5
The Evaluation of PTSD Disability Claims

This chapter addresses the evaluation of posttraumatic stress disorder (PTSD) compensation and pension (C&P) claims by the Veterans Benefits Administration (VBA) of the Department of Veterans Affairs (VA). It contains a brief summary of the means by which veterans may obtain compensation for service-related disabilities, background on the claims evaluation process, and the committee’s response to elements of the charge related to these evaluations.

VETERANS’ DISABILITY COMPENSATION

Veterans receive disability compensation related to their military service via three basic processes: (1) through the Department of Defense (DOD) Disability Evaluation System (DES); (2) through the federal Transition Assistance Program; and (3) by filing a claim with the VA subsequent to separation from service. Figure 5-1 illustrates the pathways to disability compensation afforded by the programs.

The Department of Defense Disability Evaluation System

The core functions of the DOD DES are to ensure that the military force remains fit and to provide compensation for those service members on regular active duty, in the Reserve, or in the National Guard whose military careers are cut short by illness or injury before they meet time-in-service requirements for retirement benefits eligibility. DOD disability benefits are



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PTSD Compensation and Military Service 5 The Evaluation of PTSD Disability Claims This chapter addresses the evaluation of posttraumatic stress disorder (PTSD) compensation and pension (C&P) claims by the Veterans Benefits Administration (VBA) of the Department of Veterans Affairs (VA). It contains a brief summary of the means by which veterans may obtain compensation for service-related disabilities, background on the claims evaluation process, and the committee’s response to elements of the charge related to these evaluations. VETERANS’ DISABILITY COMPENSATION Veterans receive disability compensation related to their military service via three basic processes: (1) through the Department of Defense (DOD) Disability Evaluation System (DES); (2) through the federal Transition Assistance Program; and (3) by filing a claim with the VA subsequent to separation from service. Figure 5-1 illustrates the pathways to disability compensation afforded by the programs. The Department of Defense Disability Evaluation System The core functions of the DOD DES are to ensure that the military force remains fit and to provide compensation for those service members on regular active duty, in the Reserve, or in the National Guard whose military careers are cut short by illness or injury before they meet time-in-service requirements for retirement benefits eligibility. DOD disability benefits are

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PTSD Compensation and Military Service FIGURE 5-1 Military disability compensation pathways. NOTE: The TAP is left out of this flowchart but is part of all three pathways. granted to “compensate for the loss of a military career” (DOD, 2006). To qualify for DOD disability compensation, a service-incurred or service-aggravated illness or injury must render a service member permanently unfit to perform the “duties of office, grade, rank, or rating” and must not be the result of “misconduct or willful neglect” (Howard, 2006). Disability is determined according to the effects that a condition has on a service member’s ability to perform according to military occupational specialty.

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PTSD Compensation and Military Service As a rule,1 a disability rating is based solely on the “unfitting” condition (DOD, 1996). DOD compensation awards are based both on disability ratings and on time in service. The compensation may be awarded as a lump-sum severance payment or as monthly payments2 (GAO, 2006). The standard for the determination of DOD disability ratings—DOD Instruction 1332.39; Title 10, United States Code Chapter 61—is the Department of Veterans Affairs’ Schedule for Rating Disabilities (VASRD) (DOD, 1996). But while the VASRD, as described in the U.S. Code of Federal Regulations, Title 38, Part 4 (38 CFR, Part 4), provides the standard for DOD disability ratings, the DOD considers absolute application of VASRD provisions incompatible with its mission. Thus, the DOD differs from the VA both in how it views the purpose of disability compensation and in how it implements the VASRD. Furthermore, within the DOD variation exists among service branch DESs. DOD regulations are consistent across the different branches, in that they require each DES to have a medical evaluation boardand a physical evaluation board, but both the boards and the appeals processes are constituted differently from branch to branch (GAO, 2006). Concurrent Receipt When a service member is granted monthly DOD disability compensation, officially referred to as permanent disability retirement, he or she is also entitled to be considered for disability compensation through the VA. Until January 2004 permanent disability retirement pay was, by statute, reduced by the dollar amount of VA disability compensation received (Henning, 2006). But Public Law 108-136, in addition to altering other DOD retirement payment policies,3 authorized a 10-year phase-out of the reduction of military retirement due to VA compensation and allowed concurrent receipt of VA and DOD compensation for those veterans with a combined disability rating at or above 50 percent (DOD, 2006). As part of the military retirement offset phase-out, on January 1, 2005 veterans rated 1 There are limited circumstances where “the sum of several conditions which render a member unfit” are considered collectively in a disability evaluation (Howard, 2006). 2 To qualify for monthly compensation, a service member must have accrued 20 years of service or have at least a 30 percent disability rating. Compensation is given as a lump sum for service members with less than 20 years in service or a disability rating of 20 percent or less. Service members are eligible for compensation for “non-aggravated pre-existing” conditions if they have at least 8 years of active-duty service. Service members may also be placed on the temporarily disabled retired list (GAO, 2006). 3 Two other programs affecting a smaller number of veterans that have had the same material effect as concurrent receipt are the Special Compensation for Severely Disabled Retirees; effective October 1999 and repealed January 2004) and the Combat-Related Special Compensation (enacted in 2002) programs (Henning, 2006).

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PTSD Compensation and Military Service at 100 percent by the VA became entitled to their full military retirement pay without any offset of VA disability compensation. Those who are not rated at 100 percent according to the schedule of ratings but who receive 100 percent VA compensation under the provision of individual unemployability (IU) are slated to have their full military retirement entitlement restored beginning in October 2009 (DOD, 2006; Henning, 2006). Transition Assistance Program TAP is a joint federal program of the DOD, VA, and the Department of Labor designed to help service members make the initial transition from military service to the civilian workforce. It was first implemented in 1990. Military members who have served at least 180 days on active duty are eligible to participate in TAP. Disabled service members are eligible regardless of time served (GAO, 2005). TAP has four core elements that are intended to help service members adjust successfully to civilian life. Of the four components, VA administers two: the Disabled Transition Assistance Program (DTAP), which offers briefings about the VA’s vocational rehabilitation programs, and Benefits Delivery at Discharge (BDD), where VA representatives start processing disability claims before the service member leaves active service. TAP and DTAP briefings All service members who attend a TAP briefing receive a general overview of VA benefits and services. Benefits briefings cover education, insurance, and home loan guaranty entitlements—generally, GI Bill-related items4—and are offered to active-duty members at 215 military installations worldwide.5 The majority of active-duty members can participate in TAP as early as one year before leaving service as a standard component of military out-processing. Retiring service members are eligible for TAP two years before separation (GAO, 2005). Active-duty service members are usually offered TAP at their assigned duty stations. It is less clear how activated Reserve personnel and National Guard personnel access TAP, as demobilization of these personnel takes place in a few days and occurs in areas remote from places of employment or residence (GAO, 2005). DTAP briefings are provided to service members who are separating from active duty with a disability that may be related to their service. 4 The 1944 Serviceman’s Readjustment Act, also known as the GI Bill of Rights entitled veterans to certain home loan and education benefits. The latest iteration, the Montgomery GI Bill, was enacted in 1985 (VBA, 2005). 5 As of June 2005 (GAO, 2005).

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PTSD Compensation and Military Service They are focused on the VA’s Vocational Rehabilitation and Employment Program. While briefings are typically held in a group setting, special provisions can be made for service members who are hospitalized, convalescing, or receiving outpatient treatment (U.S. Army, 2006). Representatives from veterans services organizations can also conduct TAP and DTAP briefings (VBA, 1999). Disabled Transition Assistance Program and Benefits Delivery at Discharge The VA has two separate programs that allow personnel to initiate disability claims while still on active duty. The first program, DTAP, “offers [to disabled service members] personalized vocational rehabilitation and employment assistance at major military medical centers where such separations occur and at other military installations” (DVA, 2005a). The second program, BDD,6 offers assistance to “service members at participating military bases with development of VA disability compensation claims prior to their discharge” (DVA, 2005a). Personnel with access to BDD have the opportunity to have their predischarge or exit physicals conducted according to VA protocols by DOD examiners, VA examiners, or contracted examiners (DVA, 2005a). There is an official Memorandum of Understanding (MOU) between the DOD and the VA for the BDD examination process. MOUs are also developed at the local level. These agreements discuss the exchange of information and resources between the DOD and the VA and also seek to ensure that examining clinicians have access to both service medical records and VA examination protocols. It is unclear if BDD replaces DTAP in certain circumstances and how DBB and DTAP eligibility, access, and participation vary. Ideally, when service members attend TAP briefings, they receive an overview of the vocational rehabilitation program and its eligibility requirements. If they believe that they may be eligible for vocational rehabilitation and express an interest in that program, they can “self-select” into DTAP. They are then given the more in-depth briefings on vocational rehabilitation and can begin the evaluation process. Barriers to participation in these transition-assistance programs do exist. Members of the Reserves and National Guard, for example, often participate in more than a dozen demobilization activities, including a physical examination, in the matter of just a few days (GAO, 2005), and this gives them little opportunity to participate in a transition-assistance program as well. Furthermore, members of the Reserves and National Guard were 6 Service members that are within 180 days of discharge are eligible for BDD examinations (VBA, 2005).

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PTSD Compensation and Military Service found to be less likely to have been briefed in transition on “certain education benefits and medical coverage requir[ing] service members to apply while they are still on active duty,” and some of those who had received briefings remained unaware of the limited application window for these benefits (GAO, 2005). Reserve and National Guard personnel on medical holdover status do not have the same access to TAP/DTAP programs that active duty personnel on holdover status do because of variation in the processing of military orders (VDBC, 2006). According to the GAO, no “data are available regarding participation in the VA components of TAP,” and “[r]egarding DTAP, no data are available to determine the number of eligible individuals, and VA’s records do not distinguish the number who participate in the component from the total of all recipients of VA outreach briefings” (GAO, 2005). No matter what disability rating has been determined by the DOD, if a veteran desires compensation from VA, he or she must submit a separate application for disability benefits and have the VA rate their condition all over again. It is possible for a service member found fit for duty by the DOD with respect to a particular condition to be awarded disability compensation by the VA for the same condition. It is even possible to go “from 100 percent fit [for] duty [according to DOD] to 100 percent disabled” according to the VA for the same condition (Howard, 2006). VA Disability Claims Adjudication Veterans’ disability benefits claims may go through many stages of processing and review before a decision is made. Figure 5-2 summarizes this process. VBA Claims Processing A veteran initiates the claims process by filing VA Form 21-526 with a VA Regional Office (VARO). An applicant may also file an application for benefits through the Veterans’ Online Applications website. Online applications are automatically forwarded to the VARO with original jurisdiction. By law (codified in 38 CFR §3.159), VA must provide claimants certain support in the development of these claims. Assisting with the acquisition of evidence, including requests for evidence from pertinent sources, is a major part of VA’s duty to assist the veteran (DVA, 2004). Claims are processed at VARO Veteran Service Centers (VSCs). According to the Veterans Benefits Administration Adjudication Procedure Manual M21-1MR (VBA, 2005), each VSC using the Claims Process Improvement (CPI) model is composed of six teams. The composition and function of these teams is summarized in Table 5-1.

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PTSD Compensation and Military Service FIGURE 5-2 Veterans Benefits Administration Claims Process (CPI model). *Team also makes post-rating contacts; †Not the only type of special review, but the only one that can be initiated by the claimant’s representative; ‡DRO may not reduce existing rating; ° VA Form 9; ♦May affirm, modify, reverse or remand; ◊VA Form 8. Although regional offices have some discretion in assignments to the teams, a triage team will generally consist of about eight members and will include the following of employees: coach, assistant coach, rating veteran service representatives (RVSRs), veterans service representatives (VSRs),

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PTSD Compensation and Military Service TABLE 5-1 Veteran Service Center Teams Team Functions Triage Reviews and controls all incoming mail Processes actions which can be completed without the claim folder or which may require brief review of the claim folder to verify eligibility Predetermination Develops evidence for rating issues Prepares administrative decisions Rating Makes decisions on claims that require consideration of medical evidence Postdetermination Develops evidence for nonrating issues Processes awards Notifies claimants of decisions Appeals Handles decisions with which claimants have formally disagreed Public Contact Handles personal interviews and telephone inquiries SOURCE: VBA manual M21-1MR, part III, subpart I, chapter 1 (2005). senior VSR, claims assistant, file bank coach, and file clerk/program clerk (VBA, 2005).7 Beyond the management of incoming mail and related files, the triage team is authorized to process those claims requiring only minimal review of the evidence. The VBA M21-1MR does not provide details on what is considered to be a “minimal review.” The predetermination team manages claims requiring administrative decisions and determines when a claim is ready for a decision or rating. If a clinical examination8 is required to adjudicate a claim, the team can order one to be performed. Examinations can be requested by more than one team/team member. VSRs in the Predetermination Team have primary responsibility for requesting examinations. A RVSR may provide guidance on examination requests as necessary. RVSRs also have authority to directly request examinations. The Veterans Service Center Manager (VSCM) can authorize an examination in any case in which s/he believes it is warranted (VBA, 2005). The committee was unable to determine the percentage of disability claims adjudicated without a clinical evaluation, as VBA does not track these data. The predetermination team has as many as eight team members, with the same titles and pay grades as triage team members. 7 Details of the federal classification and job grades listed in parentheses can be found on the U.S. Office of Personnel Management website at http://www.opm.gov/fedclass/. 8 Information on C&P clinical examinations is presented in Chapter 4.

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PTSD Compensation and Military Service A rating team consists of a coach, assistant coach, rating VSRs, and a claims assistant (VBA, 2005). The rating team is responsible for rating claims that have been deemed “ready to rate” by the predetermination team. The rating team may also receive claims directly from the triage, appeals, or public contact teams. The membership of the postdetermination team has the same general composition as the rating team, with fewer RVSRs and more VSRs. This team receives developed claims from which it promulgates ratings and prepares notification letters. A veteran or a representative acting on her or his behalf can file an appeal to a disability determination or rating by requesting a reevaluation. The appeals team—coach, decision review officer, senior VSR, RVSR, VSR, claims assistant, and file clerk/program clerk—oversees this process, which consists of several stages.9 Initially, if a claim is denied or a veteran disagrees with the level of the disability level awarded, she or he files a notice of disagreement. The claimant is then contacted by a Decision Review Officer (DRO) and is given the choice to have that person conduct a de novo (new) review. If the claimant is not satisfied with the DRO’s decision or chooses otherwise, then s/he can file a substantive appeal to the Board of Veterans’ Appeals (BVA). If the BVA’s decision fails to resolve the claimant’s concerns, s/he can file a lawsuit in the U.S. Court of Appeals for Veterans Claims. A veteran can also reopen a claim based on new and material evidence and begin the process anew. In theory, a claim that has been processed and then appealed at the local regional office level could have 40 VBA rating-team members and a U.S. Army and Joint Services Records Research Center (JSRRC)10 representative involved in the rating decision, assuming the VARO was fully staffed according to the CPI model. While detailed requirements of knowledge, skills, and abilities are published for each rating-related position, VA regulations allow for the delegation of responsibility for nearly all of these positions. It is not known how staffing varies by VSC or whether the CPI model is the norm or the gold standard. Complete tracking of the VBA personnel chain involved in the adjudication process is complicated by the repeated use of titles across teams, by the flexible assignment of responsibilities within and among teams, and by the many variations in local VARO policies and procedures. An additional factor that makes review difficult is that understaffed VAROs are 9 Separately, staff at the VA Central Office or at a regional office can initiate an administrative review or appeal in circumstances where they believe that an error was made in the evaluation of a claimant’s evidence or the application of regulations or procedures related to a claim. 10 The JSRRC—formerly know as the Center for Unit Records Research—is a repository for records related to military conflicts.

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PTSD Compensation and Military Service authorized to “broker” claims to other regions for processing. Therefore, this summary has been provided as a general reference and not an absolute accounting of the VBA claims adjudication process. The benefits application process is intended to be nonadversarial and supportive to claimants. As noted elsewhere, VA’s duty to assist includes helping veterans to gather evidence to support their claims, including provision of VA records and facilitation of requests for information from DOD and other sources. If a veteran disputes a determination, the initial stages of appeals process are conducted without anyone representing an opposing viewpoint and with consideration of all possible theories of entitlement (Violante, 2004). In addition, “[w]hen, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant” (38 CFR §3.102). It is only when an action reaches the U.S. Court of Veterans’ Appeals that it takes on the characteristics of a formal legal proceeding, with the potential for presentation of evidence contrary to the claimant’s assertions or interest. Nonetheless, the process has been described as “complex, legalistic, and protracted” and as particularly difficult for veterans with PTSD to manage because of the stresses and uncertainties involved (Sayer et al., 2005). The situation may be exacerbated in some circumstances by skeptical and cynical attitudes toward PTSD compensation-seeking veterans among certain VA staff (Sayer and Thuras, 2002; Van Dyke et al., 1985). The VASRD Rating Process11 The primary task of a rater is to assign one more ratings of disability based on the input received from the veteran, the clinician, and other members of the rating team. The VA disability rating depends on a complex assessment of many factors, and numerous variables play a role in determining the amount of the disability awarded. The VASRD does not take into account military rank, tenure, sex, or wartime cohort. The VA Office of the Inspector General did, however, find that variations in award ratings were correlated with certain factors, including (DVA, 2005b): enlisted (higher award) versus officer status; military retiree (higher award) versus nonmilitary retiree; attorney representation (higher award); 11 The Institute of Medicine report A 21st Century System for Evaluating Veterans for Disability Benefits (IOM, 2007) addresses the VASRD rating process in detail and offers several recommendations for improving it and its implementation.

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PTSD Compensation and Military Service number of veterans applying for benefits (higher number, higher award); period of service (Vietnam veterans receive highest awards); branch of service (Marine Corps veterans receive highest award); and rater experience (more experience, higher award). The same report also found that a lack of time to develop claims often leads to inadequate development of claims or to determinations that could support two different ratings for the same case (DVA, 2005b). In addition, there are aspects of how disabilities are rated that may influence the amount of an award. For example, some disabilities, especially those based on self-reports, are more difficult to rate, and this may create a lack of reliability in the award decisions. The validity of currently employed instruments has also been called into question, as there have been substantial advances in fields related to disability assessment in the context of disease, illness, function, impairment, and rehabilitation since the establishment of the VASRD. These issues were recognized by a 2005 VA review (DVA, 2005b): Our analysis of rating decisions shows that some disabilities are inherently more susceptible to variations in rating determinations. This is attributed to a combination of factors, including a disability rating schedule that is based on a 60-year-old model and some diagnostic conditions that lend themselves to more subjective decision making…. The VA disability compensation program is based on a 1945 model that does not reflect modern concepts of disability. Over the past 5 decades, various commissions and studies have repeatedly reported concerns about whether the rating schedule and its governing concept of average impairment adequately reflects medical and technological advancements and changes in workplace opportunities and earning capacity for disabled veterans. Although some updates have occurred, proponents for improving the accuracy and consistency of ratings advocate that a major restructuring of the rating schedule is long overdue (p. vi). The assessment of psychiatric illness is particularly challenging. The VA Inspector General’s 2005 review of state variances in disability compensation payments found that mental disorders—including PTSD—had the fourth highest variability in disability rating of the 15 body systems (DVA, 2005b). In contrast, ratings that can be independently validated (amputation, for example) were highly reliable and consistent. The 2005 VA report also found that the number of PTSD cases receiving disability awards and the amounts of the awards given in these cases are both growing. From fiscal year (FY) 1999 to FY 2004 the number and

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PTSD Compensation and Military Service TABLE 5-10 AMA Guides to the Evaluation of Permanent Impairment Classes of Impairment due to Mental and Behavioral Disorders Area or Aspect of Functioning Class 1 No Impairment Class 2 Mild Impairment Class 3 Moderate Impairment Class 4 Marked Impairment Class 5 Extreme Impairment Activities of daily living No impairment noted Impairment levels are compatible with most useful functioning Impairment levels are compatible with some, but not all, useful functioning Impairment levels significantly impede useful functioning Impairment levels preclude useful functioning Social functioning Concentration Adaptation SOURCE: AMA, 2001. Reprinted with permission. tinued supervision and confinement in the home or another facility, or has severe limitations impeding useful action in almost all social and interpersonal daily functions; and Extreme (50–70 percent): unable to care for self or to be safe without supervision, or has severe limitation of daily functions requiring total dependence on another person. Table 5-10, reproduced from the AMA Guides (2001), summarizes the impairment categories identified by the association. SSA “Blue Book” Many of the criteria used by the SSA for assessing impairment due to mental disorders are captured in the AMA Guides discussed above. A key difference between Social Security and VA disability is that in Social Security ratings the impairment must be severe enough to prevent any substantial gainful activity (SGA). Thus, unlike VASRD ratings, there are not varying degrees of partial disability but rather an “either-or” ability or inability to achieve SGA. The following key criteria in the paragraphs below are excerpted from the so-called Blue Book (SSA, 2005). Functional limitations are assessed in four areas: activities of daily living; social functioning; concentration, persistence, or pace; and episodes of decompensation. The severity in one or more of these areas must be marked, defined as more than moderate but less than extreme. A marked limitation must interfere seriously with the ability to function independently, appropriately, effectively, and on a sustained basis (§§ 404.1520a and 416.920a).

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PTSD Compensation and Military Service Activities of daily living include activities such as cleaning, shopping, cooking, taking public transportation, paying bills, maintaining a residence, grooming and hygiene, using telephones and directories, and using a post office. An assessment will examine the level of independence (i.e., not needing supervision or direction), appropriateness, effectiveness, and sustainability of each of these activities. Social functioning includes the ability to get along with others: family members, friends, neighbors, and so on. Evidence of impairment of social functioning may include a history of altercations, evictions, firings, fear of strangers, avoidance of interpersonal relationships, or social isolation. Conversely, strength in social functioning can be exhibited by participation in group activities, consideration for others, awareness of others’ feelings, and the ability to initiate social contacts and communicate clearly with others. Social functioning in the workplace may involve interactions with the public, responding appropriately to supervisors, or cooperating with coworkers. Concentration, persistence, or pace refers to the ability to sustain focused attention and concentration for a duration sufficient to permit the timely and appropriate completion of tasks commonly found in work settings. Major limitations in this area can often be assessed through clinical examination or psychological testing with such tests as subtracting serial sevens from 100, tasks requiring short-term memory, or tasks that must be completed within established time limits. In work evaluations, concentration, persistence, or pace is assessed by testing the ability to sustain work in either real or simulated work tasks, for example, by filing index cards, locating telephone numbers, or disassembling and reassembling objects. Strengths include the ability to work at a consistent pace for acceptable periods of time and until a task is completed and the ability to repeat a sequence of actions to achieve a goal or an objective. A marked limitation might exist if the completion of tasks requires extra supervision or assistance or cannot be done in accordance with quality and accuracy standards, at a consistent pace without an unreasonable number and length of rest periods, or without undue interruptions or distractions. Episodes of decompensation are exacerbations or temporary increases in symptoms or signs that would ordinarily require increased treatment or being placed in a less stressful situation. Episodes of decompensation may be inferred from medical records showing significant alteration in medication or from documentation of the need for a more structured psychological support system, such as hospitalization, placement in a halfway house, or living in a highly structured household. The term “repeated episodes of decompensation, each of extended duration” implies at least three episodes within one year, or an average of at least once every four months, with each episode lasting for at least two weeks.

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PTSD Compensation and Military Service Summary Observations The AMA publications and SSA programs reviewed above provide guidance on the evaluation of disabilities resulting from mental disorders, but their systems generally shy away from the kind of numerical rating specificity that is at the heart of the VA compensation system. The committee thus concludes that these other evaluation methods are not more appropriate to use for evaluating mental-disorder disability than the one VA currently uses. However, these other methods do offer some insights into the components of a comprehensive disability assessment, which ultimately informed the committee’s conclusions and recommendations on VA’s rating criteria for PTSD. Conclusions—Rating Criteria for PTSD As mentioned above, there are two major limitations regarding the current VASRD approach to rating mental disorders. First, there is a single rating scheme that lumps together heterogeneous symptoms and signs, allowing very little differentiation across specific conditions. Second, OSI is the driving factor for each level of disability for mental disorders. Not only is OSI ill defined, but secondary factors used for physical disorders (Table 5-5) are not explicitly considered, which leaves a disproportionate reliance on OSI. The committee concludes that these criteria are—at best—a crude and overly general instrument for the assessment of PTSD disability and therefore recommends that rating criteria be developed that are specific to PTSD and based on the DSM. It is beyond the scope of the committee’s charge to specify the criteria and disability levels that should be associated with such a revised rating schedule. However, in response to VA’s charge, the committee offers for VA’s consideration a framework that it developed for establishing a revised PTSD disability rating system. This framework—illustrated in Table 5-11—takes a multidimensional approach in order to provide a more comprehensive evaluation of disability. Although the table focuses specifically on PTSD, it is likely that the approach used in the framework could be effective for other mental disorders as well. Five dimensions are assessed in rating disability: symptoms, psychosocial functional impairment, occupational functional impairment, treatment factors, and health-related quality of life. The second and third factors can also be considered as two elements of an overarching construct, functional impairment. PTSD symptoms could be assessed by a skilled clinical interview as described in the Best Practice Manual (Watson et al., 2002), which may be supplemented by the standardized PTSD symptom severity scales discussed

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PTSD Compensation and Military Service in Chapter 3—the Clinician-Administered PTSD Scale (CAPS) or the PTSD Checklist (PCL), for example. The primary feature that distinguishes the committee’s framework from the current rating criteria is that it specifies that the psychosocial and occupational aspects of functional impairment be separately evaluated and that a claimant be rated on the dimension on which he or she is more affected. This differs from the current scheme, which defines the rating level solely in terms of occupational impairment. The committee believes that the emphasis on occupational impairment in the current criteria unduly penalizes veterans who may be symptomatic or impaired in other dimensions but who are capable of working, and thus it may serve as a disincentive to both work and recovery. Psychosocial functional impairment might be assessed with the Post-Military Psychosocial Adjustment interview items recommended in the Best Practice Manual (Watson et al., 2002). The number and severity of psychosocial-functioning variables could be ranked in some ordinal fashion. This dimension is also where the distress related to PTSD that is not captured by symptom severity alone might be graded. Occupational functional impairment would cover not only inability to work or absenteeism but also partial work impairment as reflected in decreased work performance (also known as presenteeism). This impairment might be captured by assessing concentration, pace, persistence, and other factors that decrease work productivity, or else by standardized scales (for example, the Work Limitation Questionnaire), though the validity and applicability of each approach would need to be determined. The fact that medical disorders can be rated 100 percent without requiring total unemployability suggests that, in order to avoid creating disincentives to return to work, Level V could be coded for profound occupational impairment in a person who is sporadically employed. Research indicates that people with severe mental illness constrain their work activity in order to retain social welfare benefits (Polak and Warner, 1996; MacDonald-Wilson et al., 2001), which in turn acts as an impediment to recovery.15 Eliminating occupational impairment as the defining factor in rating the severity of disability would remove this deterrent. Furthermore, having occupational impairment as one of several dimensions—rather than as the predominant factor—in rating disability would result in greater parity between the rating of mental disorders and physical disorders. Treatment factors such as intensity, complexity, and response are given a discrete dimension in the framework, as is the case for a number of physical disorders rated in the VASRD. The treatments considered would be those that are evidence-based, such as cognitive therapies, antidepressants, 15 The literature regarding disincentives to recovery is addressed in Chapter 6.

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PTSD Compensation and Military Service and the like. The ratings along the treatment dimension would be higher in those cases where there were conditions such as substance use that often occur in conjunction with PTSD and that complicate treatment and treatment response and thus adversely affect disability. This dimension would, of course, be assessed only in claimants for whom treatment records were available. The committee notes that the treatment dimension would likely play a far greater role in reevaluations than in initial examinations since many initial claimants may be filing for disability in order to obtain access to treatment. Health-related quality of life is one of the assessment factors specified in the VA’s Automated Medical Information Exchange worksheets for initial and review PSTD examinations (reproduced in Appendix C), but it is not explicitly mentioned in the current rating criteria. Since these worksheets are intended to ensure that a rating specialist receives all information necessary to rate a claim, it is clear that VA believes this factor to be important. Section M of the initial examination worksheet16 (Integrated Summary and Conclusions) calls for the clinician to: describe changes in psychosocial functional status and quality of life following trauma exposure (performance in employment or schooling, routine responsibilities of self-care, family role functioning, physical health, social/interpersonal relationships, recreation/leisure pursuits); and describe linkage between PTSD symptoms and aforementioned changes in impairment in functional status and quality of life. Particularly in cases where a veteran is unemployed, specific details about the effects of PTSD and its symptoms on employment are especially important. The worksheets do not specify how quality of life is to be evaluated, but the committee notes that this dimension could be assessed with standardized, well-validated measures such as the SF-36 (Ware, 1993; McHorney et al., 1993), CDC HRQoL-14 (CDC, 2007), or other health-related quality-of-life scales. The percentage ratings provided in each row of Table 5-11 should not be taken as a final recommendation but instead are intended to illustrate how such a multidimensional approach is compatible with the current VASRD ordinal rating system. Furthermore, it should be noted that the percentage ratings are not intended to read across a row; in other words, it is not the intent to require an individual to meet a particular severity level in every dimension in order to qualify for that VASRD disability rating—for example, requiring that an individual be given Level III ratings or greater on all five dimensions in order to attain a 50 percent disability rating. Rather 16 Analogous language is contained in Section L of the review examination worksheet.

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PTSD Compensation and Military Service the percentages reflect the ordinal severity level within each dimension. There are various ways that the ratings from the individual dimensions can be aggregated to obtain a composite disability rating. The committee does not endorse any particular means, but observes that examples include: All domains equal approach: add up the percent disability for each domain, and divide by the number of domains. Worst domains dominate approach: take that average of the two (or three) highest-rated domains. Hierarchical domains approach: assign greater weight to certain domains (for example, symptom severity > occupational impairment > psychosocial functioning > treatment response > quality of life). Multi-attribute rating scale approach: use case vignettes and an expert panel to derive a system of scoring and weighting. Several factors were not included in the multidimensional rating framework. The type and severity of the stressor is not included, for example. There are several reasons for this particular omission. First, the stressor is not an outcome but presumably a causal factor in the pathogenesis of PTSD. Second, it is evaluated as criterion A of the DSM-IV diagnostic criteria for PTSD (APA, 1994). Third, the VA requires that the stressor be ascertained except in special circumstances. Fourth, any impairment related to the particular type and severity of stressor should be picked up in one or more of the other dimensions. Another factor not included as a dimension was complications (or comorbidity) related to PTSD, such as substance abuse or chronic pain. Since these can be coded elsewhere, the VASRD would discourage double-counting them (known as pyramiding17) and thereby inflating the disability rating of PTSD as well. Indeed, the veteran benefits from having disabilities rated separately. The mandate underlying the VASRD18 specifies that ratings be based on the impairment of earning capacity, a standard that would suggest that a focus on occupational function is proper. However, as documented in Chapter 1, there is abundant evidence that both the VA and the Congress take other criteria into account when setting ratings policy. The committee believes that it is appropriate to apply this broader approach to PTSD ratings. The committee wishes to emphasize that this framework is only a starting point for the revision of the ratings schedule for PTSD and that the final product must be the result of careful consideration by the VA. 17 38 CFR §4.14 18 U.S. Code Title 38, Part II, Chapter 11, subchapter VI, §1155, Authority for schedule for rating disabilities.

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PTSD Compensation and Military Service TABLE 5-11 Example of a Multidimensional Approach to PTSD Disability Rating Qualitative Severity Level     Functional Impairment (%)a PTSD Symptomsb Psychosocialc or I (10) Mild No psychosocial or occupational impairment   II (30) Moderate Mild psychosocial impairment (e.g., frequent altercations with family or friends, sexual dysfunction, avoids activities) or III (50) Moderately severe Moderate psychosocial impairment (e.g., divorce, estrangement from children, engages in high-risk behavior) or IV (70) Severe Severe psychosocial impairment (e.g., trouble with the law, self-mutilation) or V (100) Incapacitating Very severe psychosocial impairment (suicidality, violent behavior, extreme social isolation) or aThese percentage ratings are not intended to read across a row, i.e., requiring an individual to meet a particular severity level across all dimensions in order to qualify for that VASRD disability rating (e.g., Level III ratings or greater on all five dimensions to attain a 50 percent disability rating). Rather the percentages reflect the ordinal severity level within each dimension. Various ways of aggregating individual dimension severity ratings into an overall rating are discussed in the text. bUse skilled clinical interview as described in the Best Practice Manual (Watson et al., 2002), which may be supplemented by standardized PTSD symptom severity scales, e.g., Clinician-Administered PTSD Scale (CAPS) and/or PTSD Checklist (PCL). cFor psychosocial functioning, raters could use the Post-Military Psychosocial Adjustment interview items recommended in the Best Practice Manual (Watson et al., 2002). Number and severity of psychosocial functioning variables could be ranked in some ordinal fashion. Also, this is where the distress related to PTSD not captured by symptom severity alone might be graded. Training of Raters Determining ratings for mental disabilities in general and for PTSD specifically is more difficult than for many other disorders because of the inherently subjective nature of symptom reporting. In order to promote more accurate, consistent, and uniform PTSD disability ratings, the committee recommends that the VA establish a specific certification program for raters who deal with PTSD claims, with the training to support it, as well as periodic recertification. PTSD certification requirements should be

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PTSD Compensation and Military Service   Treatment Intensity, Complexity, and Responsee Health-Related Quality of Life Impairmentf Occupationald   No formal treatment indicated Minimal Mild occupational impairment (e.g., decreased work performance, excess sick days) Responds to intermittent therapy Mild Moderate occupational impairment (e.g., frequent job changes or job losses) Responds to continuous or repeated therapy Moderate Severe occupational impairment (e.g., prolonged periods without work) Incomplete response to multiple therapeutic trials Moderately severe Profound occupational impairment (unable to participate in sustained employment) Refractory to treatment Severe dFor occupational functioning, decreased work performance (“presenteeism”) might be captured by asking about concentration, pace, persistence, and other factors that decrease work productivity, or by standardized scales (e.g., Work Limitation Questionnaire), though the validity and applicability of each approach would need to be determined. Also the fact that medical disorders may be rated 100 percent without requiring total “unemployability” suggests Level V could be coded for profound occupational impairment in a person who is sporadically employed (to avoid disincentives to return to work). eTreatments would be those that are evidence-based (cognitive therapies, antidepressants, and the like). Rating along the treatment dimension would reach a higher severity level if there are conditions (substance use, for example) that co-occur at high rates in PTSD, complicate treatment and treatment response, and thus adversely affect disability. This dimension would only be assessed in claimants for whom treatment records were available. fAssess factors that affect health-related quality of life (HRQoL) not captured by other dimensions such as several that are captured by SF-36 (Ware, 1993; McHorney et al., 1993), CDC HRQOL-14 (CDC, 2007), or other HRQoL scales. regularly reviewed and updated to include medical advances and to reflect lessons learned. The program should provide specialized training on the psychological and medical issues (including common comorbidities) that characterize the claimant population, and guidance on how to appropriately manage commonly encountered ratings problems. The committee believes that rater certification will foster greater confidence in ratings decisions and in the decision-making process. Requiring certification may also necessitate that some ratings be done at a facility other than the one closest to the veteran in order to ensure that

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PTSD Compensation and Military Service a qualified rater performs the evaluation in a timely manner. Because raters do not directly evaluate claimants but rather evaluate the information produced by clinicians and other members of the C&P team, the committee does not believe that this would necessarily cause problems with the delivery of services. However, it is up to VA to implement the program in a manner that facilitates open communications between clinicians, remote raters, and other dispersed personnel and ensures that the claimants and those who help them are not disadvantaged. The Institute of Medicine report A 21st Century System for Evaluating Veterans for Disability Benefits, which will be released in summer 2007, will also address and offer recommendations regarding the C&P examination and disability rating processes. FINDINGS, CONCLUSIONS, AND RECOMMENDATIONS On the basis of the review of the papers, reports, and other information presented in this chapter, the committee has reached the following findings, conclusions, and recommendations, and identified the following research needs. Findings and Conclusions The VASRD criteria for rating mental disorders disability levels are at best a crude and overly general instrument for the assessment of PTSD disability. Recommendations Data fields recording the application and reevaluation of benefits should be preserved over time rather than being overwritten when final determinations are made. Data should also be gathered at two points in the process where there is currently little information available: before claims are made and after compensation decisions are rendered. New VASRD rating criteria specific to PTSD and based on the DSM should be developed and implemented. A multidimensional framework for characterizing PTSD disability—detailed in this chapter—should be considered when formulating these criteria. VA should establish a certification program for raters who deal with PTSD claims, with the training to support it, as well as periodic recertification. PTSD certification requirements should be regularly reviewed and updated to include medical advances and to reflect lessons learned. The program should provide specialized training on the psychological and medical issues (including common comorbidities) that characterize the claimant

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