7
General Observations

In addition to answering specific questions posed in the charge, the committee wishes to make some general observations that flow from its examination of the Department of Veterans Affairs (VA’s) posttraumatic stress disorder (PTSD) disability-compensation system. This final chapter of the report addresses these items, which deal with the overall conduct of the system.

There are three general observations that capture the committee’s thinking on the issue of PTSD disability compensation practices.

1. The key to proper administration of VA’s PTSD compensation program is a thorough compensation and pension (C&P) clinical examination conducted by an experienced professional. This echoes the conclusion of an earlier Institute of Medicine (IOM) committee that examined issues regarding the diagnosis and assessment of PTSD. That committee found:


[A]n optimal assessment of a patient consists of a face-to-face interview in a confidential setting with a health professional experienced in the diagnosis of psychiatric disorders. It is critical that adequate time be allocated for that assessment. Depending on the mental and physical health of the veteran, the veteran’s willingness and capacity to work with the health professional, and the presence of comorbid disorders, the process of diagnosis and assessment will likely take at least an hour or could take many hours to complete (IOM, 2006).



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PTSD Compensation and Military Service 7 General Observations In addition to answering specific questions posed in the charge, the committee wishes to make some general observations that flow from its examination of the Department of Veterans Affairs (VA’s) posttraumatic stress disorder (PTSD) disability-compensation system. This final chapter of the report addresses these items, which deal with the overall conduct of the system. There are three general observations that capture the committee’s thinking on the issue of PTSD disability compensation practices. 1. The key to proper administration of VA’s PTSD compensation program is a thorough compensation and pension (C&P) clinical examination conducted by an experienced professional. This echoes the conclusion of an earlier Institute of Medicine (IOM) committee that examined issues regarding the diagnosis and assessment of PTSD. That committee found: [A]n optimal assessment of a patient consists of a face-to-face interview in a confidential setting with a health professional experienced in the diagnosis of psychiatric disorders. It is critical that adequate time be allocated for that assessment. Depending on the mental and physical health of the veteran, the veteran’s willingness and capacity to work with the health professional, and the presence of comorbid disorders, the process of diagnosis and assessment will likely take at least an hour or could take many hours to complete (IOM, 2006).

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PTSD Compensation and Military Service Many of the problems and issues identified by the committee in previous chapters can be addressed by consistently allocating and applying the time and resources needed for a thorough PTSD C&P clinical examination. This measure will facilitate: more comprehensive and consistent assessment of veteran reports of exposure to trauma; more complete assessment of the presence and impact of comorbid conditions; the conduct of standardized psychological testing where appropriate; more accurate assessment of the social and vocational impacts of identified disabilities; evaluation of any suspected malingering or dissembling using multiple strategies including standardized tests, if appropriate, and clinical face-to-face assessment; more detailed documentation of the claimant’s condition to inform the rater’s decision (and thus potentially lead to better and more consistent decisions); and an informed, case-specific determination of whether reexamination is appropriate and, if so, when. The committee recognizes the sometimes difficult circumstances under which VA professionals operate, and this conclusion should not be read as a criticism of the work they are doing. Indeed, the committee was impressed by the scholarship and dedication of these people who gave presentations in open meetings and responded to the committee’s questions. Still, anecdotal remarks to the committee suggest that not all evaluations are currently performed in a thorough manner. The VA may well incur increased up-front costs by implementing more consistently detailed examinations for all veterans who present for initial and review C&P evaluations for PTSD. It is not possible, though, to make an informed estimate of what the additional costs may be because the total will depend on many variables whose values are not available or are difficult to derive from public sources—notably, the time currently spent on examinations and the costs associated with those examinations. Further uncertainty is introduced by the fact that a change in policies regarding the exams may lead to changes in the number and characteristics of claimants. As noted in Chapter 6, information available to the committee indicates that clinicians currently spend from as little as 20 minutes (Arbisi, 2006) to as much as three hours or more (Watson et al., 2000) to conduct a PTSD C&P examination. There are no data characterizing the distribution of time spent or the average amount of time spent on examinations, and the

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PTSD Compensation and Military Service broad range between the lowest and the highest figures—at least a nine-fold difference—makes bounding calculations relatively uninformative. Without a figure for the amount of time currently spent, it is not possible to confidently estimate how the amount of time devoted to an examination might change. Based on 2003 data, the cost of an average C&P examination—whether administered by VA or by QTC Management Inc.—was $400 (GAO, 2005). This figure excluded the costs of testing, laboratory work, diagnostic imaging, and the like. According to the 2006 VA Office of the Inspector General report on state variances in disability ratings, QTC was receiving $590 per examination two years later—a 48 percent increase, assuming that the figures are comparable (DVA, 2005). Even if these data could be used to project the future cost of an examination, the fact that they represent an overall average makes them uninformative for psychiatric examinations because these examinations “are substantially more expensive than examinations by other specialties” (Commission on Health and Safety and Workers’ Compensation, 1993). Private-sector figures are similarly inadequate because the pricing of services there typically includes an assumption that there will be less than 100 percent cost recovery. A 2006 GAO report noted that even the VA had difficulty estimating the cost of changes to their mental health policy, indicating that the VA does not track expenditures in a way that allows such analysis (GAO, 2006). Data vital to constructing an informed estimate are thus unavailable. The committee believes it would be irresponsible to offer a number that is not well founded because it might influence decision making. Instead, it recommends that VA collect and make the information to perform such an estimate available so that the impact of conducting more uniformly thorough examinations can be fairly and openly evaluated. The committee is also aware that a policy change of this type may present challenges for the administration of exams conducted on a contractual basis, where specificity in the time spent, tests to be performed, and the like is desirable. The committee observes that the conscientious application of clinical judgment in the face of a diverse claimant population does not easily lend itself to standardization. Innovative approaches will need to be developed and tested in order to identify the best means of granting clinicians claimant-specific discretion in the conduct of the exam. It is not possible to say with any degree of certainty whether an initial examination that is more consistently thorough would result in an overall cost benefit for VA. Historic patterns of PTSD compensation grants for cohorts such as Vietnam veterans may or may not be useful in predicting trends among Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) veterans. The nature of military-related stressors and pre- and postwar social and economic conditions is considerably different from

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PTSD Compensation and Military Service earlier service periods. In the absence of a postwar economic boom, peaks for delayed-onset cases may emerge sooner than those observed for previous cohorts. Whether variation in these factors will affect PTSD expression and compensation-seeking behavior—and, if so, to what degree—is not known. At first glance one might expect that a front-end investment in more consistently thorough examinations would lead to cost savings because it would decrease false-positive awards or inappropriately high ratings. However, even if this were the case, this savings could be offset by a concomitant decrease in false-negative denials and inappropriately low ratings. There are, however, other opportunities for reducing long-term costs. Having fewer incorrect or incomplete evaluations should, for example, result in fewer challenges of examination results and ratings decisions—and fewer successful challenges. More consistently thorough evaluations will also allow the generation of information needed to identify and focus on problem areas in the system. Finally, VA could realize cost savings if a more-thorough screening of cases led to earlier and presumably more effective secondary intervention, which in turn might result in reduced lifetime functional impairment and less compensation paid over the lifetime of a recipient. More comprehensive evaluations may also yield another benefit: greater claimant satisfaction. A thorough examination by a caring professional will help demonstrate VA’s commitment to providing help to veterans in need. If the committee’s recommendations are followed, this will be coupled with more consistent ratings determinations rendered by VA staff certified to handle PTSD claims. While the C&P decisions coming out of such evaluations will not necessarily be more favorable to the claimant, he or she will have greater confidence that they were made as a result of a careful, even-handed consideration of the evidence and this may lead to greater acceptance of the results. 2. An informed evaluation of the PTSD compensation system will not be possible until VA implements a comprehensive data collection, analysis, and publication effort. The report identifies a number of instances where there are gaps in the data and in the research literature regarding PTSD disability compensation issues and offers some specific recommendations to address them. However, some data sought by the committee were not available because they were in various cases not collected, not coded, collected but not retained, annotated only in hardcopy files rather than placed in a database, or spread among the VBA and the VHA databases in ways that made retrieval and integration difficult or impossible, or due to a combination of these conditions. The data are handled this way because they are being collected for disparate purposes—the VBA data being primarily associated with the actuarial documentation of the delivery of compensation

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PTSD Compensation and Military Service while the VHA data are used to fulfill its mission as a health care delivery network. The committee believes that an informed evaluation of the PTSD compensation system will not be possible until VA implements a comprehensive and integrated data collection, analysis, and publication effort. This effort should be focused on data useful to research, policy, and planning purposes. It will allow VA to: evaluate interrater reliability and generate information that can be used to promote the accuracy and validity of ratings; more easily determine whether examinations and benefits are being properly and consistently managed throughout the VA system; establish whether there are subsections of the population that differ in ways that require the particular attention of the system (such as the elderly, certain racial or ethnic groups, female veterans, those just returning from combat, those with relatively low or with high levels of disability, those with particular comorbidities, and the like); and, most importantly, evaluate what is working and what isn’t and determine where resources should be focused. More widely and systematically collecting data for research, policy, and planning purposes and assembling these data in more user-friendly forms will allow VA to better conduct the kinds of analyses needed to make informed decisions about the scope and magnitude of the problems that exist within the PTSD disability compensation system and the best approaches to addressing them, as well as to better project the resources needed to serve future veteran populations. 3. One cannot look at the effect of compensation in isolation. The VA offers a range of other services to veterans with service-related disabilities that is unmatched by civilian benefits systems. These veterans services include compensation, pension, comprehensive medical care, vocational rehabilitation, employment counseling, education and training, home loans, housing assistance, and other supports to veterans and their families.1 It is beyond the scope of this committee to make recommendations regarding the general conduct of the VA benefits and services program. However, the committee notes that a complete evaluation of the strategies for reducing disincentives and maximizing incentives for achieving optimal mental functioning would have to include an examination of the roles and coordination of all of these services. VA has some experience with a more integrated evaluation of veteran’s needs and delivery of services through VBA’s Vo- 1 More severely disabled veterans are eligible for additional and greater benefits, depending on the nature of their disability.

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PTSD Compensation and Military Service cational Rehabilitation and Employment Service. However, problems have been identified with this program (DVA, 2004) and coordination between VBA- and VHA-administered services is limited. There are currently no processes in place for individual case planning and management, integration of services, or evaluation of opportunities to provide incentives for improvement in health and function. Further, VA does not systematically collect the information needed to evaluate the effectiveness of their PTSD treatment programs and other benefits in promoting return to function. Having these data would facilitate the determination of the best ways to deploy the full spectrum of VA services to meet the needs of individual claimants. The IOM report A 21st Century System for Evaluating Veterans for Disability Benefits, which will be released in summer 2007, offers recommendations regarding a more integrated approach to the provision of benefits (IOM, 2007). In late summer 2007, a second IOM report on PTSD treatment will focus on this component of the benefits system. VA has the opportunity to adopt a broader vision of benefits provision and the committee believes that PTSD may be a good test case for an integrated benefits approach. In developing such an approach, one component might be a rethinking of the rules for access to VA mental-health care. The VA already offers some veterans access to their services without seeking or receiving a service connection2 and should evaluate the feasibility of expanding such access—decoupling the seeking of PTSD disability through the C&P system from some form of priority access to VHA-provided mental health services. To be sure, there are already capacity constraints on this system, but the committee believes that if it were possible to provide a path to treatment that did not involve C&P review, it would enhance opportunities for recovery and wellness. In conclusion, the committee is acutely aware that resource constraints—both funds and staff—limit the ability of VA to deliver services and force difficult decisions on allocations among vital efforts. It believes that increases in the number of veterans seeking and receiving disability benefits for PTSD, the prospect of a large number of veterans of OIF and OEF entering the system, and the profound impact of the disorder on the nation’s veterans make changes in PTSD C&P policy a priority deserving of special attention and action by the VA and the Congress. 2 For example, GAO (2006) notes that at present (late 2006) the VA offers no-cost access to all of its health-care services to OIF/OEF veterans for two years following their discharge or release from active duty. This includes out- and inpatient access to mental-health counseling, drug therapy, and education.

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PTSD Compensation and Military Service REFERENCES Arbisi PA. 2006. Issues and Barriers to Implementation of Best Practice Guidelines in Compensation and Pension Examinations. Presentation to the Committee on Veterans’ Compensation for Posttraumatic Stress Disorder, July 6, 2006. Washington, DC. Commission on Health and Safety and Workers’ Compensation. 1993. Evaluating the Reforms of the Medical-legal Process using the WCIRB Permanent Disability Survey. [Online]. Available: http://www.dir.ca.gov/CHSWC/med_legal/med_sum1.html [accessed January 31, 2007]. DVA (U.S. Department of Veterans Affairs). 2004. The Vocational Rehabilitation and Employment Program for the 21st Century Veteran: Report to the Secretary of Veterans Affairs. Washington, DC: Vocational Rehabilitation and Employment Task Force. [Online]. Available: www.va.gov/op3/docs/VRE Report.pdf [accessed December 8, 2006]. DVA. 2005. Review of State Variances in VA Disability Compensation Payments. Report No. 05-00765-137. Washington, DC: VA Office of the Inspector General. [Online]. Available: http://www.va.gov/oig/52/reports/2005/VAOIG-05-00765-137.pdf [accessed November 9, 2006]. GAO (Government Accountability Office). 2005. VA and DOD Health Care: Efforts to Coordinate a Single Physical Exam Process for Servicemembers Leaving the Military. GAO-05-64. Washington, DC: GAO. GAO. 2006. VA Health Care: Spending for Mental Health Strategic Plan Initiatives Was Substantially Less Than Planned. GAO-07-66. Washington, DC: GAO. IOM (Institute of Medicine). 2006. Posttraumatic Stress Disorder: Diagnosis and Assessment. Washington, DC: The National Academies Press. IOM. 2007 (forthcoming). A 21st Century System for Evaluating Veterans for Disability Benefits. Washington, DC: The National Academies Press. Watson P, McFall M, McBrine C, Schnurr PP, Friedman MJ, Keane T, Hamblen JL. 2002. Best Practice Manual for Posttraumatic Stress Disorder (PTSD) Compensation and Pension Examinations. [Online]. Available: http://www.avapl.org/pub/PTSD%20Manual%20final%206.pdf [accessed January 13, 2007].