test the relative merits of 4 pilot options. All the
alternatives included a single VA rating to be used by both agencies.
However, the exercise was designed to evaluate the relative merits of
certain other key features, such as whether DOD or VA should conduct a
single physical examination, and whether there should be a DOD-wide
disability evaluation board, and if so, what its role would be.
Ultimately, the exercise included four pilot alternatives involving
different combinations of these features. Table 3 summarizes the pilot
alternatives.
Table 3: Summary of Pilot Alternatives Considered by DOD and VA During
August 2007 "Table Top" Exercise:
Alternative 1:
Comprehensive medical examination: None. Separate DOD and VA
examinations;
Single disability rating done by VA: Yes;
DOD-level evaluation board: Makes fitness determinations.
Alternative 2[A]:
Comprehensive medical examination: Done by VA;
Single disability rating done by VA: Yes;
DOD-level evaluation board: None. Services make fitness determinations.
Alternative 3:
Comprehensive medical examination: None. Separate DOD and VA
examinations;
Single disability rating done by VA: Yes;
DOD-level evaluation board: Adjudicates appeals of services' fitness
determinations.
Alternative 4:
Comprehensive medical examination: None. Separate DOD and VA
examinations;
Single disability rating done by VA: Yes;
DOD-level evaluation board: Conducts quality assurance reviews of
services' fitness determinations.
Source: GAO analysis of information provided by DOD.
[A] Based on the table top exercise, alternative 2 was selected for
implementation.
[End of table]
The simulation exercise was formal in that it followed a pre-determined
methodology and comprehensive in that it involved a number of
stakeholders and captured a broad range of metrics. DOD and VA were
assisted by consultants who provided data collection, analysis, and
methodological support. The pre-determined methodology involved
examining previously decided cases, to see how they would have been
processed through each of the four pilot alternatives. The 33 selected
cases intentionally reflected decisions originating from each of the
military services and a broad range and number of medical conditions.
Participants in the simulation exercise included officials from DOD,
each military service, and VA who are involved in all aspects of the
disability evaluation processes at both agencies. Metrics collected
included case outcomes including the fitness decision, the DOD and VA
ratings, and the median expected days to process cases. These outcomes
were compared for each pilot alternative with actual outcomes. In
addition, participants rank ordered their preference for each pilot
alternative, and provided feedback on expected servicemember
satisfaction as well as service and organization acceptance. They also
provided their views on legislative and regulatory changes and resource
requirements to implement alternative processes, and identified
advantages and disadvantages of each alternative.
This table top exercise enabled DOD and VA to obtain sufficient
information to support a near-term decision to implement the pilot, but
it also required some trade-offs. For example, the intensity of the
exercise--simulating four pilot alternatives, involving more than 40
participants over a 5-day period--resulted in an examination of only a
manageable number of cases. To ensure that the cases represented each
military service and different numbers and types of potential medical
conditions, a total of 33 cases were judgmentally selected by service:
8 Army, 9 Navy, 8 Marine, and 8 Air Force. However, the sample used in
the simulation exercise was not statistically representative of each
military service's workload; as such it is possible that a larger and
more representative sample could have yielded different outcomes. Also,
expected servicemember satisfaction was based on the input of the DOD
and VA officials participating in the pilot rather than actual input
from the servicemembers themselves.
Based on the data from this exercise, the Senior Oversight Committee
gave approval in October 2007 to proceed with piloting an alternative
process with features that scored the highest in terms of participants'
preferential voting and projected servicemember satisfaction. These
elements included a single VA rating (as provided in all the
alternatives tested) and a comprehensive medical examination conducted
by VA. The selected pilot design did not include a DOD-wide disability
evaluation board.[Footnote 25] Rather, the services' physical
evaluation boards would continue to determine fitness for duty, as
called for under Alternative 2.
The Pilot Is Geared toward Quick Expansion, but Evaluation Plans Lack
Key Elements:
DOD and VA officials have described to us a plan for expanding the
pilot that is geared toward quick implementation, but may have limited
pilot results available to them at a key juncture. With respect to time
frames, the pilot, which began in November 2007, is scheduled to last 1
year, through November 2008. However, prior to that date, planners have
expressed interest in expanding the pilot outside the Washington
metropolitan area. Pilot planners have told us that around July 2008--
which is not long after the first report on the pilot is due to
Congress [Footnote 26]--they may ask the Senior Oversight Committee to
decide on expansion to more locations based on data available at that
time. They suggested that a few additional locations would allow them
to collect additional experience and data outside the Washington, D.C.
area before decisions on broader expansion are made. According to DOD
and VA officials, time frames for national expansion have not yet been
decided. However, DOD also faces deadlines for providing Congress an
interim report on the pilot's status as early as October 2008, and for
issuing a final report.[Footnote 27]
While expanding the pilot outside the Washington, D.C. area will likely
yield useful information to pilot planners, due to the time needed to
fully process cases, planners may have limited pilot results available
to guide their decision making. As of February 17, 2008, 181 cases were
currently in the pilot process, but none had completed the process.
After conducting the simulation exercise, pilot planners set a goal of
275 days (about 9 months) for a case to go through the entire joint
disability evaluation process. If the goal is an accurate predictor of
time frames, potentially very few cases will have made it through the
entire pilot process by the time planners seek to expand the pilot
beyond the Washington area. As a result, DOD and VA are accepting some
level of risk by expanding the pilot solely on the basis of early pilot
results.
In addition to having limited information at this key juncture, pilot
planners have yet to designate criteria for moving forward with pilot
expansion and have not yet selected a comparison group to identify
differences between pilot cases and cases processed under the current
system, to allow for assessment of pilot performance. DOD and VA are
collecting data on decision times and rating percentages, but have not
identified how much improvement in timeliness or consistency would
justify expanding the pilot process. Further, pilot planners have not
laid out an approach for measuring the pilot's performance on key
metrics--including timeliness and accuracy of decisions--against the
current process. Selection of the comparison group cases is a
significant decision, because it will help DOD and VA determine the
pilot's impact, compared with the current process, and help planners
identify needed corrections and manage for success. An appropriate
comparison group might include servicemembers with a similar
demographic and disability profile. Not having an appropriate
comparison group increases the risk that DOD and VA will not identify
problem areas or issues that could limit the effectiveness of any
redesigned disability process. Pilot officials stated that they intend
to identify a comparison group of non-pilot disability evaluation
cases, but have not yet done so.
Another key element lacking from current evaluation plans is an
approach for surveying and measuring satisfaction of servicemembers and
veterans with the pilot process. As noted previously, several high-
level commissions identified servicemember confusion over the current
disability evaluation system as a significant problem. Pilot planners
told us that they intend to develop a customer satisfaction survey and
use customer satisfaction data as part of their evaluation of pilot
performance but, as of February 2008, the survey was still under
development. Even after the survey has been developed, results will
take some time to collect and may be limited at key junctures because
the survey needs to be administered after servicemembers and veterans
have completed the pilot process. Without data on servicemember
satisfaction, the agencies cannot know whether or the extent to which
the pilot they are implementing has been successful at reducing
servicemember confusion and distrust over the current process.
Concluding Observations:
Over the past year, the Army has made substantial progress toward
improving care for its servicemembers. After problems were disclosed at
Walter Reed in early 2007, senior Army officials assessed the situation
and have since dedicated significant resources--including more than
2,000 personnel--and attention to improve this important mission.
Today, the Army has established Warrior Transition Units at its major
medical facilities and doctors, nurses, and fellow servicemembers at
these units are at work helping wounded, injured, and ill
servicemembers through what is often a difficult healing process. Some
challenges remain, such as filling all the Warrior Transition Unit
personnel slots in a competitive market for medical personnel,
lessening reliance on borrowed personnel to fill slots temporarily, and
getting servicemembers eligible for Warrior Transition Unit services
into those units. Overall, the Army is to be commended for its efforts
thus far; however, sustained attention to remaining challenges and
reliable data to track progress will be important to sustaining gains
over time.
For those servicemembers whose military service was cut short due to
illness or injury, the disability evaluation is an extremely important
issue because it affects their service retention or discharge and
whether they receive DOD benefits such as retirement pay and health
care coverage. Once they become veterans, it affects the cash
compensation and other disability benefits they may receive from VA.
Going through two complex disability evaluation processes can be
difficult and frustrating for servicemembers and veterans. Delayed
decisions, confusing policies, and the perception that DOD and VA
disability ratings result in inequitable outcomes have eroded the
credibility of the system. The Army has taken steps to increase the
number of staff that can help servicemembers navigate its process, but
is challenged to meet stated goals. Moreover, even if the Army is able
to overcome challenges and sufficiently ramp up staff levels, these
efforts will not address the systemic problem of having two consecutive
evaluation systems that can lead to different outcomes.
Considering the significance of the problems identified, DOD and VA are
moving forward quickly to implement a streamlined disability evaluation
that has potential for reducing the time it takes to receive a decision
from both agencies, improving consistency of evaluations for individual
conditions, and simplifying the overall process for servicemembers and
veterans. At the same time, DOD and VA are incurring some risk with
this approach because the cases used were not necessarily
representative of actual workloads. Incurring some level of risk is
appropriate and perhaps prudent in this current environment; however,
planners should be transparent about that risk. For example, to date,
planners have not yet articulated in their planning documents the
extent of data that will be available at key junctures, and the
criteria they will use in deciding to expand the pilot beyond the
Washington, D.C. area. More importantly, decisions to expand beyond the
few sites currently contemplated should occur in conjunction with an
evaluation plan that includes, at minimum, a sound approach for
measuring the pilot's performance against the current process and for
measuring servicemembers' and veterans' satisfaction with the piloted
process. Failure to properly assess the pilot before significant
expansion could potentially jeopardize the systems' successful
transformation.
Mr. Chairman, this completes our prepared remarks. We would be happy to
respond to any questions you or other Members of the Subcommittee may
have at this time.
For further information about this testimony, please contact Daniel
Bertoni at (202) 512-7215 or bertonid@gao.gov, or John H. Pendleton at
(202) 512-7114 or pendletonj@gao.gov. Contact points for our Offices of
Congressional Relations and Public Affairs may be found on the last
page of this statement. GAO staff who made major contributions to this
testimony are listed in appendix I.
[End of section]
Appendix I: GAO Contacts and Staff Acknowledgments:
GAO Contacts:
Daniel Bertoni at (202) 512-7215 or bertonid@gao.gov:
John H. Pendleton at (202) 512-7114 or pendletonj@gao.gov:
Acknowledgments:
In addition to the contacts named above, Bonnie Anderson, Assistant
Director; Michele Grgich, Assistant Director; Janina Austin; Susannah
Compton; Cindy Gilbert; Joel Green; Christopher Langford; Bryan
Rogowski; Chan My Sondhelm; Walter Vance; and Greg Whitney, made key
contributions to this statement.
[End of section]
Footnotes:
[1] The data include Active, Reserve, and National Guard servicemembers
wounded in action from October 7, 2001, to February 2, 2008. Over two-
thirds of these servicemembers are in the Army.
[2] Office of the Inspector General, Department of the Army, Report on
the Army Physical Disability Evaluation System (Washington, D.C.: Mar.
6, 2007).
[3] 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.: Apr.
2007); Task Force on Returning Global War on Terror Heroes, Report to
the President (April 2007); President's Commission on Care for
America's Returning Wounded Warriors, Serve, Support, Simplify (July
2007).
[4] GAO, Military Disability System: Improved Oversight Needed to
Ensure Consistent and Timely Outcomes for Reserve and Active Duty
Service Members, GAO-06-362 (Washington, D.C.: Mar. 31, 2006).
[5] Veterans' Disability Benefits Commission, Honoring the Call to
Duty: Veterans' Disability Benefits in the 21st Century (October 2007).
[6] GAO, DOD and VA: Preliminary Observations on Efforts to Improve
Health Care and Disability Evaluations for Returning Servicemembers,
GAO-07-1256T (Washington, D.C.: Sept. 26, 2007).
[7] The Navy is responsible for the medical care of servicemembers in
the Marine Corps.
[8] The system is composed of categories of medical facilities that
offer varying levels of services.
[9] The Warrior Transition Unit also includes other staff, such as
human resources and financial management specialists.
[10] The Army also established three Warrior Transition Units in
Germany.
[11] Servicemembers who separate from the military with a DOD
disability rating of 30 percent or higher receive health care benefits
for life regardless of years of service.
[12] VA determines the degree to which veterans are disabled in 10
percent increments on a scale of 0 to 100 percent.
[13] The three pilot locations are Walter Reed Army Medical Center,
Washington, D.C.; National Naval Medical Center, Bethesda, Maryland;
and Malcolm Grow Air Force Medical Center, Andrews Air Force Base,
Maryland.
[14] For the current pilot locations, examinations are conducted at the
Washington, D.C., VA Medical Center.
[15] The Army's January 2008 assessment defined full operational
capability across a wide variety of areas identified in the Army's
Medical Action Plan, not just personnel fill. For example, the
assessment included whether facilities and barracks were suitable and
whether a Soldier and Family Assistance Center was in place and
providing essential services. In addition, the commander assessed
whether the unit could conduct the mission-essential tasks assigned to
it. As a result, such ratings have both objective and subjective
elements, and the Army allows commanders to change the ratings based on
their judgment.
[16] The ratios are 1:200 for primary care managers; 1:18 for nurse
case managers at Army medical centers that normally see servicemembers
with more acute conditions and 1:36 for other types of Army medical
treatment facilities; and 1:12 for squad leaders.
[17] These staff include the Triad--primary care managers, nurse case
managers, and squad leaders--as well as other Warrior Transition staff
such as platoon sergeants, behavioral health specialists, social
workers, and administrative personnel.
[18] The survey was distributed to 4,430 servicemembers, which
represented about 60 percent of the total Warrior Transition Unit
population at the time of the survey. Some servicemembers may not have
received a survey because, according to an Army official, they were
receiving care through a Community Based Health Care Organization, were
on leave, or were undergoing treatment. Additionally, three units'
survey responses were received too late to incorporate into the Army's
analyses.
[19] Board physicians, unlike board liaisons and legal staff who are
dedicated to serving servicemembers in the disability evaluation
process, are part of the Warrior Transition Units.
[20] According to Army officials, the Judge Advocates General's Corps
has approximately 4,200 military and civilian attorneys and a
significant portion of these can provide legal assistance to
servicemembers. However, these officials also noted that these
attorneys are not dedicated exclusively to the disability evaluation
process and the extent to which these attorneys actually provide legal
support to servicemembers during the disability evaluation process is
unknown.
[21] These 19 are intended to be active duty attorneys. The Army
intends to assign active duty attorneys to the disability evaluation
process for a limited time period out of concern for the attorney to
gain experience in other legal practice areas.
[22] Although board physicians are part of the Warrior Transition
Units, staffing targets for board physicians are based on the number of
servicemembers in the disability evaluation process as opposed to the
number of servicemembers in the Warrior Transition Units.
[23] Two of the Army treatment facilities not meeting the 200 to 1
servicemember to physician ratio--Fort Riley, Kansas, and Fort Knox,
Kentucky--each had a ratio of 201 to 1.
[24] GAO-06-362, p. 26.
[25] The DOD Disability Advisory Council will conduct a quality control
review of some service physical evaluation board decisions.
[26] Pursuant to the National Defense Authorization Act for Fiscal Year
2008, enacted January 28, 2008, the Secretary of Defense must submit an
initial report on the pilot within 90 days after enactment. The report
is to include a description of the pilot program's scope and objectives
and the methodology to be used to achieve the objectives. Pub. L. No.
110-181, §1644(g).
[27] Under section 1644(g), the interim report must be submitted no
later than 180 days after the date of the submittal of the initial
report. Not later than 90 days after the completion of all of the pilot
programs carried out under the act, the Secretary of Defense must
submit a report setting out a final evaluation and assessment of the
pilot programs. The final report is to include any recommendations for
legislative or administrative action that the Secretary considers
appropriate in light of the pilot programs.
[End of section]
GAO's Mission:
The Government Accountability Office, the audit, evaluation and
investigative arm of Congress, exists to support Congress in meeting
its constitutional responsibilities and to help improve the performance
and accountability of the federal government for the American people.
GAO examines the use of public funds; evaluates federal programs and
policies; and provides analyses, recommendations, and other assistance
to help Congress make informed oversight, policy, and funding
decisions. GAO's commitment to good government is reflected in its core
values of accountability, integrity, and reliability.
Obtaining Copies of GAO Reports and Testimony:
The fastest and easiest way to obtain copies of GAO documents at no
cost is through GAO's Web site [hyperlink, http://www.gao.gov]. Each
weekday, GAO posts newly released reports, testimony, and
correspondence on its Web site. To have GAO e-mail you a list of newly
posted products every afternoon, go to [hyperlink, http://www.gao.gov]
and select "Subscribe to Updates."
Order by Mail or Phone:
The first copy of each printed report is free. Additional copies are $2
each. A check or money order should be made out to the Superintendent
of Documents. GAO also accepts VISA and Mastercard. Orders for 100 or
more copies mailed to a single address are discounted 25 percent.
Orders should be sent to:
U.S. Government Accountability Office:
441 G Street NW, Room LM:
Washington, D.C. 20548:
To order by Phone:
Voice: (202) 512-6000:
TDD: (202) 512-2537:
Fax: (202) 512-6061:
To Report Fraud, Waste, and Abuse in Federal Programs:
Contact:
Web site: [hyperlink, http://www.gao.gov/fraudnet/fraudnet.htm]:
E-mail: fraudnet@gao.gov:
Automated answering system: (800) 424-5454 or (202) 512-7470:
Congressional Relations:
Ralph Dawn, Managing Director, dawnr@gao.gov:
(202) 512-4400:
U.S. Government Accountability Office:
441 G Street NW, Room 7125:
Washington, D.C. 20548:
Public Affairs:
Chuck Young, Managing Director, youngc1@gao.gov:
(202) 512-4800:
U.S. Government Accountability Office:
441 G Street NW, Room 7149:
Washington, D.C. 20548:
