3
Impairment, Disability, and Quality of Life

The primary focus of this study is the extent to which the Department of Veterans Affairs’ (VA) Schedule for Rating Disabilities (Rating Schedule) is “an appropriate, valid, and reliable instrument for evaluating medical impairment and determining degree of disability.” The statement of work for the committee clarified our assignment to ask how well the Rating Schedule and associated regulations enable VA to determine the proper levels of disability to compensate veterans with injuries and diseases incurred in, or aggravated by, military service for (1) “impact on quality of life” and (2) “impairment in earnings capacity.” This chapter begins with a section that provides a model of disability and defines our understanding of quality of life and impairment in earning capacity, as well as other concepts used in the model, including medical impairment and limitations in the activities of daily living.

A MODEL OF DISABILITY AND DEFINITIONS

The most useful model for purposes of this report was developed by an earlier Institute of Medicine (IOM) committee in 1991 (IOM, 1991). It has four domains of disablement: pathology, impairment, functional limitation, and disability (see Figure 3-1). More recent conceptual models, such as the International Classification of Functioning, Disability and Health (ICF) (WHO, 2001),1 are not linear, recognizing, for example, that there is not always a stepwise progression from pathology to impairment to functional

1

See Figure 1 in WHO (2001).



The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement



Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.

OCR for page 69
A 21st Century System for Evaluating Veterans for Disability Benefits 3 Impairment, Disability, and Quality of Life The primary focus of this study is the extent to which the Department of Veterans Affairs’ (VA) Schedule for Rating Disabilities (Rating Schedule) is “an appropriate, valid, and reliable instrument for evaluating medical impairment and determining degree of disability.” The statement of work for the committee clarified our assignment to ask how well the Rating Schedule and associated regulations enable VA to determine the proper levels of disability to compensate veterans with injuries and diseases incurred in, or aggravated by, military service for (1) “impact on quality of life” and (2) “impairment in earnings capacity.” This chapter begins with a section that provides a model of disability and defines our understanding of quality of life and impairment in earning capacity, as well as other concepts used in the model, including medical impairment and limitations in the activities of daily living. A MODEL OF DISABILITY AND DEFINITIONS The most useful model for purposes of this report was developed by an earlier Institute of Medicine (IOM) committee in 1991 (IOM, 1991). It has four domains of disablement: pathology, impairment, functional limitation, and disability (see Figure 3-1). More recent conceptual models, such as the International Classification of Functioning, Disability and Health (ICF) (WHO, 2001),1 are not linear, recognizing, for example, that there is not always a stepwise progression from pathology to impairment to functional 1 See Figure 1 in WHO (2001).

OCR for page 69
A 21st Century System for Evaluating Veterans for Disability Benefits FIGURE 3-1 The four domains of disablement (IOM, 1991:Figure 4).

OCR for page 69
A 21st Century System for Evaluating Veterans for Disability Benefits limitation to disability. A functional limitation may result in yet another impairment, for example, or an impairment may not limit function but be disabling, such as disfigurement.2 The 1991 IOM model is practical to use because it not only has the concepts of impairment, functional limitation, and disability and includes mediating factors (e.g., lifestyle and behavioral, biological, and environmental), but also acknowledges the interaction between quality of life and the disablement process. The committee does not find the IOM definition to be inconsistent with the more conceptually sophisticated ICF. (See Box 3-1 for a summary of the disability-related concepts and terms used by the committee in this report.) Impairment Impairment is a loss of physiological integrity in a body function or anatomical integrity in a body structure (WHO, 2001). Impairment is caused by disease, injury, or congenital defect. It may be a secondary consequence of yet another impairment, as when a person has a shorter leg from an injury and later develops arthritis in the hip because the abnormal gait resulting from the short leg causes trauma in the joint. Disability compensation systems, such as VA’s or workers’ compensation programs, generally determine the amount of compensation by rating the severity of the permanent impairment—the sequelae or residuals of a disease or injury. Impairments can be defined in relation to a physiological or anatomical structure or functional limitations. The next chapter will assess the extent to which the Rating Schedule bases compensation on degree of impairment alone, but below are some examples of ratings of disability based on severity of impairment: Ribs, removal of (diagnostic code 5297): More than six 50 percent Five or six 40 percent Three or four 30 percent Two 20 percent One or resection of two or more ribs without regeneration 0 percent Paralysis of fifth (trigeminal) cranial nerve (8205): Complete 50 percent Incomplete, severe 30 percent Incomplete, moderate 10 percent 2 This complexity was recognized in the text of IOM (1991: 8–10).

OCR for page 69
A 21st Century System for Evaluating Veterans for Disability Benefits BOX 3-1 Basic Concepts and Definitions of Terms Used activities of daily living/instrumental activities of daily living—functional limitations at the person level; measures of the net impact of an impairment or impairments on an individual’s ability to engage in life situations. disability—a broad term that includes work disability and quality of life. disabling process—a product of the interaction of the person and the environment, thereby influencing one’s quality of life. domains—aspects of an individual’s activities, such as the physical, psychological, and social. functional assessment—measure of the degree to which an individual can perform chosen roles (as well as duties and responsibilities) without physical, social, psychological, or cognitive limitation. health-related quality of life—measures what an individual values and whether there is much satisfaction in one’s life; components can include signs or symptoms, treatment side effects, or physical, cognitive, emotional, and social functioning. impairment—loss of physiological integrity in a body function or anatomical integrity in a body structure; caused by disease, injury, or congenital defect (WHO, 2001). IOM model of disablement domains—the model’s four domains are (1) pathology, (2) impairment, (3) functional limitation, and (4) disability. The model encompasses the concepts of impairment, functional limitation, and disability, and includes mediating factors—lifestyle and behavioral, biological, and environmental—and acknowledges the interaction between quality of life and the disablement process (IOM, 1991). loss in quality of life—the consequences of an injury or disease other than work disability. quality of life—includes the cultural, psychological, physical, interpersonal, spiritual, financial, political, temporal, and philosophical dimensions of a person’s life; reflects changes in people and the environment over time across many of its domains (Tate et al., 1996); the perception of physical and mental health over time (CDC, 2007). work disability—(1) actual loss of earnings resulting from the injury or disease and (2) presumed loss of earning capacity [or impairments of earning capacity] resulting from the injury or disease.

OCR for page 69
A 21st Century System for Evaluating Veterans for Disability Benefits Note: Dependent upon relative degree of sensory manifestation or motor loss. Some kinds of impairments are rated according to the degree of functional limitation of the body structure or process. These include range of motion of limbs and decreased capacity of an organ (loss of breathing capacity of the lung has already been described above): Thigh, limitation of flexion of (5252): Flexion limited to 10° 40 percent Flexion limited to 20° 30 percent Flexion limited to 30° 20 percent Flexion limited to 45° 0 percent Arteriosclerotic heart disease (coronary artery disease) (7005): 100 percent—Chronic congestive heart failure; or workload of 3 metabolic equivalents of task (METs)3 or less results in dyspnea, fatigue, angina, dizziness, or syncope; or left ventricular dysfunction with an ejection fraction of less than 30 percent 60 percent—More than one episode of acute congestive heart failure in the past year; or workload of greater than 3 METs but not greater than 5 METs results in dyspnea, fatigue, angina, dizziness, or syncope; or left ventricular dysfunction with an ejection fraction of 30 to 50 percent 30 percent—Workload of greater than 5 METs but not greater than 7 METs results in dyspnea, fatigue, angina, dizziness, or syncope; or evidence of cardiac hypertrophy or dilatation on electrocardiogram, echocardiogram, or X-ray 10 percent—Workload of greater than 7 METs but not greater than 10 METs results in dyspnea, fatigue, angina, dizziness, or syncope; or continuous medication required 3 One MET is equivalent to a metabolic rate that consumes 3.5 milliliters of oxygen per kilogram of body weight per minute (roughly the oxygen uptake of someone sitting quietly). http://prevention.sph.sc.edu/tools/compendium.htm (accessed May 1, 2007).

OCR for page 69
A 21st Century System for Evaluating Veterans for Disability Benefits Limitations in the Activities of Daily Living It is common to differentiate functional limitations at the physiologic or anatomic level, as in the examples above, from functional limitations at the person level, which are measured by scales of activities of daily living (ADLs) and instrumental activities of daily living (IADLs) (Box 3-2). ADLs and IADLs are considered to be measures of the net impact of an impairment or impairments on an individual’s ability to engage in life situations. The distinction is useful because physicians are trained to evaluate impairment but rarely are taught to evaluate the capacity of individuals to function in daily life. Evaluation of impairment is based on an examination of a patient and his or her test results, medical history, and symptoms, while evaluating the functional capacity of an individual is based on performance measures (e.g., ambulation, lifting specified loads). The Veterans Health Administration (VHA) uses ADL and IADL assessments, for example, in deciding whether a post-stroke patient needs inpatient rehabilitation, the level of inpatient care needed, and readiness for discharge (VA, 2007). The Veterans Benefits Administration (VBA) does not use ADLs, IADLs, or other whole-person functional assessments to evaluate service-connected injuries and diseases, except for mental disorders. For mental disorders, the Rating Schedule has criteria to assess the degree of occupational and social impairment on a six-point scale from 0 to total. BOX 3-2 ADLs and IADLs Activities of daily living (ADLs) scales were developed beginning in the 1960s to assess ability to perform self-care activities such as dressing, bathing, grooming, toileting, transferring (getting into or out of bed or a chair), and eating. The original purpose was to assess the disability of individuals in inpatient rehabilitation settings and nursing homes to determine what kind of help they need and to monitor their progress (Katz et al., 1963; Mahoney and Barthel, 1965). ADL scales have been adapted to clinical settings. Instrumental activities of daily living (IADLs) were developed to assess the ability of elderly and disabled individuals to live independently in the community (Lawton and Brody, 1969). These activities include managing money, using a telephone, preparing meals, performing light or heavy housework, walking across the room, climbing up stairs, going outside, shopping, and getting around in the community. Neither ADLs nor IADLs directly measure capacity to work.

OCR for page 69
A 21st Century System for Evaluating Veterans for Disability Benefits The Australian Department of Veterans’ Affairs uses ADLs to determine impairment ratings of conditions for which criteria either do not exist in the body system tables or are inadequate or inappropriate. The intent of using ADLs is to assess conditions that result in a veteran being housebound or nearly housebound, chairbound, or bedridden (e.g., effects of severe strokes, Parkinson’s disease, heart failure, respiratory disease, or liver or kidney failure) or to assess non-specific indicators of disease or injury (e.g., pain, lethargy, or poor prognosis of life expectancy). An ADL-based rating of a single condition can be combined with body system-based ratings of other conditions, or the ADLs can be used to rate all conditions. The evaluator grades six ADLs—movement in bed, transfers, locomotion, dressing, personal hygiene, and feeding—on a scale from 0 to 8. The total of the six scores is converted using a table to an impairment rating ranging from 0 to 70. The evaluator also uses a second set of criteria based on effects of symptoms such as pain or lethargy and decreased life expectancy to derive an impairment rating from 0 to 35. The higher of the two ratings is used to determine the amount of compensation (Australian DVA, 2005). Disability This chapter uses disability as a broad term that includes work disability and quality of life in order to be responsive to the tasks assigned to the committee. Work disability refers to the loss of earning capacity (or impairment in earning capacity) or the actual loss of earnings resulting from an injury or disease. Loss in quality of life refers to the consequences of an injury or disease other than work disability. These definitions are refined in the rest of this chapter. Impairments of Earning Capacity (Work Disability) Work disability has two meanings. Actual loss of earnings is the extent of actual loss of earnings resulting from the injury or disease. Loss of earning capacity (which is the same as impairments of earning capacity) is the presumed loss of earning capacity resulting from the injury or disease. Loss of earning capacity is more a legal or economic concept than a medical concept. It is used in the legal system as a basis for determining damages in personal injury cases. It was carried over into workers’ compensation programs, which were established in the early 20th century to replace the tort system in dealing with accidents at work. When disability benefits for veterans were established by an amendment of the War Risk Insurance Program in 1917, the concept of a rating schedule to compensate for

OCR for page 69
A 21st Century System for Evaluating Veterans for Disability Benefits diminished earning capacity was borrowed from state workers’ compensation programs.4 Conceptually, loss of earning capacity is not the same as loss of actual earnings because, for various reasons, some people earn less than they could earn, or they earn more than expected given the seriousness of their injuries. In legal proceedings, there must be a reasonable basis for determining earning capacity. Vocational specialists often have a key role in determining what jobs a person might be able to perform given his or her age, education, occupation, skills, knowledge, and experience, and what such jobs usually pay. In practice, past earnings are usually the basis for tort awards, because there is little evidence of earning capacity except actual preinjury earnings (Horner and Slesnick, 1999). Quality of Life Despite the limitations of our current models for measuring disability, researchers have pointed out the importance of including more global measures of health status and health-related quality of life (HRQOL) when measuring outcomes (IOM, 1997). It is also important to emphasize that these measures are not meant to replace traditional measures of impairment, limitations in ADLs, or work disability. The current role of these broader measures of outcomes such as HRQOL is to expand the scope of evaluation research and the scope of policy making. More research is needed to better understand how HRQOL relates to work disability, including loss of earning capacity. According to the IOM model of disability (1997), the disabling process is a product of the interaction of the person and the environment, thereby influencing one’s quality of life. Defining Quality of Life The concept of quality of life (QOL) can be traced back to the ancient Western philosopher Aristotle, who described it as “happiness,” a “certain kind of virtuous activity of the soul” (Zhan, 1992). Attempts to define QOL in the United States at the societal level were initiated by President Eisenhower’s Commission on National Goals (Weisgerber, 1991). Later during the 1970s the concept began being used in reference to the individual (Wolfensberger, 1994). Historically, the United States has measured the success of its efforts to improve the health of its citizens on the basis of mortality statistics. Gains in human longevity no doubt have been accompanied by 4 The 1917 amendments authorized “monetary payments, for disability incurred or aggravated in armed service, based largely upon the practices of state employees compensation laws, and called ‘disability compensation’ instead of ‘pensions’” (Griffith, 1945).

OCR for page 69
A 21st Century System for Evaluating Veterans for Disability Benefits increases in the incidence and prevalence of morbidity and accompanying disabilities (IOM, 1997). Within the last few decades, the emphasis on such measurement has changed from the quantity to the quality of life. Both the economic and human costs of disability are enormous. Approximately one-third of people with physical, mental, or sensorial disabilities have disabilities so severe that they are unable to carry out the major activities of their age group, such as attending school, working, parenting, or providing self-care (IOM, 1997). As a result, attention must be focused not only on preventing disease and injury but on treatment and rehabilitation. By definition, the concept of QOL covers many dimensions of one’s life: cultural, psychological, physical, interpersonal, spiritual, financial, political, temporal, and philosophical. Furthermore, QOL is dynamic because it reflects changes in people and the environment over time across many of its domains (Tate et al., 1996). Shumaker et al. (1990) define QOL on three levels varying from global to specific. The global dimension or overall assessment is “an individual’s overall satisfaction with life, and one’s general sense of well-being.” The middle level includes the four domains of physical, psychological, social, and economic aspects of QOL, and the lowest level includes all aspects of each domain that are specifically assessed by different QOL measures. Psychological well-being, therefore, might be determined by a combination of factors such as the absence of negative states such as depression, anxiety, or posttraumatic stress disorder, and by the presence of positive states such as effective coping skills and a healthy self-esteem. Different approaches have been used to evaluate the QOL of individuals with disease and injury. Highlighting its importance to successful rehabilitation, the concept has been studied in a variety of conditions including cardiovascular disease, cancer, renal disease, spinal cord injury, traumatic brain injury, stroke, and lung disease, to mention a few. QOL is viewed as an important indicator of a patient’s overall health across time. HRQOL components can include signs or symptoms, treatment side effects, or physical, cognitive, emotional, and social functioning. During the progression of chronic disease or disability, HRQOL components can interact with other QOL dimensions (e.g., financial, workplace, and environmental accessibility factors) in a number of situations. These dimensions also may affect a person’s ability to cope with injury or disease and successfully respond to interventions. The concept of QOL is thus critical to the enabling-disabling process as outlined in Enabling America, which assessed the state of rehabilitation science and engineering (IOM, 1997). This report illustrated how biological, environmental (physical and social), and lifestyle/behavioral factors are involved in reversing the disabling process. The availability of

OCR for page 69
A 21st Century System for Evaluating Veterans for Disability Benefits more comprehensive health services is particularly important and timely because of the growing needs of veterans with disabilities and the demand for rehabilitation services that extend beyond the physical realm. New developments in rehabilitation science and engineering are essential to restore human functional capacity and to improve a person’s quality of life and interactions with the surrounding environment. QOL Assessments There are many approaches to assessing the health of a person. Most include measurements in several domains. The term domain is used to describe the physical, psychological, and social aspects of an individual’s activities. For example, measures of physical impairments, which might include anatomical or physiological abnormalities, are thought to contribute to overall function and quality of life. In addition, measures of limitations of function, such as gait velocity or prehension, are done because they provide an accurate and quantitative picture of what an individual is able to perform. Measures of disability are also acknowledged as being useful because they place the abnormalities within the context of an individual’s daily routines. In 1948, the World Health Organization (WHO) prompted a major departure from the disease-driven orientation previously adopted to define the concept of health and to assess outcomes. WHO stated that “physical, mental, and social well-being and not merely absence of disease” defines health. The definition helped set the conceptual framework for what constitutes treatment goals, thereby acknowledging the importance of using multidimensional outcome measures that would include the domains of physical, mental, and social health, and measures of function and disability. Toward this end, WHO devised the International Classification of Functioning, Disability and Health (ICF) to reflect advances in science and to acknowledge the individual’s values and goals within the context of his or her unique social and physical environment. The ICF comprises four domains: measures of body function; measures of body structures; measures of activity and participation at the level of the person; and environmental support (physical and social). There has been considerable interest in the multi-domain approach to assessment for several reasons:

OCR for page 69
A 21st Century System for Evaluating Veterans for Disability Benefits The information age has educated individuals about what is possible The public has higher expectations about what can be achieved by an individual following illness and injury The Americans with Disabilities Act has identified regulations about the need to remove environmental barriers and increase opportunities for people with disabilities Medical practice and health services have advanced such that amelioration of disability and restoration of function is feasible with greater frequency In general, the health-care establishment is committed to helping reduce the burden of disease, but has become increasingly aware of patient priorities, which include the desire to be independent, to maintain valued activity, and to have a sense of well-being in all aspects of daily life—in short, to achieve a good quality of life. The Centers for Disease Control and Prevention (CDC) defines QOL as the perception of physical and mental health over time (CDC, 2007). When it is referred to as HRQOL, QOL is frequently linked with function and/or health status. Function is not the same as QOL. Functional assessment is designed to measure what individuals are doing. It is a measure of the degree to which an individual can perform chosen roles (as well as duties and responsibilities) without physical, social, psychological, or cognitive limitation. What distinguishes the functional assessment from the QOL or the HRQOL instrument is the component of measuring patient satisfaction. HRQOL is designed to measure what an individual values and whether there is much satisfaction in one’s life. Many instruments have been developed. Some have been designed to rate specific activities based on their importance to an individual and others to assess the impact of these activities on the individual’s feelings of satisfaction and competence. QOL measures address the value of the activity to the individual. Functional measures and QOL indicators are measures of different but complementary phenomena, and a substantial body of data show that physical findings and disease severity do not always correlate with patient self-reported QOL. Controversy exists about whether such measures are more about life than health and whether health care should consider QOL measures as relevant given that the social, financial, and spiritual components of life usually most influence quality. Nevertheless, as individuals become more knowledgeable about health-care options, and as data are provided about the risks and benefits of these options, individuals are (and should be) participating more in decision making. As a result, an increasing number of

OCR for page 69
A 21st Century System for Evaluating Veterans for Disability Benefits tional percentage points for loss of QOL.5 The resulting total of the medical impairment rating and the QOL rating is called the “disability assessment.” This is done for each condition, and the results are combined to determine the overall rating, which forms the basis for the amount of compensation.6 The Canadian method of compensating for loss of QOL is administratively feasible but far from a full assessment of QOL. Most Canadian provinces compensate workers for non-economic loss in addition to or, in some cases, when compensation for non-economic loss would be higher, in place of compensating for loss of earning capacity. Non-economic loss is usually based on degree of impairment, measured by the American Medical Association’s (AMA’s) Guides to the Evaluation of Permanent Impairment or similar impairment schedule. Although intended to compensate for losses suffered despite ability to work, Sinclair and Burton’s study of the Ontario workers’ compensation program found that impairment ratings based on the AMA Guides did not well predict loss of quality of life (Sinclair and Burton, 1995). The Australian Department of Veterans’ Affairs (DVA) compensates veterans for “permanent impairment, pain and suffering and the lifestyle restrictions which are a result of the accepted [i.e., service-connected] injury or disease” (Australian DVA, 2006). First, DVA determines an impairment rating between 5 and 100 percent using a Guide to Determining Impairment and Compensation (Australian DVA, 2005). Second, DVA determines a lifestyle rating based on the extent an individual is limited in fulfilling roles normal for a veteran without a service-connected injury or disease. The lifestyle rating is an average of ratings on four scales—personal relationships, mobility, recreational and community activities, and employment and domestic activities (Australian DVA, 2005).7 The impairment rating and lifestyle rating are then combined using a table, and the resulting compensation factor (expressed as a percentage between 0 and 1) is multiplied by the maximum permanent impairment pay amount to produce the monthly amount of compensation (Australian DVA, 2005). The lifestyle factor accounts for 15 percent of the compensation factor for impairment ratings up to 50, a lesser amount for impairment ratings between 50 and 80, and 0 percent of the compensation factor for impairment ratings 80 and higher (because the compensation factor for impairment ratings of 80 and higher is 1, the maximum that can be awarded). 5 The maximum rating for impairment plus loss of QOL is 100 percent. 6 The rating manual is available at http://www.vac-acc.gc.ca/clients/sub.cfm?source=dispen/2006tod/ch_02_2006/ (accessed March 19, 2007). 7 There are two scales for the last domain, one for domestic activities and one for employment activities. The higher of the two ratings is used.

OCR for page 69
A 21st Century System for Evaluating Veterans for Disability Benefits THE RELATIONSHIPS AMONG THE CONCEPTS IN THE DISABILITY MODEL The preceding section provided a model of disability and definitions and discussions of the salient concepts embedded in that model, including impairment, limitations in ADLs, work disability (including impairments in earning capacity), and QOL. One crucial point is that a distinction must be made between the purpose of a disability compensation program (a topic considered in the next section) and the operational basis for the benefits (a topic considered in this section, in the next chapter, and in Appendix C). Use of Proxies for Wage Loss in Workers’ Compensation State workers’ compensation programs differ with respect to whom they cover, which injuries and diseases are covered, benefit levels, and administrative rules. All states provide benefits for temporary disabilities (that is, benefits between the date of injury and the date of “maximum medical improvement,” when the healing period is completed). During the temporary disability period, workers’ compensation benefits are only paid if the worker has an actual loss of earnings. After the date of maximum medical improvement, states differ in their approaches to permanent disability benefits. Almost all state workers’ compensation statutes have a schedule, or list, of body parts that are covered and an indication of how loss of each body part, such as a finger, hand, leg, eye, or hearing, is compensated for workers with permanent partial disability, which constitutes the vast majority of cases with permanent consequences. Scheduled permanent partial disability benefits are based on an assessment of the degree of permanent impairment, where the permanent impairment is used as a proxy for the expected losses of earnings. Spine injuries, head injuries, organ damage, and occupational diseases, however, are usually not on the schedule. Nonscheduled permanent partial disability cases are paid on the basis of three approaches. The most common approach is to pay for the degree of permanent impairment without regard to future earnings losses, usually based on use of the AMA Guides, where the permanent impairment is used as a proxy for actual losses of earnings. The second approach pays permanent partial disability benefits after a determination of the worker’s loss of earning capacity, based on the extent of permanent impairment and other factors, such as his or her age and previous work experience. A few states pay permanent partial disability benefits based on the worker’s actual wage losses, which is much more complicated to administer. Some states use a combination of two or even all three approaches, depending on the type and severity of the worker’s injury (Barth, 2003/2004; Burton, 2005).

OCR for page 69
A 21st Century System for Evaluating Veterans for Disability Benefits Use of Proxies for Wage Loss in the Veterans Disability Compensation Program Although the official name of the VA Rating Schedule is the Veterans Administration Schedule for Rating Disabilities, it mostly uses proxy measures of assessing the extent of work disability. Proxy measures include degree of anatomic loss (e.g., 70 percent for amputation or loss of use of a dominant hand);8 and extent of functional loss of an organ (e.g., 10, 30, 60, or 100 percent for diminished lung capacity because of asthma, bronchitis, emphysema, or chronic obstructive pulmonary disease).9 The Rating Schedule considers social and economic impacts only in rating mental disorders. For example, 30 percent is given for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal [sic]), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events).10 Although the veterans disability compensation program borrowed the ideas of a schedule of monthly benefits for particular impairments and loss of earning capacity from workers’ compensation, some significant changes were made. In the state programs, the schedule normally lists a duration of benefits that depends on the severity of the permanent impairment, which is paid out weekly at a fraction of the worker’s preinjury wages (typically two-thirds) until the total is reached. In the veterans compensation program, the monthly amount is paid for life. The VA approach assumes the impairment is permanent, an assumption at odds with current thinking on rehabilitation. The schedule also included all injuries and diseases, not just specific body parts. The loss of earning capacity rather than actual wage loss probably seemed more appropriate because many veterans do not have a civilian job before entering the service. Implicitly, the policy 8 Diagnostic codes 5124 (amputation) and 5125 (loss of use) in the Rating Schedule (loss, or loss of use, of the non-dominant hand is rated 60 percent). 9 As measured by a FEV1 (forced expiratory volume in one second) test. An FEV1 result of less than 40 percent of predicted value equals a rating of 100 percent, 40–55 percent equals 60 percent, 56–70 percent equals 30 percent, and a 71–80 percent equals 10 percent (diagnostic codes 6600 and 6602–6604 in the Rating Schedule). 10 These are the criteria for all of the mental disorders except eating disorders (diagnostic codes 9201–9440 in the Rating Schedule).

OCR for page 69
A 21st Century System for Evaluating Veterans for Disability Benefits acknowledged the difference between impairment and disability by (1) recognizing that individuals with the same severity of impairment will have a range of earnings and (2) allowing veterans with impairments to earn as much as they want without affecting the amount of their compensation. In 1933, VA officially recognized that some individuals are not able to earn as much as others with the same degree of impairment, by establishing the individual employability (IU) benefit and, further, allowing individuals who do not meet the minimum schedular rating degree to quality for IU to appeal to the administrator for total disability benefits. Perhaps because earning capacity is not the same as actual earnings, successive VA Rating Schedules, including the current one, have not been based on empirical comparisons of the actual earnings of veterans at the various rating levels with veterans who are not rated for disability. In 1945, for example, VA’s Disability Policy Board, mostly made up of physicians and some lawyers, set the criteria for rating the conditions in the Rating Schedule: According to a former Director of VA’s Compensation and Pension Service, VA’s Department of Medicine and Surgery, now the Veterans Health Administration, provided the Board with a medical monograph—a detailed description of etiology and manifestations—for each of the conditions included in the schedule at that time. The Board used these monographs to estimate the relative effects different levels of severity of a condition have on the average veteran’s ability to compete for employment in the job market … [and] set the ratings on this basis (GAO, 1997). According to VA, the 1945 Rating Schedule was “more detailed than the 1933 schedule.” It “reflected society’s reduced reliance on manual labor and had a greater appreciation of the effect of mental disability.” “The 1945 scheme remains in effect with changes made as the need arose and with the assistance from Veterans Health Administration” (Pamperin, 2006). The Disability Policy Board of eight physicians and lawyers was responsible for revising the Rating Schedule until it was abolished in 1969 (GAO, 1989). In 1956, the President’s Commission on Veterans’ Pensions, chaired by retired Army general Omar Bradley, commissioned surveys of representative samples of veterans and of veterans receiving disability compensation and compared the median earnings of each group, for example, veterans without disabilities, veterans rated 10 percent, veterans rated 20 percent, and so on, up to veterans rated 100 percent. The results showed veterans had lower earnings as rating levels increased, with an especially sharp drop off at 100 percent (President’s Commission, 1956). When the amount of monthly compensation was added in, however, veterans with disabilities had about the same income as veterans without disabilities except at the

OCR for page 69
A 21st Century System for Evaluating Veterans for Disability Benefits 100 percent rating level. On average, veterans rated 100 percent earned about 10 percent less than veterans without disabilities. Probably as a result of this finding, Congress raised the benefit amount for 100 percent in 1957 relative to the rest of the rating levels, a difference that has widened over the years (Economic Systems, 2004a). When the Bradley Commission looked at the average income of veterans with mental and neurological diseases and those with general medical and surgical conditions separately, it found that the former group had 10–20 percent less income than the latter at most rating levels (President’s Commission, 1956). In 1971, VA conducted an “economic validation” of the Rating Schedule, with a sample size large enough to compare 1967 earnings of veterans at one or more rating levels of most of the diagnostic categories with those of veterans without disabilities with similar demographic characteristics. Known as the ECVARS study, for Economic Validation of the Rating Schedule, it found that the difference between the earnings plus compensation of veterans with disabilities at a given rating level and the earnings of veterans without disabilities varied by condition, in some cases giving veterans with disabilities higher rating percentages than percentages of actual earnings losses, in other cases giving them lower rating percentages than actual earnings losses.11 Like the Bradley Commission, ECVARS found that the drop-off in earnings was especially severe for those rated 100 percent, and that those with mental conditions consistently had substantially lower earnings. In all, ECVARS found that for about 330 of the 700 conditions studied, the rating criteria overestimated average loss in earnings, and for about 75, the rating criteria underestimated the average loss in earnings (GAO, 1997). VA submitted a Rating Schedule with criteria adjusted according to the ECVARS findings, but Congress declined to act on it (U.S. Congress, Senate, Committee on Veterans’ Affairs, 1973). In conclusion, average impairments in earnings is an abstract concept that cannot be measured directly. Its origins are legal, not medical. As used by VA, it is based on judgment, and it is not linked to observed average losses of actual earnings by veterans at each rating level or with particular conditions. PURPOSE OF SERVICE-CONNECTED DISABILITY COMPENSATION Compensation for average loss of earning capacity is the official statutory purpose of the veterans disability compensation program. The concept of average loss dates from the War Risk Insurance program amendments of 1917: 11 The ECVARS is also discussed in Chapter 4 and in Appendix C.

OCR for page 69
A 21st Century System for Evaluating Veterans for Disability Benefits A schedule of ratings of reductions in earning capacity from specific injuries or combinations of the injuries of a permanent nature shall be adopted and applied by the Bureau. The ratings shall be based as far as is practicable upon the average impairments of earning capacity resulting from such injuries in civil occupations, and not upon the impairment in each individual case, so that there shall be no reduction in the rate of compensation for individual success in overcoming the handicap of a permanent injury (Douglas, 1918:473).12 Several widely accepted conceptual models of disability exist and, although they differ in details, all in some way distinguish among medical impairment, functional capacity, and disability (WHO, 2001; IOM, 1991, 1997; NCMRR, 1993; Nagi, 1976). Rather than assuming that the level of impairment is highly correlated with the extent of disability, they conceive of disability as the result of the interaction between an individual’s functional limitations and his or her environment, unlike the anatomical approach of the Rating Schedule. This approach accounts for the fact that individuals with similar impairments have different degrees of disability. These models of disability also conceive of disability as broader than inability to work. Disability also includes the inability to engage in any of the range of activities that most people enjoy, such as going to school, interacting socially, having a family, traveling, and managing one’s legal and economic affairs. The ability to participate in this range of activities represents a person’s QOL. Disability in America included QOL as a factor in disability. The report called for improved QOL measurement to use in assessments of health and disability because QOL corresponds to overall well-being with both physical and psychosocial dimensions and is more than the absence of disease or injury (IOM, 1991). The Rating Schedule is a tool or instrument used by VA to rate disability on a scale ranging from 0 to 100 percent in intervals of at least 10 percent. As a tool, the Rating Schedule is a means to an end or a method of achieving a purpose. Therefore, to evaluate the performance of the Rating Schedule and to make recommendations for improving it, the purpose of the compensation program should be as clear as possible. If there are multiple purposes, each should be clear, and the appropriate desired trade-offs should be specified. There are differences in views about what is or should be the purpose or the intent of compensating veterans. The statutory purpose is clearly economic: To compensate veterans for “the average impairments of earning capacity resulting from such injuries in civil occupations.” The intent may not have been to compensate for each individual’s actual loss 12 The Bureau referred to in the law is the Bureau of War Risk Insurance, a predecessor agency of today’s VA.

OCR for page 69
A 21st Century System for Evaluating Veterans for Disability Benefits of earnings, but the fundamental reason for the program was to provide economic assistance to servicemembers and their families.13 At the time it was established, the program was clearly seen as a form of social insurance to protect veterans and their families from economic hardship (Douglas, 1918). A recent study of veterans disability compensation legislation cites a number of indications of congressional intent to provide economic security (Economic Systems, 2004b). Another view of the purpose of the disability compensation program is that it is in part an indemnification against enduring losses, such as blindness, amputation, or PTSD, and other permanent effects, such as pain, and it includes losses that do not seem likely to affect a veteran’s earning capacity or ability to work. Proponents of the latter opinion point out features of the program, many mandated by Congress, that imply compensation for losses other than earning capacity, such as disfigurement, loss of a limb or an organ, pain and suffering, social maladjustment, and diminished QOL. The same legislative history cited above for references to the economic intent of disability compensation also found instances of intent to compensate for loss of QOL (Economic Systems, 2004b). VA itself acknowledges a broader purpose in its 2006–2011 strategic plan. Strategic goal one is “Restore the capability of veterans with disabilities to the greatest extent possible, and improve the quality of their lives and that of their families.” Objective two under this goal is “Provide timely and accurate decisions on disability compensation claims to improve the economic status and quality of life of service-disabled veterans” (VA, 2006:36).14 In addition, using the degree of anatomic and functional loss of body structures and processes (i.e., impairment) as the basis for amount of compensation, rather than evaluating the veteran’s ability to function in daily life and earn a living (i.e., disability), makes the compensation in part an indemnification or recognition of permanent damage or loss. FINDINGS AND RECOMMENDATIONS The conceptualization of disability and disability rating has evolved since the Rating Schedule was developed. For the most part, the statutory and regulatory provisions of the VA disability compensation program are based on impairments used as a proxy for work disability. There are, however, policies within the disability compensation system that do not strictly follow the view that the sole purpose of benefits is to compensate for work 13 Other sections of the act as amended in 1917 provided for allowances for families with a member serving in the military and for life insurance for servicemembers. 14 Objective one is provision of specialized health care to maximize the functioning of disabled veterans.

OCR for page 69
A 21st Century System for Evaluating Veterans for Disability Benefits disability. The Rating Schedule seems intended to evaluate impairments as proxies for a diverse set of objectives (indemnification against limitations in the ADLs, work disability, and losses in QOL) without making clear the relationships among these constructs. This inconsistency in the VA system in part reflects the evolving concepts and approaches to assessing disability. Today, disability is seen to be more than impairment of earning capacity. Over the years, VA and Congress have implicitly recognized the extent of impact that service-connected injuries and diseases can have on veterans by including conditions in the Rating Schedule that have little if any effect on ability to work. These expansions of the conditions covered by the Rating Schedule have been ad hoc, however, and may not address the full range or extent of nonwork impacts of injuries and diseases suffered while in military service. A clear legislative statement of the purpose or purposes of the veterans disability compensation program would be tremendously helpful in evaluating and updating the Rating Schedule and the procedures for its application, which would include the appropriateness of the rating criteria, which tests and examinations should be used, and determination of the appropriate types and amounts of expertise needed for implementation, such as using medical rather than vocational experts. A conceptual model—the ICF—links impairment and limitations in ADLs to work disability as well as nonwork disability (e.g., pain and suffering, distress, and poor personal relationships). The ICF, and similar models such as Nagi’s and the IOM’s (Nagi, 1976; IOM, 1991, 1997),15 reflect the way we think about disability today. These more modern conceptual models of disability require broader thinking about impairments, functional limitations, and their relationship to disability (both work and nonwork). It calls for more complex assessments from disability determination systems. It requires more data to make the determinations, and it also requires more empirical evidence about the relationships among the components of the model. Empirical evidence measuring the relationships among impairment, functioning of the individual, work disability, and quality of life is key to a valid and fair system of disability determination. In the absence of empirical evidence, the relationships should be based on up-to-date expert opinion. The VA disability assessment process also provides a key opportunity to assess the rehabilitation needs of veterans with impairments, and then to ameliorate them and restore function, when possible. It also provides for an opportunity to prevent disability. A system of services for veterans transitioning to civilian life, including health, vocational rehabilitation, 15 An appendix to the 1991 IOM report contains perhaps the most complete explication of Nagi’s conceptual framework.

OCR for page 69
A 21st Century System for Evaluating Veterans for Disability Benefits employment, and education services, calls for multidimensional qualitative and quantitative measures to assess disability. Recommendation 3-1. The purpose of the current veterans disability compensation program as stated in statute currently is to compensate for average impairment in earning capacity, that is, work disability. This is an unduly restrictive rationale for the program and is inconsistent with current models of disability. The veterans disability compensation program should compensate for three consequences of service-connected injuries and diseases: work disability, loss of ability to engage in usual life activities other than work, and loss in quality of life. (Specific recommendations on approaches to evaluating each consequence of service-connected injuries and diseases are in Chapter 4.) The committee is aware that adopting Recommendation 3-1 would be difficult and costly. Legislative endorsement would be very helpful, if not required, to ensure its adoption and implementation. If the recommendation is adopted, the Rating Schedule and the procedures needed to implement it will need to be revised to reflect the expanded purposes for disability benefits endorsed by the committee. This can be done in phases after appropriate research and analysis and pilot projects to study the feasibility of changes have been effected. This issue is addressed in Chapters 4 and 5. Expanding the bases for veterans disability compensation also has cost implications. There will be start-up costs incurred in developing the instruments for evaluating degree of functional limitation and loss of QOL, transitional costs, probably higher administrative costs, and possibly greater compensation costs (if the current Rating Schedule does not adequately compensate for loss of function and QOL). Although the committee was not asked to consider costs in recommending improvements in medical evaluation of veterans for disability benefits, the issue is addressed at the end of Chapter 4. In addition, if disability compensation is considered in the larger context of veterans benefits and is taken in conjunction with today’s views on the rights of individuals with disabilities to live as full a life as possible, it is possible to justify a more comprehensive evaluation of a veteran’s needs—medical, educational, vocational, and compensation. Currently, the assessment process is piecemeal and fragmented. Either the veteran must receive a rating to access related services, such as health care and vocational rehabilitation and employment services, or the other service is separate, such as with education. This issue is addressed in Chapter 6.

OCR for page 69
A 21st Century System for Evaluating Veterans for Disability Benefits REFERENCES Australian DVA (Department of Veterans’ Affairs). 2005. Guide to determining impairment and compensation. Instrument No. M9 of 2005. Military Rehabilitation and Compensation Commission, Australian Government. http://www.comlaw.gov.au/ComLaw/Legislation/LegislativeInstrument1.nsf/0/18CD3003DD8A7A1DCA25700E0019A473?OpenDocument/ (accessed May 22, 2007). Australian DVA. 2006. Permanent impairment compensation payments. Fact Sheet MRC 07. Department of Veterans’ Affairs, Australian Government, October 31. www.dva.gov.au/factsheets/default.htm (accessed May 22, 2007). Barth, P. S. 2003/2004. Compensating workers for permanent partial disabilities. Social Security Bulletin 65(4):16–23. http://www.ssa.gov/policy/docs/ssb/v65n4/v65n4p16.pdf (accessed March 19, 2007). Burton, J. F., Jr. 2005. Permanent partial disability benefits. In Workplace injuries and diseases: Prevention and compensation, edited by K. Roberts, J. F. Burton, Jr., and M. M. Bodah. Kalamazoo, MI: W. E. Upjohn Institute for Employment Research. Chapter 4. CDC (Centers for Disease Control and Prevention). 2007. Health-related quality of life. http://www.cdc.gov/hrqol/ (accessed March 23, 2007). Douglas, P. H. 1918. The War Risk Insurance Act. Journal of Political Economy 26(5):461–483. Economic Systems, Inc. 2004a. VA disability compensation program: Literature review. Washington, DC: Department of Veterans Affairs. http://www.va.gov/op3/docs/Final_Report-LiteratureReview.pdf (accessed March 19, 2007). Economic Systems, Inc. 2004b. VA disability compensation program: Legislative history. Washington, DC: VA. http://www.va.gov/op3/docs/Disability_Comp_Legislative_Histor_Lit_Review.pdf (accessed March 19, 2007). GAO (Government Accountability Office). 1989. Veterans’ benefits: Need to update medical criteria used in VA’s disability rating schedule. GAO/HRD-89-28. Washington, DC: GAO. http://www.gao.gov/archive.gao.gov/d17t6/137639.pdf (accessed March 19, 2007). GAO. 1997. VA disability compensation: Disability ratings may not reflect veterans’ economic losses. GAO/HEHS-97-9. Washington, DC: GAO. http://www.gao.gov/archive/1997/he97009.pdf (accessed March 19, 2007). Griffith, C. M. 1945. The Veterans Administration. In Doctors at war, edited by M. Fishbein. New York: E. P. Dutton & Company. Chapter XIV. Horner, S. M., and F. Slesnick. 1999. The valuation of earning capacity definition, measurement and evidence. Journal of Forensic Economics 12(1):13–32. IOM (Institute of Medicine). 1991. Disability in America: Toward a national agenda for prevention, edited by A. M. Pope and A. R. Tarlov. Washington, DC: National Academy Press. IOM. 1997. Enabling America: Assessing the role of rehabilitation science and engineering, edited by E. Brandt and A. M. Pope. Washington, DC: National Academy Press. Katz, S., A. B. Ford, R. W. Moskowitz, B. A. Jackson, and M. W. Jaffe. 1963. Studies of illness in the aged. The Index of ADL: A standardized measure of biological and psychosocial function. Journal of the American Medical Association 185(12):914–919. Kazis, L. E. 2000. The Veterans SF-36 health status questionnaire: Development and application in the Veterans Health Administration. Medical Outcomes Trust Monitor 5:1–2. Lawton, M. P., and E. M. Brody. 1969. Assessment of older people: Self-maintaining and instrumental activities of daily living. The Gerontologist 9(3):179–186. Mahoney, F. I., and D. W. Barthel. 1965. Functional evaluation: The Barthel Index. Maryland State Medical Journal 14:61–65.

OCR for page 69
A 21st Century System for Evaluating Veterans for Disability Benefits Nagi, S. Z. 1976. An epidemiology of disability among adults in the United States. Milbank Memorial Fund Quarterly 54:439–467. NCMRR (National Center for Medical Rehabilitation Research). 1993. Research plan for the National Center for Medical Rehabilitation Research. NIH Publication No. 93-3509. Bethesda, MD: NCMRR. http://www.nichd.nih.gov/publications/pubs/upload/plan.pdf (accessed February 20, 2007). Pamperin, T. 2006. Overview of the department and the schedule for rating disabilities. Presentation to the IOM Committee on Medical Evaluation of Veterans for Disability Compensation, Washington, DC, May 25. Perlin, J., L. Kazis, K. Skinner, et al. 2000. Health status and outcomes of veterans: Physical and mental component summary scores, Veterans SF-36, 1999 large health survey of veteran enrollees. Washington, DC: Office of Quality and Performance, Veterans Health Administration, VA. President’s Commission (The President’s [Bradley] Commission on Veterans’ Pensions). 1956. A Report to the President: Veterans’ benefits in the United States, Volume I, Parts I and II: Findings and recommendations. 84th Cong., 2nd Sess. House Committee Print No. 236. Washington, DC: U.S. Government Printing Office. Shumaker, S. A., R. T. Anderson, and S. M. Czajkowski. 1990. Psychological tests and scales. In Quality of Life Assessments in Clinical Trials, edited by B. Spilker. New York: Raven Press. Pp. 95–114. Sinclair, S., and J. F. Burton, Jr. 1995. Development of a schedule for compensation of non-economic loss: Quality-of-life values vs. clinical impairment ratings. In Research in Canadian Workers’ Compensation, edited by T. Thomason and R. P. Chaykowski. Kingston, Ontario: IRC Press. Tate, D. G., M. Dijkers, and L. Johnson-Greene. 1996. Outcome measures in quality of life. Topics in Stroke Rehabilitation 2(4):1–17. U.S. Congress, Senate, Committee on Veterans’ Affairs. 1973. Veterans Administration proposed revision of Schedule for Rating Disabilities. 93rd Cong., 1st Sess. February 12. Senate Committee Print No. 3. Washington, DC: U.S. Government Printing Office. VA (Department of Veterans Affairs). 2006. Department of Veterans Affairs strategic plan, FY 2006-2011. http://www1.va.gov/op3/docs/VA_2006_2011_Strategic_Plan.pdf (accessed November 15, 2006). VA. 2007. Stroke rehabilitation VA/DoD clinical practice guidelines. http://www.oqp.med.va.gov/cpg/STR/STR_base.htm (accessed June 21, 2007). Weisgerber, R. A. 1991. Quality of life for persons with disabilities: Skill development and transitions across life stages. Rockville, MD: Aspen. WHO (World Health Organization). 1980. International classification of impairments, disabilities and handicaps. Geneva, Switzerland: WHO. WHO. 2001. International classification of functioning, disability and health: Short version. Geneva, Switzerland: WHO. Wolfensberger, W. 1994. Let’s hang up ‘‘quality of life’’ as a hopeless term. In The Quality of life for persons with disabilities. Disabilities: International perspectives and issues, edited by D. A. Goode. Cambridge, MA: Brookline Books. Zhan, L. 1992. Quality of life: Conceptual and measurement issues. Journal of Advanced Nursing 17:795–800.