2
Veterans with Disabilities in the 21st Century

An effective medical evaluation system for a veterans disability compensation program depends in part on the purpose of the program, which is addressed in Chapter 3. The effectiveness of such a system also depends in part on the volume of claims and the types of impairments for which veterans are likely to seek compensation.

The numbers and types of claims submitted to the Department of Veterans Affairs (VA) for disability compensation depend on a number of variables, some of which are demographic. According to the VA secretary, “The number of active duty servicemembers as well as reservists and National Guard members who have been called to active duty to support Operation Enduring Freedom [OEF] and Operation Iraqi Freedom [OIF] is one of the key drivers of new claims activity” (U.S. Congress, House of Representatives, Committee on Veterans’ Affairs, 2007a). The VA under secretary for benefits reported in March 2007 that nearly 1.46 million active duty servicemembers and reservists had been deployed to Afghanistan and Iraq, of whom more than 689,000 had returned and been discharged (U.S. Congress, House of Representatives, Committee on Veterans’ Affairs, 2007c). Original (i.e., first-time) compensation claims have doubled in recent years from 112,000 in fiscal year (FY) 2000 to 217,000 in FY 2006 (VA, 2007a).

However, original claims constitute only a third of the claims. The remaining two-thirds of compensation claims made each year are from veterans previously determined to have a service-connected disability, most



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A 21st Century System for Evaluating Veterans for Disability Benefits 2 Veterans with Disabilities in the 21st Century An effective medical evaluation system for a veterans disability compensation program depends in part on the purpose of the program, which is addressed in Chapter 3. The effectiveness of such a system also depends in part on the volume of claims and the types of impairments for which veterans are likely to seek compensation. The numbers and types of claims submitted to the Department of Veterans Affairs (VA) for disability compensation depend on a number of variables, some of which are demographic. According to the VA secretary, “The number of active duty servicemembers as well as reservists and National Guard members who have been called to active duty to support Operation Enduring Freedom [OEF] and Operation Iraqi Freedom [OIF] is one of the key drivers of new claims activity” (U.S. Congress, House of Representatives, Committee on Veterans’ Affairs, 2007a). The VA under secretary for benefits reported in March 2007 that nearly 1.46 million active duty servicemembers and reservists had been deployed to Afghanistan and Iraq, of whom more than 689,000 had returned and been discharged (U.S. Congress, House of Representatives, Committee on Veterans’ Affairs, 2007c). Original (i.e., first-time) compensation claims have doubled in recent years from 112,000 in fiscal year (FY) 2000 to 217,000 in FY 2006 (VA, 2007a). However, original claims constitute only a third of the claims. The remaining two-thirds of compensation claims made each year are from veterans previously determined to have a service-connected disability, most

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A 21st Century System for Evaluating Veterans for Disability Benefits of them veterans of World War II, Korea, and Vietnam.1 As the population of veterans ages, the Veterans Benefits Administration (VBA) can expect to see a growing percentage of claims for worsening chronic conditions, such as cardiovascular diseases, mental illnesses, and diabetes, and secondary conditions resulting from already service-connected disabilities.2 This in turn has implications for VA’s Schedule for Rating Disabilities (Rating Schedule) and the process for applying it in the rating process. VBA is already reporting higher rates of claims for complications of diabetes.3 Often, these are more complex claims, requiring a determination that a new impairment, such as kidney or coronary heart disease, is as likely as not caused by the veteran’s service-connected diabetes, an issue that is addressed more fully in Chapter 9. If the incidence of a particular condition is likely to increase substantially, VBA might want to review and, if warranted, update the criteria in the Rating Schedule, to ensure that appropriate specialists are available to conduct examinations, and to provide specialized training and information resources to the raters. Similarly, if a war is under way, VBA can expect to see a new cohort of veterans with wounds and other injuries and diseases encountered in wartime situations. As protective equipment, frontline emergency medicine, and medical evacuation techniques improve, more seriously injured servicemembers will survive at a higher rate. For example, the average time to evacuate a wounded servicemember from the battlefield to stateside care is 3 days, compared with 10 to 14 days during the Persian Gulf War in 1991 and 45 days during the Vietnam War (U.S. Congress, Senate, Defense Appropriations Subcommittee, 2007). The ratio of wounded to killed in the current wars in Iraq and Afghanistan is 9.1 to 1, compared with 3.2 to 1 in Vietnam and 2.3 to 1 in World War II.4 1 According to data provided to the committee by VA, nearly half (48 percent) of the 926,000 service-connected disabilities considered for higher ratings during calendar years 2004–2006 were from reopened claims of veterans of World War II, Korea, and Vietnam, and more than a third (36 percent) of the 4.3 million disabilities considered for service connection (i.e., claimed for the first time) during the same three-year time period were from veterans of the same three wars. 2 It should be noted that members of the National Guard and reserves called up to serve in Afghanistan and Iraq who were once in the active services may have been granted service-connected disabilities earlier, and they would be considered reopened cases if they apply for injuries suffered during their current active service. 3 According to VA’s budget submission for FY 2008, “VA has started to see increasingly complex medical cases resulting in neuropathies, vision problems, cardiovascular problems, and other issues directly related to diabetes” (VA, 2007a). Nearly a quarter of the veterans currently receiving care from VA have diabetes (U.S. Congress, House of Representatives, Committee on Appropriations, 2007). 4 Calculated from Department of Defense (DoD) tables (DoD, 2007b). The Iraq and Afghanistan figures are as of February 17, 2007.

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A 21st Century System for Evaluating Veterans for Disability Benefits The main cause of injury in Iraq has been blasts from roadside bombs, resulting in a characteristic or “signature” set of multi-system injuries likely to result in permanent severe impairments and functional limitations (Scott, 2005).5 These include brain injury, blinding, hearing and vestibular impairment, nerve and organ damage, burns, and amputation of one or more extremities, some or all of which can happen to one person.6 Some of these injuries are caused by bomb fragments and flying debris, but some are caused by overpressure from the blast wave. The latter injuries may not be as apparent, such as closed-head brain injury and internal lung and other organ damage. As a VA physician treating these injuries told the Veterans’ Disability Benefits Commission, such impairments may be underestimated (Scott, 2005).7 Given the unprecedented combination of severe injuries distinctive of combat in southwest Asia, VBA may want to reassess the ability of the Rating Schedule and rating process to evaluate blast injuries to the brain and other internal organs and to rate the disability caused by interaction of impairments in multiple body systems. THE VETERAN POPULATION There are approximately 24 million living veterans of active duty in the U.S. military. VA expects this number to fall to less than 15 million over the next 25 years, barring a large increase in troop levels (Figure 2-1).8 As the number of veterans declines, the average age increases. The median age of veterans is 60 years, up from 57 as recently as 2000 (VA, 2001b, 2006b). 5 As of February 10, 2007, 68 percent of the wounded in action in Iraq were injured by an improvised explosive device, landmine, or other explosive device (12,000 of the 18,000 for which the cause of injury was known) (DoD, 2007a). 6 According to the director of the Polytrauma Rehabilitation Center at the Tampa VA medical center, “A typical patient has TBI [traumatic brain injury], vision and/or hearing loss, pain, wounds, burns and orthopedic problems (including amputations)” (U.S. Congress, House of Representatives, Committee on Veterans’ Affairs, 2007b). A Veterans Health Administration handbook on polytrauma rehabilitation procedures notes that TBI often occurs with other injuries, “such as amputation, auditory and visual impairments, SCI [spinal cord injury], PTSD [posttraumatic stress disorder], and other mental health conditions” (VA, 2005a). 7 The diagnosis of closed-head brain injuries from blasts is based on symptoms such as headaches, decreased memory, inability to concentrate, slower thinking, irritability, anger, depression, and other personality and behavioral changes (DVBIC, 2007). Of the first 433 traumatic brain injury patients seen at Walter Reed Army Medical Center between January 2003 and April 2005, 89 percent had closed-head brain injuries rather than penetrating wounds (Warden, 2006). 8 Starting in 2008, the projection includes DoD estimates of separations from active duty forecast by the Office of the Actuary of the Department of Defense, based on an assumption that the size of the military will remain about 1.38 million. This projection of the actual number of servicemembers is very uncertain, because it depends on external events and advances in technology that cannot be predicted.

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A 21st Century System for Evaluating Veterans for Disability Benefits FIGURE 2-1 Estimated and projected cumulative number of veterans by period of service, FY 2000–FY 2032. NOTES: Veterans of more than one period are counted in the latest period in which they served; for example, veterans who served in WWII, Korea, and Vietnam are counted as part of the Vietnam era service period. Gulf War includes veterans from the beginning of the first Gulf War in 1990 through 2007. Post Gulf War includes new veterans in 2008 and later. This means that individuals who served in OEF/OIF are counted as Gulf War veterans if they separate from service before 2008 and as Post Gulf War veterans if they separate in 2008 or later. SOURCE: IOM (2007). The number of veterans ages 65 and older is expected to increase in the near future but begin to decrease within 10 years, from 9.2 million in 2012 to 6.7 million in 2032. They will constitute a larger percentage of living veterans, however, increasing from 39 to 46 percent of the total between 2007 and 2017, before declining slightly to 45 percent in 2032 (Figure 2-2). VA expects the percentage of women veterans to double during the next 25 years, from the current 7 percent to 14 percent in 2032. The percentage of non-Hispanic white veterans, currently 80 percent of living veterans, is projected to decrease to 71 percent by 2032. The percentages of Hispanic, non-Hispanic black, and other minority veterans would increase in the same time period, from 5 to 9 percent, 10 to 15 percent, and 3 to 5 percent, respectively (IOM, 2007).

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A 21st Century System for Evaluating Veterans for Disability Benefits FIGURE 2-2 Projected percentages of veterans by age group, FY 2007–FY 2032. SOURCE: IOM (2007). VA does not forecast the number of veterans it expects to apply for or be granted disability benefits beyond the next few years, but experience has shown that more recent veterans tend to apply at higher rates, and that the percentage of veterans service connected for disability compensation has been increasing accordingly. Approximately 12 percent of the veterans who served during the Gulf War era (i.e., since August 1990) had been granted a service-connected disability rating when OEF was launched in Afghanistan in October 2001, compared with 9.5 percent of Vietnam era veterans and 10.4 percent of World War II veterans (VA, 2002). As of the end of May 2006, approximately 105,000 veterans of the current wars in Iraq and Afghanistan had been granted disability compensation—about 18 percent of those who had separated from service at that time (VA, 2006a).9 Thus the number of veterans service connected for disability compensation is increasing, although the overall number of veterans is decreasing. In FY 2000, when there were 27 million veterans, 2.3 million were receiving disability compensation. The annual number of claims received for service- 9 If the same percentage of the 34,000 claims then pending were granted compensation as the claims already processed, the percentage of veterans of Iraq and Afghanistan with service-connected disabilities would have been 24 percent.

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A 21st Century System for Evaluating Veterans for Disability Benefits connected compensation, which was 579,000 in FY 2000, reached 806,000 in FY 2006. In 2008, when VA estimates there will be 23 million veterans (13 percent fewer than in 2000), 2.9 million are expected to be receiving compensation (25 percent more than in 2000). THE POPULATION OF VETERANS WITH DISABILITIES In FY 2006, about 2.7 million veterans were receiving $26.5 billion monthly in disability compensation from VA. VA estimates that compensation payments to veterans will increase to about $32.4 billion in FY 2008, when there will be an estimated 2.9 million beneficiaries. Compensation per veteran is expected to average $11,258 in 2008, up from $9,864 in 2006 (VA, 2007a).10 Period of Service Of the 2.3 million veterans with service-connected disabilities at the end of FY 2000, the largest group was Vietnam era veterans, followed by (in descending order) veterans serving in peacetime, World War II, the Gulf War, and the Korean conflict. This composition is expected to change substantially by 2008, when the number of Gulf War veterans is expected to have increased by 160 percent, while the number of World War II and Korean War veterans is expected to fall by 19 and 3 percent, respectively (Figure 2-3). As a result, Gulf War veterans will constitute 29 percent of service-connected beneficiaries in 2008, compared with 14 percent in 2000. Age In FY 2005, more than half of the 2.6 million veterans with service-connected disabilities were older than age 55 (Figure 2-4). Most of the rest were between ages 36 and 55. Only 8 percent were ages 35 or younger. The median age was 60 in FY 2006, compared with 59 in FY 2000 (VA, 2006b). Disability Rating Levels Each condition for which a veteran receives VA disability compensation is given a rating, expressed as a percentage between 0 and 100 in increments of 10; higher ratings are intended to reflect greater severity than lower 10 This does not include ancillary benefits, as described in Chapter 6, for which veterans with service-connected disabilities may be eligible.

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A 21st Century System for Evaluating Veterans for Disability Benefits FIGURE 2-3 Number of veterans with service-connected disabilities, by period of service, FY 2000–FY 2008. NOTE: Gulf War veterans are those who served on or since August 2, 1990, including veterans of OEF/OIF. SOURCES: VA (2001b, 2002, 2003, 2004a, 2005b, 2006b, 2007a). ratings. Conditions can be rated 0 percent when they have been determined by VA to be service connected and disabling, but not to the extent that they would affect an average veteran’s ability to work.11 If a veteran has more than one rated condition, VA calculates a combined percentage intended to represent the net impact of the multiple conditions on the veteran. For example, a 40 percent rating and a 20 percent rating result in a combined rating of 50 percent. The combined rating level determines the amount of monthly compensation. (The procedure for combining ratings is described in Chapter 4.) 11 Technically, as will be explained in Chapter 3, veterans rated 0 percent disabled have minor impairments that are not considered to be disabling on average. For example, the most common impairments rated 0 percent are minor hearing loss, hemorrhoids, and scars. Similarly, someone who has lost both legs but is a successful lawyer or teacher is rated 100 percent for the severity of his or her impairment, rather than 0 percent for lack of disability.

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A 21st Century System for Evaluating Veterans for Disability Benefits FIGURE 2-4 Veterans receiving disability benefits by age range, FY 2005 (percentages). SOURCE: VA (2006b). In FY 2005, veterans with disabilities were being compensated for approximately 7.7 million separate conditions that VA considered disabling, an average of about 3 each. The largest group of the 2.6 million veterans with disabilities had a combined rating of 10 percent (30 percent), followed by those with a 20 percent rating (15 percent). Fewer than 10 percent were rated totally (100 percent) disabled (Figure 2-5). The distribution of rating levels by individual condition is quite different. Of the total of 7.7 million conditions, the largest number is rated 10 percent, followed by conditions rated at 0 percent. Only 3 percent are rated 100 percent (Figure 2-6). The Most Prevalent Disabling Conditions There are two ways to consider prevalence of disabilities, either by the major (i.e., highest-rated) condition of each individual veteran or by the

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A 21st Century System for Evaluating Veterans for Disability Benefits FIGURE 2-5 Veterans by combined rating level, FY 2005 (percentages). SOURCE: VA (2006b). 7.7 million separate conditions the 2.7 individual veterans have among them. In FY 2005, posttraumatic stress disorder (PTSD) was the major diagnosis for the largest number of veterans, or 203,000, followed by diabetes mellitus and tinnitus, each with 102,000 (left half of Table 2-1).12 PTSD, diabetes, and tinnitus together were the major diagnosis for 15 percent of service-connected veterans in FY 2005. The three conditions were much less prominent 10 years earlier, however, when they were ranked 9th, 22nd, and 14th, respectively, as major diagnoses, and accounted for less than 5 percent of the veterans with disabilities (VA, 1995). (In FY 1995, the three most prevalent major conditions were impairment of the knee other than ankylosis, generalized anxiety disorder, and lumbosacral strain, 12 According to the American Tinnitus Association, tinnitus is “the perception of sound in the ears or head where no external source is present.” Although often referred to as “ringing in the ears,” some people with tinnitus hear hissing, roaring, whistling, chirping, or clicking. Both the volume and the continuity of the perceived sound varies from person to person with tinnitus (ATA, 2007).

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A 21st Century System for Evaluating Veterans for Disability Benefits FIGURE 2-6 Disabling conditions by rating level, FY 2005 (percentages). NOTE: These are the 7.7 million separate conditions for which the 2.7 million service-connected veterans have been rated. SOURCE: Appendix Table 2-1. which together accounted for 11 percent of veterans with disabilities at that time.) The most numerous service-connected conditions in FY 2005 were defective hearing (354,000 ratings), tinnitus (340,000 ratings), and orthopedic conditions for which there was no diagnostic code (300,000 ratings); they were rated using the code for a similar, or “analogous,” condition (right half of Table 2-1). These conditions ranked higher because they tend to have lower ratings such as 10 or 0 percent, and while many veterans have these lower ratings, they also have higher ratings for other conditions. For example, 354,000 veterans were rated for impaired hearing, but only 71,000 had it as their highest-rated condition. Another point of comparison is the prevalence of the same conditions in the general population, although one should bear in mind that some or many veterans may have impairments (e.g., tinnitus, diabetes, PTSD) that are not service connected or for which, if service connected, applications for benefits have not been submitted, making the comparison inexact. The

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A 21st Century System for Evaluating Veterans for Disability Benefits TABLE 2-1 Number of Veterans and Number of Rated Conditions, by Diagnostic Code, End of FY 2005   Number of Veterans by Major Condition Number of Conditions Rated per Diagnostic Code Rank Major Condition (Diagnostic Code) Number of Veterans Condition (Diagnostic Code) Number of Conditions 1 PTSD (9411) 203,378 Defective hearing (6100–6110) 353,897 2 Diabetes mellitus (7913) 101,883 Tinnitus (6260) 339,573 3 Tinnitus (6260) 101,758 Analogous to an orthopedic diagnostic code (5299) 300,098 4 Knee, other impairment of (5257) 98,662 Scars, other (7805) 283,337 5 Arthritis, due to trauma (5010) 98,132 Arthritis, due to trauma (5010) 272,047 6 Intervertebral disc syndrome (5293) 86,469 PTSD (9411) 244,876 7 Analogous to an orthopedic diagnostic code (5299) 75,628 Knee, other impairment of (5257) 235,158 8 Sacroiliac injury and weakness (5295) 74,644 Diabetes mellitus (7913) 220,532 9 Defective hearing (6100–6110) 70,915 Hypertensive vascular disease (7101) 193,055 10 Hypertensive vascular disease (7101) 57,252 Arthritis, degenerative, hypertrophic, or osteoarthritis (5003) 162,004   All diagnostic codes 2,636,979 All diagnostic codes 7,675,811 SOURCE: VA (2005c). 12-month prevalence of PTSD in U.S. adults ages 18 and older is estimated to be 3.5 percent (Kessler et al., 2005a). The estimated lifetime prevalence of PTSD is 6.8 percent (Kessler et al., 2005b). The baseline analysis of the Millennium Cohort found that the prevalence of PTSD among veterans was 2.4 percent, although it was between 3.5 and 3.8 percent among some subgroups—those without a high school diploma, ages 17–24, or who served

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A 21st Century System for Evaluating Veterans for Disability Benefits TABLE 2-5 Most Common Conditions of Veterans of the Afghanistan and Iraq Wars, 2001–2006 Diagnostic Code Condition Number of Grants 6260 Tinnitus 35,871 5237 Lumbosacral or cervical strain 32,733 6100 Defective hearing 28,907 5299 Conditions analogous to musculoskeletal impairments listed in the VA Rating Schedule 23,892 5271 Limited motion of the ankle 16,454 9411 PTSD 16,131 5260 Limitation of flexion of leg 15,335 5257 Limitation of knee other than ankylosis 12,048 5201 Limitation of motion of arm 11,337 7101 Hypertensive vascular disease 11,303 SOURCE: VA (2006a). mittees on Veterans’ Affairs, 2007a). More than 400 OEF/OIF veterans had suffered major burns by 2006 (Kupersmith, 2006).20 According to March 2007 testimony from Blinded Veterans of America, 16 percent of all casualties evacuated from Iraq between March 2003 and April 2005 had eye injuries. Walter Reed Army Medical Center had surgically treated about 690 soldiers for blindness or moderate to severe significant visual injuries. The National Naval Medical Center had surgically treated approximately 450 traumatic eye injuries (U.S. Congress, Senate and House of Representatives, Committees on Veterans’ Affairs, 2007b). Another source of information on the potential disability status of OEF/ OIF veterans is the types of conditions for which they seek health care at the Veterans Health Administration (VHA). According to the latest analysis of those data, as of the end of August 2006, 205,097 (32 percent) of the 631,174 OEF/OIF military personnel who had separated from service and become veterans had sought VA health care for a current health problem (VA, 2006c). Most of those who sought care were male, were between the ages of 20 and 29, and had separated from the Army. About equal numbers were former active duty and reserve or National Guard members. OEF/OIF veterans filed disability claims with VHA for a wide variety of conditions (Appendix Table 2-4). The largest percentage of conditions matched ICD-9 codes that belonged within the category of diseases of the musculoskeletal and connective system (43 percent), followed by mental 20 Major burns are defined as those covering more than 10 percent of the body.

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A 21st Century System for Evaluating Veterans for Disability Benefits disorders (36 percent), and symptoms, signs, and ill-defined conditions without an immediately obvious cause or with laboratory abnormalities that cannot be coded elsewhere in the ICD-9 (33 percent). A total of 73,157, or about one-third of, OEF/OIF veterans received a diagnosis of a possible mental disorder (Appendix Table 2-5). The most common diagnosis was PTSD (33,754), followed by non-dependent abuse of drugs (28,732), and depressive disorders (23,462).21 Although these statistics are suggestive, they do not mean that, for example, 36 percent of all OEF/OIF veterans have diagnosable mental disorders. Veterans who seek care at VA are self-selected. If very sick, they are perhaps unemployed or underemployed and lacking health insurance, which they do not need for VA services. Of OIF soldiers who completed post-deployment health assessments between May 1, 2003, and April 30, 2004, 19 percent reported a mental health concern, compared with 11 percent of soldiers returning from Afghanistan and 9 percent of soldiers returning from other locations. OIF veterans whose post-deployment health was reassessed three to six months after deployment showed even higher rates of mental health concerns; 35 percent reported some kind of mental health concern on at least one general screening question related to PTSD, depression, alcohol use, relationship/interpersonal concerns, or suicidal ideation. Data from the Army’s health-care system show that 35 percent of soldiers who returned from Iraq accessed military mental health services at some time during the first year after return, most often within the first two months. Twelve percent of all soldiers who returned from OIF were diagnosed with a mental health problem within the first year after return (U.S. Congress, House of Representatives, Committee on Veterans’ Affairs Subcommittee on Health, 2006). CONCLUSION Veterans likely to seek disability compensation from VA currently and in the future are a diverse group. Some are veterans of the current wars in Afghanistan and Iraq, and most of them are young. If the wars end soon, and if the same percentage of those deployed as those who were in the first Gulf War leave active service within 10 years (67 percent), and the same percentage of those who have left active service apply for disability compensation as did veterans of the first Gulf War as of September 30, 2001 (about 33 percent), VA can expect to receive about 290,000 claims from veterans of OEF/OIF. The number is likely to be larger, because a higher percentage (28 percent) of the deployed servicemembers have been activated 21 These three diagnoses alone total more than 73,157, because some veterans had multiple diagnoses of mental disorder.

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A 21st Century System for Evaluating Veterans for Disability Benefits from the National Guard and reserves than in the first Gulf War. (At this point, 48 percent of those deployed to OEF/OIF have left the service, and 28 percent of them have filed claims for disability compensation.) If this group continues to have the same impairments as it has had to date, most claims that will be adjudicated will be for hearing problems, musculoskeletal impairments, and mental disorders, especially PTSD. However, the majority of veterans will continue to be from earlier periods of service and, therefore, will be approaching middle or advanced age. They will be filing reopened claims as their service-connected conditions become worse and new conditions appear, either secondary to already service-connected conditions or made presumptive by legislation or regulation. The percentage of reopened claims has declined from 75 percent in 2000, but is still two-thirds of all claims. This means that VA will continue to receive a substantial number of claims for cardiovascular conditions, cancers, diabetes and its complications, deteriorating hearing and vision, joint replacements, and other problems associated with advancing age. Claims for such conditions are likely to continue to increase in number as evaluation tools improve and problems are detected earlier. In addition, there will be a relatively small but important set of mostly younger veterans with multiple impairments, including traumatic brain injuries, which must be adequately evaluated and rated. REFERENCES ATA (American Tinnitus Association). 2007. About tinnitus. http://www.ata.org/about_tinnitus/ (accessed May 14, 2007). DoD (Department of Defense). 2007a. Global war on terrorism [casualties] by reason, October 7, 2001, through February 10, 2007. http://siadapp.dior.whs.mil/personnel/CASUALTY/gwot_reason.pdf (accessed March 9, 2007). DoD. 2007b. Military casualty information. http://siadapp.dior.whs.mil/personnel/CASUALTY/castop.htm (accessed March 6, 2007). DoD. 2007c. Military casualty information. http://siadapp.dior.whs.mil/personnel/CASUALTY/OIF-Wounded-After.pdf and http://siadapp.dior.whs.mil/personnel/CASUALTY/OEFWIA.pdf (accessed March 9, 2007). DoD. 2007d. Military casualty information. http://siadapp.dior.whs.mil/personnel/CASUALTY/gwot_reason.pdf (accessed March 9, 2007). DVBIC (Defense and Veterans Brain Injury Center). 2007. Blast injury FAQs. http://www.dvbic.org/blastinjury.html (accessed March 12, 2007). Embrey, E. P. 2007. Force health protection. PowerPoint presentation by the Deputy Assistant Secretary of Defense for Force Health Protection and Readiness. http://www.amsus.org/sm/presentations/Feb07-B.ppt#293,1,ForceHealthProtection (accessed March 14, 2007). Heller, A. J. 2003. Classification and epidemiology of tinnitus. Otolaryngology Clinics of North America 36(2):239–248. Hoffman, H. J., and G. W. Reed. 2004. Epidemiology of tinnitus. In Tinnitus: Theory and management, edited by J. B. Snow, Jr. Hamilton, Ontario, Canada: B. C. Decker. Pp. 16–41.

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A 21st Century System for Evaluating Veterans for Disability Benefits Hoge, C. W., C. A. Castro, S. C. Messer, D. McGurk, D. I. Cotting, and R. L. Koffman. 2004. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. New England Journal of Medicine 351(1):13–22. IOM (Institute of Medicine). 2006. Staff analyses of claims data provided by VA, December 19, in response to Data Request 07-042, submitted by the Veterans’ Disability Benefits Commission. IOM. 2007. Staff analyses of data from VetPop2004 Version 1.0 State and National Tables, Table 2L. http://www.va.gov/vetdata/docs/VP2004B.htm (accessed March 1, 2007). Kessler, R. C., W. T. Chiu, O. Demler, and E. E. Walters. 2005a. Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Archives of General Psychiatry 62(6):617–627. Kessler, R. C., P. A. Berglund, O. Demler, R. Jin, K. R. Merikangas, and E. E. Walters. 2005b. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Archives of General Psychiatry 62(6):593–602. Kupersmith, J. 2006. Global conflicts: Implications for VA research. PowerPoint presentation by the Chief Research and Development Officer, Veterans Health Administration, VA. http://www.academyhealth.org/2006/kupersmith.pdf (accessed March 9, 2007). NIDDK (National Institute of Diabetes and Digestive and Kidney Diseases). 2005. National Diabetes Statistics. http://diabetes.niddk.nih.gov/dm/pubs/statistics/#7/ (accessed May 18, 2007). Riddle, J. R., T. C. Smith, B. Smith, T. E. Corbeil, C. C. Engel, T. S. Wells, C. W. Hoge, J. Adkins, M. Zamorski, and D. Blazer. 2007. Millennium Cohort: The 2001–2003 baseline prevalence of mental disorders in the U.S. military. Journal of Clinical Epidemiology 60(2):192–201. Ryan, M. A., T. C. Smith, B. Smith, P. Amoroso, E. J. Boyko, G. C. Gray, G. D. Gackstetter, J. R. Riddle, T. S. Wells, G. Gumbs, T. E. Corbeil, and T. I. Hooper. 2007. Millennium Cohort: Enrollment begins a 21-year contribution to understanding the impact of military service. Journal of Clinical Epidemiology 60(2):181–191. Sayer, N. A., C. Chiros, B. Clothier, H. Lew, T. Pickett, S. Scott, and B. Sigford. 2006. Predictors of functional improvement during acute inpatient rehabilitation among combatinjured OIF and OEF servicemembers. Poster presented at 2006 annual meeting of the American Military Surgeons of the United States, San Antonio, TX. Scott, S. G. 2005. Polytrauma rehabilitation system of care. PowerPoint presentation made at February 2005 meeting of the Veterans’ Disability Benefits Commission, St. Petersburg, FL. http://www.1888932-2946.ws/vetscommission/e-documentmanager/gallery/Documents/February_2006/DrScottColFryerPresentation.pdf (accessed March 1, 2007). Seal, K. H., D. Bertenthal, C. R. Miner, S. Sen, and C. Marmar. 2007. Bringing the war back home: Mental health disorders among 103,788 U.S. veterans returning from Iraq and Afghanistan seen at Department of Veterans Affairs facilities. Archives of Internal Medicine 167(5):476–482. U.S. Congress, House of Representatives, Committee on Appropriations. 2007. Prepared statement of Joel Kupersmith, M.D., Chief Research and Development Officer, VA, before the Subcommittee on Military Construction, Veterans’ Affairs and Related Agencies, 110th Cong., 1st Sess., March 14. https://www.va.gov/OCA/testimony/hac/smqlva/070314JK.asp (accessed May 14, 2007). U.S. Congress, House of Representatives, Committee on Veterans’ Affairs. 2006. Prepared statement of Colonel Charles W. Hoge, U.S. Army Director of Division of Psychiatry and Neuroscience, Walter Reed Army Institute of Research, before the Subcommittee on Health’s hearing on posttraumatic stress disorder and traumatic brain injury, 109th

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A 21st Century System for Evaluating Veterans for Disability Benefits Cong., 2nd Sess. September 28. http://veterans.house.gov/hearings/schedule109/sep06/9-28-06/CharlesHoge.html (accessed March 15, 2007). U.S. Congress, House of Representatives, Committee on Veterans’ Affairs. 2007a. Prepared statement of James R. Nicholson, Secretary of Veterans Affairs, before the Full Committee. 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 Steven G. Scott, Medical Director, VA Tampa Polytrauma Rehabilitation Center, before the Subcommittee on Oversight and Investigation. 110th Cong., 1st Sess., March 8. http://veterans.house.gov/hearings/schedule110/mar07/03-08-07/StevenScott.shtml (accessed March 9, 2007). U.S. Congress, House of Representatives, Committee on Veterans’ Affairs. 2007c. Prepared statement of Ronald R. Aument, Deputy Under Secretary for Benefits, VA, before the Subcommittee on Disability Assistance and Memorial Affairs. 110th Cong., 1st Sess., March 13. http://veterans.house.gov/hearings/schedule110/mar07/03-13-07/Aument.pdf (accessed March 9, 2007). U.S. Congress, Senate, Defense Appropriations Committee. 2007. Prepared statement of Lt. Gen. (Dr.) James G. Roudebush, Surgeon General of the Air Force, before the Defense Appropriations Subcommittee. 110th Cong., 1st Sess., March 7. http://appropriations.senate.gov/hearings.cfm (accessed March 9, 2007). U.S. Congress, Senate and House of Representatives, Committees on Veterans’ Affairs. 2007a. Prepared statement of Bradley S. Barton, National Commander, Disabled American Veterans. 110th Cong., 1st Sess., February 27. http://veterans.house.gov/hearings/schedule110/feb07/02-27-07/BradleyBarton.shtml (accessed March 9, 2007). U.S. Congress, Senate and House of Representatives, Committees on Veterans’ Affairs. 2007b. Prepared statement of Larry Belote, National President, Blinded Veterans of America. 110th Cong., 1st Sess., March 8. http://veterans.senate.gov/index.cfm?FuseAction=Hearings.CurrentHearings&rID=946&hID=256/ (accessed March 16, 2007). VA (Department of Veterans Affairs). 1995. VA report RCS 20-0227, as of March 31, 1995 (unpublished). VA. 2001a. 2001 National Survey of Veterans: Final report. Washington, DC: Department of Veterans Affairs. http://www.va.gov/vetdata/docs/NSV%20Final%20Report.pdf (accessed June 22, 2007). VA. 2001b. Veterans Benefits Administration annual benefits report for fiscal year 2000. Washington, DC: Veterans Benefits Administration. http://www.vba.va.gov/bln/dmo/reports/fy2000_abr_v3.pdf (accessed March 1, 2007). VA. 2002. Veterans Administration annual benefits report for fiscal year 2001. Washington, DC: Veterans Benefits Administration. http://www.vba.va.gov/bln/dmo/reports/FY2001_ABR.pdf (accessed March 1, 2007). VA. 2003. Veterans Administration annual benefits report for fiscal year 2002. Washington, DC: Veterans Benefits Administration. http://www.vba.va.gov/bln/dmo/reports/fy2002/2002_abr_all.pdf (accessed March 1, 2007). VA. 2004a. Veterans Administration annual benefits report for fiscal year 2003. Washington, DC: Veterans Benefits Administration. http://www.vba.va.gov/bln/dmo/reports/fy2003/2003_abr.pdf (accessed March 1, 2007). VA. 2004b. VetPop2004 Version 1.0 State and National Tables Table 5L: Veterans 2000– 2033 by race/ethnicity, gender, period, age. http://www.va.gov/vetdata/docs/VP2004B.htm (accessed December 18, 2006). VA. 2005a. Polytrauma rehabilitation procedures. VHA handbook 1172.1. http://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=1317 (accessed March 12, 2007).

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A 21st Century System for Evaluating Veterans for Disability Benefits VA. 2005b. Veterans Administration annual benefits report for fiscal year 2004. Washington, DC: Veterans Benefits Administration. http://www.vba.va.gov/bln/dmo/reports/fy2004/2004_abr.pdf (accessed March 1, 2007). VA. 2005c. VA report RCS 20-0227, as of September 30, 2005 (unpublished). VA. 2006a. Compensation and pension benefit activity among 633,867 veterans deployed to the Global War on Terrorism. Washington, DC: Office of Performance Analysis and Integrity, Veterans Benefit Administration. Prepared November 8, 2006. Unpublished document provided by VA to the Committee on Medical Evaluation of Veterans for Disability Compensation on March 14, 2007. VA. 2006b. Veterans Benefits Administration annual benefits report for fiscal year 2005. Washington, DC: Veterans Benefit Administration. http://www.vba.va.gov/bln/dmo/reports/fy2005/2005_abr.pdf (accessed March 1, 2007). VA. 2006c. Analysis of VA health care utilization among U.S. Southwest Asian war veterans: Operation Iraqi Freedom and Operation Enduring Freedom. Washington, DC: Office of Public Health and Environmental Hazards, Veterans Health Administration. VA. 2006d. VA report RCS 20-0227, as of September 30, 2005 (unpublished). VA. 2007a. FY2008 budget submission, volume II: National Cemetery Administration, benefits programs, and departmental administration. Washington, DC: Office of Budget, Department of Veterans Affairs. http://www.vba.va.gov/bln/dmo/reports/FY2001_ABR.pdf (accessed March 1, 2007). VA. 2007b. Polytrauma and blast-related injuries. QUERI (Quality Enhancement Research Initiative) fact sheet. http://www.va.gov/hsrd/publications/internal/polytrauma_factsheet.pdf (accessed March 14, 2007). VA. 2007c. Unpublished tables of claims data provided by VA Office of Performance Analysis and Integrity to the Committee on Medical Evaluation of Veterans for Disability Compensation. Warden, D. 2006. TBI during wartime: The Afghanistan and Iraq experience. Presentation at 2nd Federal Traumatic Brain Injury Interagency Conference, Bethesda, MD, March 9. http://www.tbi-interagency.org/pdf/dwarden.pdf (accessed March 21, 2007).

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A 21st Century System for Evaluating Veterans for Disability Benefits APPENDIX TABLE 2-1 Individual Service-Connected Conditions by Rating, FY 1995 and FY 2005   FY 1995 FY 2005 Rating Number of Rated Conditions Percent of Total Number of Rated Conditions Percent of Total 0% 1,775,993 34.9% 2,363,021 31.0% 10% 1,894,441 37.2% 3,052,872 40.0% 20% 476,706 9.4% 813,832 10.6% 30% 433,832 8.5% 593,025 7.7% 40% 145,030 2.9% 212,238 2.8% 50% 91,040 1.8% 166,344 2.2% 60% 88,745 1.7% 142,177 1.8% 70% 27,916 0.5% 97,526 1.3% 80% 9,008 0.2% 10,331 0.1% 90% 2,669 0.1% 3,202 * 100% 140,905 2.8% 221,219 2.9% Total 5,086,285 100.0% 7,675,787 100.0% *Less than 0.05 percent. SOURCE: VA (1995) for 1995 numbers and VA (2006b) for 2005 numbers.

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A 21st Century System for Evaluating Veterans for Disability Benefits APPENDIX TABLE 2-2 Five Most Common Service-Connected Conditions by Period of Service, All Veterans Receiving Disability Compensation as of FY 2005 Period of Service Condition Number of Conditions Percent of All Conditions WWII         Defective hearing 42,464 5.8%   Frozen feet, residuals of (immersion foot) 39,169 5.4%   Tinnitus 32,491 4.5%   Generalized anxiety disorder 31,367 4.3%   Scars, other 30,571 4.2%   PTSD 25,281 3.5%   Arthritis, due to trauma 24,420 3.3%   Scars, superficial, tender and painful 15,584 2.1%   Flatfoot, acquired 15,359 2.1%   Scars, disfiguring, head, face, or neck 11,718 1.6%   All 728,911 100.0% Korea         Defective hearing 25,529 7.2%   Tinnitus 22,100 6.2%   Frozen feet, residuals of (immersion foot) 19,808 5.6%   Scars, other 15,476 4.4%   PTSD 10,994 3.1%   Arthritis, due to trauma 10,030 2.8%   Scars, superficial, tender and painful 7,147 2.0%   Duodenal ulcer 6,825 1.9%   Scars, disfiguring, head, face, or neck 5,758 1.6%   Generalized (analogous to) musculoskeletal conditions 5,552 1.6%   All 355,344 100.0% Vietnam         Diabetes mellitus 190,199 6.9%   PTSD 179,737 6.5%   Defective hearing 129,323 4.7%   Scars, other 121,850 4.4%   Tinnitus 120,625 4.4%   Generalized (analogous to) musculoskeletal conditions 78,270 2.9%   Hypertensive vascular disease 72,169 2.6%   Arthritis, due to trauma 69,034 2.5%   Other impairment of knee 62,713 2.3%   Arthritis, degenerative, hypertrophic, or osteoarthritis 52,920 1.9%   All 2,745,555 100.0%

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A 21st Century System for Evaluating Veterans for Disability Benefits Period of Service Condition Number of Conditions Percent of All Conditions Gulf War         Generalized musculoskeletal conditions 131,092 5.9%   Tinnitus 104,039 4.7%   Arthritis due to trauma 100,374 4.5%   Other impairment of knee 81,677 3.7%   Hypertensive vascular disease 64,558 2.9%   Lumbosacral strain 61,658 2.8%   Scars, other 60,350 2.7%   Defective hearing 60,023 2.7%   Arthritis, degenerative, hypertrophic, or osteoarthritis 54,042 2.4%   Limited motion of ankle 53,002 2.4%   All 2,233,479 100.0% Peacetime         Generalized musculoskeletal conditions 78,233 4.9%   Other impairment of knee 77,768 4.9%   Arthritis due to trauma 68,068 4.2%   Defective hearing 64,013 4.0%   Tinnitus 60,278 3.8%   Scars, other 54,823 3.4%   Hypertensive vascular disease 50,247 3.1%   Lumbosacral strain 44,736 2.8%   Arthritis, degenerative, hypertrophic, or osteoarthritis 39,646 2.5%   Intervertebral disc syndrome 37,103 2.3%   All 1,602,697 100.0% SOURCE: VA (2006b).

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A 21st Century System for Evaluating Veterans for Disability Benefits APPENDIX TABLE 2-3 20 Most Frequent Service-Connected Conditions Among Women and Men, 2004–2006 Women Men Condition Number of Grants Condition Number of Grants Lumbosacral or cervical strain 11,113 Tinnitus 161,090 Migraine 10,255 Defective hearing 135,394 Tinnitus 5,901 Diabetes mellitus 85,005 Scars, other 5,807 PTSD 74,491 Limitation of flexion of leg 5,566 Hypertensive vascular disease 51,033 Major depressive disorder 5,378 Lumbosacral or cervical strain 50,136 Tenosynovitis 5,155 Penis, deformity with loss of erectile power 38,719 Degenerative arthritis of the spine 4,997 Paralysis of sciatic nerve 38,356 Scars, superficial, tender, and painful 4,847 Degenerative arthritis of the spine 36,672 Allergic or vasomotor rhinitis 4,687 Limitation of flexion of leg 35,798 Hernia, hiatal 4,671 Scars, other 33,537 Eczema 4,443 Limited motion of the ankle 30,182 Limited motion of the ankle 4,258 Arthritis, due to trauma 29,306 Flatfoot, acquired 3,992 Hernia, hiatal 25,251 Hypertensive vascular disease 3,734 Scars, superficial, tender, and painful 24,924 Asthma, bronchial 3,534 Tenosynovitis 24,806 PTSD 3,313 Eczema 23,666 Hallux valgus 3,303 Paralysis of the median nerve 22,227 Arthritis, due to trauma 3,236 Intervertebral disc syndrome 20,929 Paralysis of the median nerve 2,988 Arteriosclerotic heart disease 19,854 SOURCE: VA (2007c).

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A 21st Century System for Evaluating Veterans for Disability Benefits APPENDIX TABLE 2-4 Frequency of Diagnoses Among Recent Veterans of Iraq and Afghanistan Broad ICD-9 Category Frequency % Infectious and parasitic diseases (001–139) 21,362 10.4 Malignant neoplasms (140–208) 1,584 0.8 Benign neoplasms (210–239) 6,571 3.2 Diseases of endocrine/nutritional/metabolic systems (240–279) 36,409 17.8 Diseases of blood and blood-forming organs (280–289) 3,591 1.8 Mental disorders (290–319) 73,157 35.7 Diseases of nervous system/sense organs (320–389) 61,524 30.0 Diseases of circulatory system (390–459) 29,249 14.3 Diseases of respiratory system (460–519) 36,190 17.6 Diseases of digestive system (520–579) 63,002 30.7 Diseases of genitourinary system (580–629) 18,886 9.2 Diseases of skin (680–709) 29,010 14.1 Diseases of musculoskeletal system/connective system (710–739) 87,590 42.7 Symptoms, signs, and ill-defined conditions (780–799) 67,743 33.0 Injury/poisonings (800-999) 35,765 17.4 SOURCE: VA (2006d). APPENDIX TABLE 2-5 Frequency of Mental Diagnoses Among Recent Veterans of Iraq and Afghanistan Disease Category (ICD-9CM Code) Number of OEF/OIF Veterans PTSD (309.81) 33,754 Nondependent abuse of drugs (305) 28,732 Depressive disorders (311) 23,462 Neurotic disorders (300) 18,294 Affective psychoses (296) 12,386 Alcohol dependence syndrome (303) 5,413 Sexual deviations and disorders (302) 3,239 Special symptoms, not elsewhere classified (307) 3,178 Drug dependence (304) 2,387 Acute reaction to stress (308) 2,273 SOURCE: VA (2006d).