5
The Medical Examination and Disability Rating Process

Processing claims for veterans disability compensation, including determining the ratings, is the responsibility of the Veterans Benefits Administration (VBA), one of the three major organizations within the Department of Veterans Affairs (VA).1 VA established VBA in 1953 (then called the Department of Veterans Benefits) to administer the GI Bill and the compensation and pension program.

VBA’s mission is “to provide benefits and services to the veterans and their families in a responsive, timely, and compassionate manner in recognition of their service to the nation” (VA, 2007e). According to VA’s strategic plan, disability compensation is part of strategic goal 1: “Restore the capability of veterans with disabilities to the greatest extent possible, and improve the quality of their lives and that of their families.” To achieve this goal, VA has set out specific program objectives in its strategic plan. The objective most relevant to the disability compensation program is objective 1.2: “Provide timely and accurate decisions on disability compensation claims to improve the economic status and quality of life of service-disabled veterans” (VA, 2006c).

Chapter 4 addressed the effectiveness of VA’s Schedule for Rating Disabilities (Rating Schedule) in assessing degree of disability for impairment purposes, with a particular focus on whether it is medically up to date and whether it is constructed appropriately to measure severity of impairment, limitation of function, quality of life, or extent of disability. This chapter

1

The other organizations are the Veterans Health Administration (VHA) and the National Cemetery Administration.



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A 21st Century System for Evaluating Veterans for Disability Benefits 5 The Medical Examination and Disability Rating Process Processing claims for veterans disability compensation, including determining the ratings, is the responsibility of the Veterans Benefits Administration (VBA), one of the three major organizations within the Department of Veterans Affairs (VA).1 VA established VBA in 1953 (then called the Department of Veterans Benefits) to administer the GI Bill and the compensation and pension program. VBA’s mission is “to provide benefits and services to the veterans and their families in a responsive, timely, and compassionate manner in recognition of their service to the nation” (VA, 2007e). According to VA’s strategic plan, disability compensation is part of strategic goal 1: “Restore the capability of veterans with disabilities to the greatest extent possible, and improve the quality of their lives and that of their families.” To achieve this goal, VA has set out specific program objectives in its strategic plan. The objective most relevant to the disability compensation program is objective 1.2: “Provide timely and accurate decisions on disability compensation claims to improve the economic status and quality of life of service-disabled veterans” (VA, 2006c). Chapter 4 addressed the effectiveness of VA’s Schedule for Rating Disabilities (Rating Schedule) in assessing degree of disability for impairment purposes, with a particular focus on whether it is medically up to date and whether it is constructed appropriately to measure severity of impairment, limitation of function, quality of life, or extent of disability. This chapter 1 The other organizations are the Veterans Health Administration (VHA) and the National Cemetery Administration.

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A 21st Century System for Evaluating Veterans for Disability Benefits addresses the process by which the Rating Schedule is applied, focusing on the timeliness, accuracy, and consistency of decisions on veterans claims. The key medical aspects of the disability claims process are development of medical evidence, such as information about degree of impairment, functional limitation, and disability, which usually includes a disability examination conducted by a VHA clinician or medical contractor; the rating process, in which the medical evidence is compared with the criteria in the Rating Schedule and a percentage rating is determined; and the appeal process, in which the adequacy and meaning of the medical evidence is often the central question. ORGANIZATION OF THE VETERANS BENEFITS ADMINISTRATION VBA is an organization of about 13,000 employees. Staffing in fiscal year (FY) 2006 was 12,810 full-time equivalents (FTEs) and is estimated to be 13,104 FTEs in FY 2007. Approximately half the staff (an estimated 6,425 in FY 2007) is directly devoted to administration of the disability compensation program (VA, 2007b). VBA has 57 regional offices, including at least one in every state in the nation (except Wyoming, which is served by the Denver, Colorado, regional office), as well as offices in Puerto Rico and the Philippines, and additional locations in Korea and Germany. Within VBA, the Compensation and Pension (C&P) Service administers the disability compensation program. C&P Service also administers the dependency and indemnity compensation, death compensation, disability pension, death pension, burial benefits, automobile allowance/adaptive equipment, clothing allowance, and specially adapted housing programs.2 Each regional office includes a veterans service center (VSC), which is the component that processes disability compensation claims. These centers function under a standardized structure called the claims process improvement (CPI) model, which was recommended in 2001 by the Claims Processing Task Force appointed by the VA secretary to address the growing backlog of claims.3 The model was designed to increase efficiency in 2 The other program components of VBA are the Vocational Rehabilitation, Education, Loan Guaranty, and Insurance Services. 3 These descriptions of the organization and structure of a VSC are based on information provided to the Institute of Medicine (IOM) staff by the Baltimore, Maryland, Regional Office, as well as VA’s Compensation and Pension Adjudication Procedure Manual, M21-1MR, Part III, Subpart I, Chapter 1. http://www.warms.vba.va.gov/admin21/m21_1/mr/part3/subpti/ch01.doc (accessed February 28, 2007).

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A 21st Century System for Evaluating Veterans for Disability Benefits processing compensation and pension claims and to reduce the number of errors. The model was fully implemented in 2002, and it established a consistent organizational structure and standard work processes across all regional offices.4 The model requires triage of incoming mail and analysis of incoming claims; emphasizes the importance of complete and accurate development of claims by veterans service representatives (VSRs) specially trained to do the work; and promotes specialization that improves quality and the expeditious handling of claims, while at the same time allowing management the flexibility to adjust resources to meet the demands of changing workload requirements. Specialized Team Structure Each VSC uses six separate teams specialized to handle specific steps in the compensation claim process. Public Contact Team The public contact team handles personal interviews and telephone inquiries. Team members assist walk-ins, answer telephones, answer routine correspondence (including e-mails), respond to veterans assistance inquiries, and address outreach and fiduciary issues. VSRs on the public contact team interview veterans and collect as much information as possible to complete a veteran’s claim. If the veteran provides a birth certificate and the master record indicates an award can be prepared immediately, a VSR on the public contact team can prepare the veteran’s award. If additional records are needed, such as from a VA medical center, or if the veteran was recently released from the military and his or her service medical records and separation examination are on record, the public contact team will forward the claim to the triage team. The public contact team’s regular outreach activities include contacts with veterans service organizations (VSOs), nursing homes, state fairs, stand-downs, and benefit clinics. Personnel on the public contact team include a coach (GS-13); assistant coach (GS-12); VSR (rotational) (GS-11); 4 Prior to this, regional offices had more latitude to vary their organization and procedures.

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A 21st Century System for Evaluating Veterans for Disability Benefits public contact and outreach specialist (GS-10); public contact specialist (GS-9); field examiner (GS-10); legal instrument examiner (GS-9); and intake specialist (GS-7). One of the primary objectives of the public contact team is to promote a bilateral exchange of information with the triage team. Triage Team The triage team helps coordinate the work of the other specialized teams. Team members review, control, and process all incoming mail. They also process actions that can be completed with little or no review of the claim folder. Personnel in the triage team include a coach (GS-13); assistant coach (GS-12); rating VSR (GS-12); senior VSR (GS-12); VSR (GS-11); claims assistant (GS-6); file bank coach (GS-6); and file clerk/program clerk (GS-4). Predetermination Team The predetermination team’s primary role is to develop evidence necessary for a rating to be made. This team is responsible for most of the medical development activity in the following cases: original and reopened compensation; compensation claimed due to injury or death caused by VA medical care or evaluation; original and reopened disability pension; original and reopened dependency and indemnity compensation (DIC); and basic eligibility issues requiring a rating decision. Staff on the team also prepare administrative decisions, including decisions on

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A 21st Century System for Evaluating Veterans for Disability Benefits character of discharge; line of duty; willful misconduct; deemed valid marriage (death claims); and common law marriage (live claims). Personnel in the predetermination team are the same as in the triage team. Rating Team5 The rating team makes decisions on claims that require consideration of medical evidence. Rating VSRs (RVSRs) on the rating team rate claims that have been certified by the predetermination team as “ready to rate.” They may prepare a rating for partial grant if there is insufficient evidence to rate all of a veteran’s medical conditions (referred to as issues), but there is sufficient evidence to make an award on one or more issues. In such a case, the rating specialist rates the issue(s) ready to be rated, prepares a separate deferred rating for the unresolved issues, and returns the claims file to the predetermination team for further development. Personnel on the rating team include a coach (GS-13); assistant coach (GS-12); RVSR (GS-12); and claims assistant (GS-6). Postdetermination Team The postdetermination team develops evidence for non-rating issues, processes awards, and notifies claimants of decisions. This team also completes entitlement determinations for issues that do not require a rating, such as accrued benefits; apportionment decisions; competency issues; income changes; original pension; dependency issues; burials; 5 The rating process, which involves the interpretation and application of VA’s Schedule for Rating Disabilities, is described in more detail later in this chapter.

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A 21st Century System for Evaluating Veterans for Disability Benefits death pension; hospital adjustments; specially adapted housing; and the Civilian Health and Medical Program. Personnel on the postdetermination team include a coach (GS-13); assistant coach (GS-12); senior VSR (GS-12); VSR (GS-11); and claims assistant (GS-6). Appeals Team The appeals team handles decisions with which claimants have formally disagreed (i.e., appealed). The appeals team processes both appeals submitted by veterans and cases returned by the Board of Veterans’ Appeals (BVA) for further development, called remands. The appeals team is also responsible for development of remands, which may involve returning the case to VHA for a medical examination or opinion and for making a decision on the basis of the additional information. If the adjudicator reaffirms the original denial of the case, the case is sent back to BVA for review and decision. The team is intended to increase the level of accountability and maintain control over the appeal workload. Personnel on the appeals team include a coach (GS-13); decision review officer (GS-13); senior VSR (GS-12); RVSR (GS-12); VSR (GS-11); claims assistant (GS-6); and file clerk/program clerk (GS-4). Role of the VSR and RVSR VSRs on the public contact, triage, predetermination, postdetermination, and appeals teams perform a vital role in the compensation claim adjudication process. They conduct interviews, identify issues, gather relevant evidence, adjudicate certain claims, authorize payments, and input data for award generation and notification of the veteran. However, the key staff person in the actual disability rating is the RVSR, who is on the

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A 21st Century System for Evaluating Veterans for Disability Benefits rating team. The rating team and the disability rating produced by that team is the central component of the veterans disability compensation claims process.6 The RVSR serves as the decision maker for most claims involving rating decisions. He or she analyzes claims, applies the Rating Schedule, and prepares rating decisions that inform the VSR or claimant of the decision and the basis for the decision. There is routine collaboration between the RVSR and the other members of a given team, which includes VSRs and the decision review officer (DRO). The RVSR is also available to discuss claims with VSO representatives. In addition, the RVSR may directly interact with the veteran and his or her representative or advocate. An RVSR is required to analyze claims to determine if diseases and injuries were incurred or aggravated by military service in the line of duty for purposes of compensation, hospital and outpatient treatment, provision of prosthetics, vocational training, and related employment and compensation benefits; a need for examination, reexamination, and hospitalization for observation of veterans and their dependents and the character of these examinations; and the competency of veterans, their dependents, and beneficiaries, and the permanent incapacity of a veteran’s children or widow or widower for self-support, as well as testamentary capacity for insurance purposes. As needed, the RVSR may ask the VSR to initiate action to obtain evidence needed to support a veteran’s claim. In some cases, the RVSR monitors the claim to eliminate unnecessary delays. The RVSR determines service connection; percentage of disability; permanent and total disability; entitlement to compensation, pension, and vocational training; medical and dental treatment; automobiles or other conveyances; insurance; specially adapted housing; dependent education allowances; and other ancillary benefits. 6 There are also RVSRs on the triage and predetermination teams because those teams perform a limited number of the ratings in certain circumstances and also assess whether the medical evidence is sufficient to support a rating decision.

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A 21st Century System for Evaluating Veterans for Disability Benefits He or she is fully accountable for proper analysis, appropriate development, proper application of the Rating Schedule, and final rating determinations.7 MEDICAL EVALUATION PROCESS Claims for disability compensation are initiated when a veteran files an application, either online or at a regional office. VA rules require that “[a] specific claim in the form prescribed by the Secretary must be filed in order for benefits to be paid to any individual under the laws administered by VA.”8 However, any communication or action indicating an intent to apply for benefits from a claimant or his or her representative may be considered an informal claim.9 In 1998, VA and the Department of Defense (DoD) established a program called Benefits Delivery at Discharge (BDD) to help servicemembers initiate a disability compensation claim at their military bases prior to being discharged. The program is in effect in 140 locations in the United States, Korea, and Germany. It currently operates under a 2004 memorandum of agreement between VA and DoD to create a cooperative separation medical examination process to ease the transition from service to veteran status. The BDD program “enables separating service members to file disability compensation claims with VA staff at military bases, complete physical exams, and have their claims evaluated before, or closely following, their military separation” (U.S. Congress, House of Representatives, Committee on Veterans’ Affairs, 2007a). In FY 2006, 40,600 claims were filed through the BDD program (about 5 percent of the compensation claims for that year) (VDBC, 2007). BDD sites took in 30,000 claims in FY 2004 and 35,000 in FY 2005 (U.S. Congress, House of Representatives, Committee on Veterans’ Affairs, 2005c). VA reports that the BDD process reduces the average time for an adjudication decision to approximately 60 days (compared with 160–180 days for processing regular claims) (U.S. Congress, Senate, Committee on Veterans’ Affairs, 2007). VA’s goal is to have 65 percent of the original claims made by veterans within the first year after release from active duty filed at a BDD site (the actual percentage in FY 2006 was 50 percent) (VA, 2006). In 2005, VBA consolidated the rating of BDD claims in two regional offices to “bring greater consistency of decisions on claims filed by newly separated veterans” (U.S. Congress, House of Representatives, Committee on Veterans’ Affairs, 2005a). 7 Based, in part, on Position Description, Veteran Service Representative (Rating), RFSR, GS-996-12. 8 38 USC 5101(a) and 38 CFR 3.151. 9 38 CFR 3.155.

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A 21st Century System for Evaluating Veterans for Disability Benefits In addition to BDD, which is not available to wounded or injured servicemembers being considered for separation for inability to perform their duties, DoD provides VA a monthly list of servicemembers referred to a physical evaluation board by a medical evaluation board.10 The list enables VA to contact servicemembers likely to be separated while they are still in the service to facilitate their transfer to VA health care and benefits when they separate. In spinal cord injury cases, DoD and VA have a memorandum of understanding under which active duty servicemembers can be treated in VHA’s specialized spinal cord injury centers. More recently, a similar arrangement was made for treatment of traumatic brain injury (TBI) and polytrauma cases in VHA’s TBI and polytrauma centers. As of the end of FY 2006, DoD had sent VA contact information for 13,622 individuals (U.S. Congress, Senate, Committee on Veterans’ Affairs, 2007). On receipt of a “substantially complete application” (which includes the claimant’s name, his or her relationship to the veteran, sufficient service information for VA to verify the veteran’s service and claimed medical condition or conditions), VA will begin to process the claim. In accordance with the Veterans Claims Assistance Act (VCAA) of 2000, VA has a “duty to assist” the claimant. VA must give the claimant written notification of the evidence necessary to substantiate the claim. It must also tell the claimant whether VA or the claimant is responsible for obtaining that evidence. VA must make reasonable efforts to obtain relevant records not in the custody of the federal government, and it must make as many requests as necessary to obtain relevant records within the custody of federal departments or agencies, including the veteran’s service medical records and VA records of examination or treatment. However, VA encourages applicants to submit copies of their own medical records to expedite the claim (Box 5-1). The evidence development phase of disability claims processing is often the most time-consuming part of the entire process. Multiple requests may be necessary to obtain needed information. This phase of the claims process is managed by the predetermination team in the VSC. The team sets diaries (deadline dates) for receipt of requested information, then determines the need for a VA medical examination to assess the current level of disability or to provide a medical opinion about whether the current disability is related to the veteran’s military service (referred to as “medical nexus”). 10 As part of DoD’s disability evaluation system, medical evaluation boards refer individuals deemed unable to carry out their duties to a physical evaluation board, which usually results in separation from service.

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A 21st Century System for Evaluating Veterans for Disability Benefits BOX 5-1 Excerpt from VA Publication: Understanding the Disability Claim Process What VA Does After It Receives Your Claim After VA receives your Application for Compensation, it sends you a letter. The letter explains what VA needs in order to help grant your claim. It states how VA assists in getting records to support your claim. The letter may include forms for you to complete, such as medical releases. They help VA obtain pertinent medical records from your doctor or hospital. You should try to complete and return all forms VA sends within a month. Your claim can often be processed more quickly if you send a copy of your own medical records. What Records VA Obtains to Support Your Claim VA then attempts to get all the records relevant to your claimed medical conditions from the military, private hospitals or doctors, or any other place you tell us. The person who decides your claim (called a Rating Veterans Service Representative) may order a medical examination. This examination is free of charge. It is extremely important that you report for your examination at the scheduled time to avoid delaying your claim. SOURCE: VA (2007f). Compensation and Pension Examinations According to VA, “The purpose of C&P examinations is to provide the medical information needed to reach a legal decision about a veteran’s entitlement to VA monetary benefits based on disability” (Brown, 2003). Obtaining a C&P medical examination is part of VA’s duty to assist the applicant. An examination is required when a veteran files a claim for service connection and submits evidence of disability; when a service-connected veteran asserts a worsened condition; to provide medical nexus; to reconcile diagnoses; as directed by BVA; and as required by regulation (Pamperin, 2006).

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A 21st Century System for Evaluating Veterans for Disability Benefits VA may accept a medical report from a private physician if it is “adequate for rating purposes.”11 However, C&P examinations are ordered in most disability compensation claims for several reasons: to obtain current medical information; to obtain information relevant to disability (such as functional impacts of an impairment) rather than the diagnostic and treatment information sought in a standard medical examination; and to have information from someone more independent than the applicant’s treating physician might be. In FY 2005 VA obtained more than a half million C&P examinations. VHA performed 84 percent of these examinations in its own medical facilities, and the remaining 16 percent were obtained from a contract examination provider (QTC, 2006). Examinations from VHA generally take about 35 days to complete, and those from the contract provider take about 38 days (Pamperin, 2006). Generally, the predetermination team in the regional office’s VSC determines the kind of examination needed based on the available medical records and uses one or more of 58 examination worksheets (referred to as AMIE worksheets, after the Automated Medical Information Exchange system for which they were originally developed in 1997) to describe for the examiner the specific requirements of the examination. There are separate worksheets for specific diagnoses (e.g., diabetes mellitus, hypertension, cold injury, posttraumatic stress disorder [PTSD]) and for certain body systems (e.g., eye, genitourinary, dental and oral, mental, hemic disorders). There is one sheet for a general medical examination. Although there are 58 different examination worksheets, the 10 most frequently requested examinations account for 67 percent of C&P exams (Brown, 2006b) (Table 5-1). The first 57 examination worksheets were last thoroughly revised (by a workgroup with representation from VHA, VBA, and BVA) when they were incorporated in the AMIE system in 1997. Using the AMIE system, they can now be downloaded by examiners in the VA medical centers. The 58th worksheet, for social and industrial assessments surveys, was added in 2004, and the diabetes mellitus worksheet was updated the same year. In 2005, the worksheets for eating disorders; initial evaluation of PTSD; review examination for PTSD; joints; mental disorders except PTSD and eating disorders; nose, sinus, larynx, and pharynx; prisoner of war (POW) protocol examinations; and spine were updated (VA, 2007d). In 2002, another VHA/VBA/BVA workgroup developed the C&P Service Clinician’s Guide (VA, 2002a). The guide includes the worksheets and 11 38 CFR 3.326, “Examinations.”

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A 21st Century System for Evaluating Veterans for Disability Benefits Use of the Examination Templates VA does not require examiners to use printed-out examination worksheets and, consequently, many examiners do not use them. Although use of the online examination templates has increased rapidly (presumably because of their ease of use), VA also does not require their use—although it is considering such a mandate. In an October 2005 report on C&P examinations, VA’s inspector general noted progress being made in developing the templates, but expressed concern about their limited use: While VA, through the development and implementation of CPEP report templates, is making an effort to standardize C&P medical examinations, use of the templates is not yet required of VHA facilities. VBA rating personnel have seen only a limited number of examination reports submitted in the template format. We spoke with personnel at seven VAROs [VA regional offices] and were informed that use of the templates at VHA facilities is not yet common. VSC personnel at five of the seven VAROs indicated that they either have not seen any examination reports completed in the template format or they have only seen a limited number completed by one medical center in their area. Use of the templates was more frequent at medical centers serving the other two VAROs. Rating personnel at two VAROs who have seen the results of C&P examinations presented in the template format stated that they believed the examination reports need to be improved and that it was difficult to locate the information needed for rating purposes. According to VBA management, they are engaged in an effort to review and approve the report templates (VA, 2005b:69). In the same report, the inspector general went on to recommend that the examination report templates be made mandatory, and that VA needed to ensure that medical and rating staff are familiar with the templates and that they are used consistently. The VA undersecretary for benefits concurred with this recommendation, and stated: We will continue to work with the Veterans Health Administration to improve the quality of medical examinations performed to support disability compensation evaluations. We will work with the CPEP Office to ensure that all automated examination report templates thoroughly and accurately solicit the medical evidence needed to consistently evaluate the disability. We will also work with VHA to establish a formal approval process for the templates and to obtain agreement on the mandatory use of approved templates (VA, 2005b:189). By June 2006, more than 128,000 examinations had been completed using the report templates, but they were still not mandatory, despite the fact that early results had shown template examination reports to have

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A 21st Century System for Evaluating Veterans for Disability Benefits higher quality than dictated reports, often significantly. In addition, template reports were released from 7 to 17 days sooner than dictated reports. “High-level” discussions were still underway within VA about whether to mandate use of the templates (Brown, 2006b,c). Recommendation 5-2. VA should mandate the use of the online templates that have been developed for conducting and reporting disability examinations. Assessing and Improving Quality and Consistency of Examinations As noted previously, VA established CPEP in 2001 to develop and administer a QR program, and it has integrated the QR results into the performance plans of the VISN directors. Improvement in meeting the quality indicators has been rapid since 2002 when the effort began. The percentage of examinations meeting 90 percent of the quality indicators was 86 percent in January 2007, much better than the 58 percent achieved three years earlier. However, this percentage is still too low. Another concern is that the quality indicators used in the QR process are more procedural rather than substantive. They are measures of the presence or absence of a particular worksheet item in the report, not of whether the examination was good. Independent examinations of a sample of claimants to assess inter-rater reliability are not performed. Recently, CPEP began to assess the quality of the examination requests, which is critical. Previously, if the examiner provided 100 percent of the information requested, but the request was not correct, the QR system counted it as a quality examination. The next step would be for VA to make the quality of examination requests part of the performance program for predetermination teams and regional office directors. In addition, the QR program currently does not directly assess consistency among examiners. It relies on improving accuracy to narrow the differences among examiners and VISNs. Recommendation 5-3. VA should establish a recurring assessment of the substantive quality and consistency, or inter-rater reliability, of examinations performed with the templates, and if the assessment finds problems, take steps to improve quality and consistency, for example, by revising the templates, changing the training, or adjusting the performance standards for examiners. This substantive assessment should be part of the QR audit and include a mechanism for random sampling. The training program should include examples of well-done and complete reports.

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A 21st Century System for Evaluating Veterans for Disability Benefits The Rating Process Quality of Rating Decisions VBA’s QR program, STAR, was implemented in 1998 and substantially revised and expanded to monitor individual regional office accuracy in 2001. The accuracy rate has improved from 64 percent in 1998 to 80 percent in FY 2002, and to 88 percent in FY 2006. Although this represents substantial improvement, it still shows that one of every nine rating decisions is incorrect, and this leaves considerable room for further improvement. In addition, the STAR accuracy rate is based on a relatively small sample—only large enough to determine the aggregate accuracy rate of regional offices. It does not assess accuracy at the body system or diagnostic code level, and it does not measure consistency across regional offices. In 2005, in response to findings of inconsistencies by GAO and VA’s Office of Inspector General, VBA announced an effort to identify high rates of variability in claims adjudication by diagnostic code, to be followed by an assessment of decision consistency among and between regional offices for those conditions. The results would be used to identify needs for additional training, better guidance, procedural changes, or regulatory changes (U.S. Congress, House of Representatives, Committee on Veterans’ Affairs, 2005a).31 In 2005, VBA chose three conditions to assess for inconsistency: hearing loss, PTSD, and knee conditions. Ten subject-matter specialists were assigned to review 1,750 regional office decisions, followed by studies of additional conditions. These analyses were not made public. According to VA’s latest strategic plan VA will analyze ratings and claims data to track any unusual patterns of variance for further consistency review. Integrated systems and better data sharing will improve the quality of decision making by providing more accurate information to claims adjudicators. We will also develop systems and programs to evaluate employees’ information needs and deliver training to address those needs (VA, 2006c). There are many sources of variability in decision making that, if not addressed and reduced to the extent possible, make it unlikely that veterans 31 In 2007, VA’s deputy under secretary for benefits made a similar statement: “We are also identifying unusual patterns of variance in claims adjudication by diagnostic code, and then reviewing selected disabilities to assess the level of decision consistency among and between regional offices. These studies are used to identify where additional guidance and training are needed to improve consistency and accuracy, as well as to drive procedural or regulatory changes. Site surveys of regional offices also address compliance with procedures” (U.S. Congress, House of Representatives, Committee on Veterans’ Affairs, 2007b).

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A 21st Century System for Evaluating Veterans for Disability Benefits with similar disabilities are being treated the same. VA should identify conditions subject to a great deal of decision variability, understand the reasons for the variability, and act to reduce that variability. Variability cannot be totally eliminated in evaluating most disabling conditions. There will be cases in which raters with the same information and criteria reach different conclusions, especially conditions with large subjective elements such as mental disorders and back pain. Still, sources of variability that can be controlled, such as training, guidelines, and rater qualifications, should be addressed. Recommendation 5-4. The rating process should have built-in checks or periodic evaluations to ensure inter-rater reliability as well as the accuracy and validity of rating across impairment categories, ratings, and regions. For example, VA could have a sample of claims rated by two or more RVSRs and analyze the degree of consistency in the ratings given. Or the same claims could be analyzed by RVSRs using standard procedures and information sources and by raters with access to medical advisers, and the results compared to assess whether having medical advisers for raters improves decision making. A comparison of raters with a medical background, such as nurses and physician assistants, and raters without medical backgrounds would inform decisions about the qualifications of raters. These comparisons could be done using hypothetical or actual cases. BVA might do the same with appeals. VA could sample claims involving the rating of a particular diagnostic code across field offices and analyze inter-rater and inter-regional differences. Presumably these would be diagnostic codes of conditions that are relatively numerous or costly. A next step could be to determine the degree to which regulations, the adjudication manual, and other forms of guidance could be revised to reduce variability, or training or the QR system could increase consistency. Another approach to reducing unwanted variability in the rating process is the use of best practices. The adoption of the CPI model by all regional offices in 2001–2002 is an example of this approach, but there is still evidence of considerable variation across regional offices in decision outcomes, such as grant rates, rating levels, and rates of appeals. VA should study these variations and identify best practices for all offices to adopt. Better Access to Medical Expertise In some cases, disability evaluators can use an authoritative medical finding, such as a particular test score of a certain degree, to make a rating

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A 21st Century System for Evaluating Veterans for Disability Benefits decision. In most cases, however, the evidence is less direct, more complex, and perhaps conflicting. The evaluator must understand the medical evidence and use judgment, for example, in weighing conflicting medical opinions. The evaluators are not usually medical professionals themselves. Other major disability programs either involve physicians or other appropriate clinicians in the adjudication decision or have medical experts readily available to review cases, for example, to interpret medical information for disability evaluators or advise on missing information that should be requested (see Appendix D). These are in addition to arrangements for independent medical examinations where needed to provide missing or inconsistent medical information. For example, Social Security disability determinations are generally made by two-person teams, one member of which is a physician or other appropriate medical professional (e.g., audiologist). At DoD, physical evaluation boards—which also use and apply the VA Rating Schedule—have at least one physician among the three members. The Federal Employee Compensation Act program and civil service disability retirement programs have physician consultants on staff. Private disability insurance carriers have a variety of arrangements to provide disability evaluators with advice. The separation between medical examiners and rating specialists at VA is artificial and based on a misunderstanding of the role of physicians in adjudication. The U.S. Court of Appeals for Veterans Claims barred the participation of physicians in rating decisions on the grounds that they should not substitute their own clinical judgment because they represent the agency. In fact, the role of a physician-adjudicator differs from that of a physician performing a disability examination. They do not examine the claimant. They evaluate the evidence in the claimant’s file to confirm that a diagnosis was made and is adequately documented, weigh conflicting evidence in the medical records, and apply other aspects of the adjudication process. RVSRs can probably adjudicate many or most cases without physician involvement, but physician advice is helpful in complex cases. The Social Security Administration experimented successfully with having disability evaluators decide cases alone and only bring in medical consultants when, in their judgment, they needed the expert advice. Currently, RVSRs do not have readily available medical consultants. If there is a question, they have to send the case back to VHA, which adds time to the process. VBA should have medical consultants accessible to RVSRs in the regional office VSCs. With modern communications technology, these consultants could be in a national or in regional centers, and have access to the claims file, the C&P examination report, and VA medical records, if any. This would not obviate the need for C&P examinations but would expedite the adjudication decision process.

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A 21st Century System for Evaluating Veterans for Disability Benefits Recommendation 5-5. VA raters should have ready access to qualified health-care experts who can provide advice on medical and psychological issues that arise during the rating process (e.g., interpreting evidence or assessing the need for additional examinations or diagnostic tests). These health-care experts could come from VHA or outside contractors, or VBA could hire health-care providers to serve on its own staff. If they were VHA staff, arrangements would have to be made to ensure that the C&P examiner of a veteran was also not the consultant on his or her case, and training on the appropriate adjudication consultant role would have to be provided. Training of Examiners and Adjudicators VA is well along in developing a training and certification program for C&P medical examiners, and it is scheduled to be developed during FY 2007 and deployed during FY 2008. It is to be mandatory, although a date by which examiners must be certified has not yet been set. VBA has also developed an extensive training program for case adjudicators. This is critical because VBA hired approximately 1,180 new VSRs and RVSRs in FY 2006, and plans to hire many more in FY 2007 and FY 2008 to make up for attrition and to meet the increase in caseload (VA, 2006a). A centralized two-week training course is given every quarter to new VSRs. This is followed by a national standardized training 23-week curriculum given at their home regional offices, which includes full lesson plans, handouts, student guides, instructor guides, and slides for classroom instruction. Newly-hired RVSRs are also provided a nationally consistent training program. VBA gives a week-long instructor development course to trainers in the regional offices. A computer-based training program, the Training and Performance Support System, has a set of modules on rating-related topics, including evaluation of disability conditions by body system. BVA also has an extensive training program, part of which is given by an on-staff medical adviser, a physician who also acts as an informal adviser to VLJs and counsel in a role somewhat like the medical consultant role recommended in Recommendation 5-4. The QR programs of both VBA and BVA are used to identify training needs, whether on particular topics or at particular regional offices. In FY 2006, the VA under secretary for benefits directed regional offices to provide all claims adjudicators with a mandatory 70 hours of job-specific training, increasing to 80 hours in FY 2007 (U.S. Congress, House of Representatives, Committee on Veterans’ Affairs, 2006). VBA is not evaluating the effectiveness of its training programs, however. VBA has developed a certification program for VSRs and plans to

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A 21st Century System for Evaluating Veterans for Disability Benefits extend it to RVSRs and DROs. The test was developed and validated for VBA by the Human Resources Research Organization (HumRRO), a national nonprofit organization that specializes in certification testing. As of September 2006, VBA had promoted 633 VSRs to the GS-11 level through the certification testing process. It is working with HumRRO on a test for the GS-12 RVSR position (U.S. Congress, House of Representatives, Committee on Veterans’ Affairs, 2006). Recommendation 5-6. Educational and training programs for VBA raters and VHA examiners should be developed, mandated, and uniformly implemented across all regional offices with standardized performance objectives and outcomes. These programs should make use of advances in adult education techniques. External consultants should serve as advisors to assist in the development and evaluation of the educational and training programs. REFERENCES Brown, S. H. 2003. Presentation on CAPRI C&P worksheet module. VHA eHealth University class #145, May 14. http://www.vehu.med.va.gov/vehu/campcprs2003/ SessionCaptures/Hands-On/145/145_files/frame.htm (accessed March 15, 2007). Brown, S. H. 2006a. Overview of CPEP and quality assurance improvement initiatives for C&P exams. Presentation to the IOM Committee on Medical Evaluation of Veterans for Disability Compensation, Washington, DC, May 25. Brown, S. H. 2006b. Compensation and pension examination program overview. Presentation to the Veterans’ Disability Benefits Commission, Washington, DC. http://www.1888932-2946.ws/vetscommission/e-documentmanager/gallery/ Documents/June_2006/CPEPBriefing_June2006.pdf (accessed March 2, 2007). Brown, S. H. 2006c. Examiner certification and exam templates update. Presentation to the Veterans’ Disability Benefits Commission, Washington, DC. http://www.1888932-2946.ws/vetscommission/e-documentmanager/gallery/Documents/September_2006/CPEP_Presentation_09-15-2006.pdf (accessed March 16, 2007). Brown, S. H. 2007. Written response to IOM request for most recent information on quality review of compensation and pension examinations, use of online examination templates, and training and certification of examiners, attached to April 9, 2007, e-mail from Steven H. Brown, director, VA Compensation and Pension Examination Program. BVA (Board of Veterans’ Appeals). 1994. FY 1994 report of the chairman, Board of Veterans’ Appeals. Washington, DC: BVA. http://www.va.gov/Vetapp/ChairRpt/ BVA1994AR.pdf (accessed March 16, 2007). BVA. 1996a. FY 1995 report of the chairman, Board of Veterans’ Appeals. Washington, DC: BVA. http://www.va.gov/Vetapp/ChairRpt/BVA1995AR.pdf (accessed March 16, 2007). BVA. 1996b. FY 1996 report of the chairman, Board of Veterans’ Appeals. Washington, DC: BVA. http://www.va.gov/Vetapp/ChairRpt/BVA1996AR.pdf (accessed March 16, 2007). BVA. 1997. FY 1997 report of the chairman, Board of Veterans’ Appeals. Washington, DC: BVA. http://www.va.gov/Vetapp/ChairRpt/BVA1997AR.pdf (accessed March 16, 2007). BVA. 2000a. Understanding the appeal process. VA Pamphlet 01-00-1. http://www.va.gov/vbs/bva/y2000.pdf (accessed February 28, 2007).

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A 21st Century System for Evaluating Veterans for Disability Benefits BVA. 2000b. FY 2000 report of the chairman, Board of Veterans’ Appeals. Washington, DC: BVA. http://www.va.gov/Vetapp/ChairRpt/BVA2000AR.pdf (accessed March 16, 2007). BVA. 2001. FY 2001 report of the chairman, Board of Veterans’ Appeals. Washington, DC: BVA. http://www.va.gov/Vetapp/ChairRpt/BVA2001AR.pdf (accessed March 16, 2007). BVA. 2002a. How do I appeal? VA Pamphlet 01-02-02A. http://www.va.gov/vbs/bva/0102A.pdf (accessed February 28, 2007). BVA. 2002b. FY 2002 report of the chairman, Board of Veterans’ Appeals. Washington, DC: BVA. http://www.va.gov/Vetapp/ChairRpt/BVA2002AR.pdf (accessed March 16, 2007). BVA. 2003. FY 2003 report of the chairman, Board of Veterans’ Appeals. Washington, DC: BVA. http://www.va.gov/Vetapp/ChairRpt/BVA2003AR.pdf (accessed March 16, 2007). BVA. 2004. FY 2004 report of the chairman, Board of Veterans’ Appeals. Washington, DC: BVA. http://www.va.gov/Vetapp/ChairRpt/BVA2004AR.pdf (accessed March 16, 2007). BVA. 2005. FY 2005 report of the chairman, Board of Veterans’ Appeals. Washington, DC: BVA. http://www.va.gov/Vetapp/ChairRpt/BVA2005AR.pdf (accessed March 16, 2007). BVA. 2006. FY 2006 report of the chairman, Board of Veterans’ Appeals. Washington, DC: BVA. http://www.va.gov/Vetapp/ChairRpt/BVA2006AR.pdf (accessed March 16, 2007). BVA. 2007. Data from the Veterans Appeals Control and Locator System on the disposition of claims by regional office during FY 2005, provided by BVA. Congressional Commission (Congressional Commission on Servicemembers and Veterans Transition Assistance). 1999. Final report of the Congressional Commission on Servicemembers and Veterans Transition Assistance. http://www.vetbiz.gov/library/Transition%20Commission%20Report.pdf (accessed March 16, 2007). GAO (General Accounting Office). 2001. Veterans’ benefits: Quality assurance for disability claims processing. GAO-01-930R. http://www.gao.gov/new.items/d01930r.pdf (March 15, 2007). GAO. 2002a. Veterans’ benefits: Quality assurance for disability claims and appeals processing can be further improved. GAO-02-806. http://www.gao.gov/new.items/d02806.pdf (accessed February 28, 2007). GAO. 2002b. Veterans’ benefits: Despite recent improvements, meeting claims processing goals will be challenging. GAO-02-645T. http://www.gao.gov/new.items/d02645t.pdf (accessed March 15, 2007). GAO. 2005a. Veterans benefits: VA needs plan for assessing consistency of decisions. GAO-05-99. http://www.gao.gov/new.items/d0599.pdf (accessed March 15, 2007). GAO. 2005b. Veterans’ disability benefits: VA could enhance its progress in complying with court decision on disability criteria. GAO-06-46. http://www.gao.gov/new.items/d0646.pdf (accessed March 15, 2007). GAO. 2005c. VA disability benefits: Board of Veterans’ Appeals has made improvements in quality assurance, but challenges remain for VA in assuring consistency. GAO-05-655T. http://www.gao.gov/new.items/d05655t.pdf (accessed February 28, 2007). GAO. 2006. VA disability benefits: Routine monitoring of disability decisions could improve consistency. GAO-06-120T. http://www.gao.gov/new.items/d06120t.pdf (accessed March 15, 2007). GAO. 2007. Veterans’ disability benefits: Long-standing claims processing challenges persist. GAO-07-512T. http://www.gao.gov/new.items/d07512t.pdf (accessed May 28, 2007). Keller, S. 2007. Written response to IOM request for information on BVA sources of medical expertise and statistics on reasons for remands, attached to March 21, 2007, e-mail from Steve Keller, senior deputy vice chairman, Board of Veterans’ Appeals. Mansfield, G. H. 2005. Letter to Cynthia A. Bascetta, director, Education, Workforce and Income Security Issues, GAO. GAO-06-46. http://www.gao.gov/new.items/d0646.pdf (accessed March 15, 2007).

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A 21st Century System for Evaluating Veterans for Disability Benefits NAPA (National Academy of Public Administration). 1997. Management of compensation and pension benefits claim processes for veterans. Washington, DC: NAPA. Pamperin, T. 2006. Overview of disability compensation and pension examinations. Presentation to Veterans’ Disability Benefits Commission. http://www.1888932-2946.ws/vetscommission/e-documentmanager/gallery/Documents/June_2006/VBAPresentation_6-21-06.pdf (accessed March 2, 2007). QTC. 2006. QTC exam process and demo. Presentation to the Veterans’ Disability Benefits Commission. http://www.1888932-2946.ws/vetscommission/e-documentmanager/gallery/Documents/June_2006/QTCOverview_June2006.pdf (accessed March 2, 2007). Shahani, M. 2005. QTC medical services overview. Presentation to VA’s Advisory Committee on Women Veterans. http://www.va.gov/womenvet/docs/ACWV_Nov._05_meeting_web_version.doc (accessed September 5, 2006). Terry, J. P. 2006a. Briefing for the Institute of Medicine. Presentation to the IOM Committee on Medical Evaluation of Veterans for Disability Compensation, Washington, DC, July 7. Terry, J. P. 2006b. Prepared statement of James P. Perry, Chairman, Board of Veterans’ Appeals, before the Veterans’ Disability Benefits Commission. Washington, DC, January 20. http://www.1888932-2946.ws/vetscommission/e-documentmanager/gallery/Documents/January_2006/Statement_Terry_BVAChairman_Jan06.pdf (accessed February 28, 2007). Terry, J. P. 2007. Statement before the Committee on Veterans’ Affairs, U.S. Senate, March 7, 2007. http://veterans.senate.gov/index.cfm?FuseAction=Hearings.CurrentHearings&rID=943&hID=250 (accessed March 15, 2007). U.S. Congress, House of Representatives, Committee on Veterans’ Affairs. 2005a. Prepared statement of Ronald R. Aument, Deputy Under Secretary for Benefits, VA. 109th Cong., 1st Sess., December 7. http://veterans.house.gov/hearings/schedule109/dec05/12-7-05/raument.html (accessed March 5, 2007). U.S. Congress, House of Representatives, Committee on Veterans’ Affairs. 2005b. Prepared statement of Steven H. Brown, Director, Compensation and Pension Examination Program, VA, on compensation and pension examination variability. 109th Cong., 1st Sess., October 20. http://www.va.gov/OCA/testimony/hvac/sdama/051020SB.asp (accessed March 15, 2007). U.S. Congress, House of Representatives, Committee on Veterans’ Affairs. 2005c. Statement of Gordon H. Mansfield, Deputy Secretary, VA. 109th Cong., 1st Sess., September 28. http://veterans.house.gov/hearings/schedule109/sep05/9-28-05/gmansfield.pdf (accessed March 5, 2007). U.S. Congress, House of Representatives, Committee on Veterans’ Affairs. 2005d. Testimony of Michael Walcoff, Associate Deputy Under Secretary for Field Operations, Veterans Benefits Administration. 109th Cong., 1st Sess., May 5. http://www.va.gov/OCA/testimony/hvac/sdama/050505MW.asp (accessed May18, 2007). U.S. Congress, House of Representatives, Committee on Veterans’ Affairs. 2006. Prepared testimony of Michael Walcoff, Associate Deputy Under Secretary for Field Operations, Veterans Benefits Administration, VA. 109th Cong., 2nd Sess., September 13. http://veterans.house.gov/hearings/schedule109/sep06/9-13-06/MichaelWalcoff.html (accessed May 22, 2007). U.S. Congress, House of Representatives, Committee on Veterans’ Affairs. 2007a. Testimony of R. James Nicholson, Secretary of Veterans Affairs. 110th Cong., 1st Sess., February 8. http://veterans.house.gov/hearings/schedule110/feb07/02-08-07/JamesNicholson.html (accessed March 1, 2007). U.S. Congress, House of Representatives, Committee on Veterans’ Affairs. 2007b. Prepared statement of Ronald R. Aument, Deputy Under Secretary for Benefits, VA. 110th Cong., 1st Sess., March 13. http://veterans.house.gov/hearings/schedule110/mar07/03-13-07/3-13-07aument.shtml (accessed March 5, 2007).

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A 21st Century System for Evaluating Veterans for Disability Benefits VA. 2005b. Department of Veterans Affairs Office of Inspector General review of state variances in VA disability compensation payments. Report No. 05-00765-137. http://www.va.gov/oig/52/reports/2005/VAOIG-05-00765-137.pdf (accessed March 4, 2007). VA. 2005c. Fiscal year 2005 performance and accountability report. Washington, DC: Office of Budget, Office of Management, VA. http://www.va.gov/budget/report/2005/VA-2005_FULL-WEB.pdf (accessed March 15, 2007). VA. 2006a. FY 2006 performance and accountability report. Washington, DC: Office of Budget, Office of Management, VA. http://www.va.gov/budget/report/2006FullWeb.pdf (accessed March 16, 2007). VA. 2006b. VHA handbook 1601E.01, Compensation and pension (C&P) examinations. http://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=1400 (accessed March 15, 2007). VA. 2006c. VA strategic plan FY 2006-2011. http://www.va.gov/op3/docs/VA_2006_2011_Strategic_Plan.pdf (accessed March 16, 2007). VA. 2006d. Accuracy and accountability. Unpublished PowerPoint presentation. Washington, DC: C&P Service, VA. VA. 2006e. Qualifications for examiners performing compensation and pension (C&P) mental disorder examinations. VBA Fast Letter 06-03, March 15. http://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=1391 (accessed April 4, 2007). VA. 2007a. Veterans Administration fiscal year 2008 budget submission. Vol. 4, Summary. http://www.va.gov/budget/summary/VolumeIVSummaryVolume.pdf (accessed February 28, 2007). VA. 2007b. Veterans Administration fiscal year 2008 budget submission. Vol. 2, National Cemetery Administration, benefit programs, and departmental administration. http://www.va.gov/budget/summary/VolumeIINationalCemeteryAdministrationBenefitsProgramsandDepartmentalAdmin.pdf (accessed February 28, 2007). VA. 2007c. Monday morning workload reports, end of the fiscal year: 2000–2006. http://www.vba.va.gov/bln/201/reports/mmrindex.htm (accessed May 22, 2007). VA. 2007d. Index to disability examination worksheets. http://www.vba.va.gov/bln/21/Benefits/exams/index.htm (accessed May 20, 2007). VA. 2007e. Mission statement of the Veterans Benefits Administration. http://www.vba.va.gov/mission_vision.htm (accessed February 28, 2007). VA. 2007f. Understanding the disability claims process. http://www.vba.va.gov/bln/21/Topics/claims.htm (accessed May 18, 2007). VDBC (Veterans’ Disability Benefit Commission). 2007. Transition report. http://www.1888932-2946. ws/vetscommission/e-documentmanager/gallery/Documents/2007_February/TransitionReport_Slides_2-21-2007.pdf (accessed March 3, 2007).