This chapter lays the foundation for understanding the committee’s work on this project. The chapter begins with an overview of the Department of Veterans Affairs (VA), focusing on its mission and structure and on the role of compensation within that mission. Next is a synopsis of the major issues regarding VA’s compensation of veterans with posttraumatic stress disorder (PTSD). Then a summary of the committee’s charge is presented, and the chapter concludes with brief summaries of related National Academies research efforts and a description of the report’s organization.
VA’S MISSION AND STRUCTURE
“To care for him who shall have borne the battle and for his widow, and his orphan.” Those words—an affirmation of the government’s obligation to veterans and their families made by President Lincoln at his second inaugural address in 1865—constitute the mission statement of what is today called the Department of Veterans Affairs.
The present-day VA provides three primary services: health care, benefits and related social services, and cemetery management. Each of these services is provided by one of VA’s three line organizations: the Veterans Health Administration (VHA), the Veterans Benefits Administration, and the National Cemetery Administration. The scope of these operations is vast. VHA, for instance, manages the single largest integrated health care system in the United States. In 2005, at its 156 hospitals, 877 outpatient
clinics, 136 nursing homes, 43 residential rehabilitation treatment programs, and 207 readjustment counseling centers, it provided care to approximately 5 million individual patients and hosted 54 million outpatient visits (DVA, 2006b).
Overall, VA has the second-largest1 number of employees among the federal departments, more than 235,000 in 2006 (DVA, 2006b), and its estimated FY 2006 outlays were the fifth largest2 among all federal agencies (OMB, 2006a), with total FY 2006 appropriations of approximately $73.15 billion.
THE COMPENSATION LEGISLATION MANDATE AND RATIONALE IN PRACTICE
As detailed in Chapter 2, the U.S. government has long recognized a need to provide compensation to veterans for health problems associated with military service. The current legislative mandate, contained in Title 38 of the U.S. Code, specifies a single criterion for determining the level of compensation:
The Secretary shall adopt and apply a schedule of ratings of reductions in earning capacity from specific injuries or combination of injuries. The ratings shall be based, as far as practicable, upon the average impairments of earning capacity resulting from such injuries in civil occupations (38 USC §1155).
However, there is abundant evidence that both the VA and the Congress take other criteria into account. The 1956 Bradley Commission report on veterans’ benefits observed:
In the Veterans’ Administration system, the law specifies that the percentage awards are to be based on average impairment of earning capacity. This recognizes that the fundamental purpose of disability compensation is to assure the disabled veteran and his family the essential means for economic maintenance. In actual administration, however, it is clear that the Veterans’ Administration has not been able to adhere to this basic criterion as set forth in the law (Bradley Commission, 1956).
A 2002 GAO report noted that VA had rejected a GAO recommendation to revise the ratings schedule based on economic factors. VA’s June 24,
2002 response to the report,3 signed by then-Secretary Prinicipi, stated the reasons for this rejection:
the Schedule for Rating Disabilities from its beginnings in the early 20th Century has been medically based, as are all other major disability compensation systems;
the Schedule represents a consensus among Congress, VA, and the veteran community; and
the current medically-based schedule has been a valid basis for equitably compensating America’s disabled veterans for [a long time] and VA sees no reason to validate the ratings solely from an economic perspective (GAO, 2002).
The response further noted that VA had conducted an economic validation of the ratings schedule in 1973 but had not adopted any changes “because of widespread dissatisfaction in Congress, the veterans community, and VA.”
A 2004 report commissioned by VA asserts that the Congress intended that the determination of compensation level include considerations outside of impairment of earnings capacity, stating:
[Compensation] legislation does not explicitly state that intent of the disability program is to compensate for reduction in quality of life due to service-connected disability. However, this intent is implicit because Congress has set forth certain presumptions of eligibility for disability compensation and higher benefit levels for certain disabling conditions such as loss of a limb that reflect humanitarian concern about quality of life. The quality of life factor may be a more critical issue than employability for amputees given advances in medical technology and emphasis on occupations not requiring physical labor (DVA, 2004).
The report goes on to cite specific circumstances—such as disability compensation for the loss of one or both breasts4—that it asserts reflect Congress’ intent to factor quality of life in addition to economic impairment.
THE PLACE OF DISABILITY COMPENSATION IN VA’S OPERATION
The VA estimates that “[a]bout a quarter of the nation’s population— approximately 70 million people—are potentially eligible for VA benefits and services because they are veterans, family members or survivors of
veterans” (DVA, 2006a). These benefits and services take many forms, including disability compensation to veterans, survivor compensation to their dependants, pensions, education programs, home loan guarantees, subsidized insurance, vocational rehabilitation, and employment counseling.
Benefits disbursements account for more than half of the VA’s budget. A May 2006 VA publication reported that approximately $38.5 billion was allocated for benefits in FY 2006 (DVA, 2006b). Disability compensation makes up about 80 percent of this allocation. It is awarded as a monetary payment to veterans whose disability is deemed to be service-connected.
According to the Code of Federal Regulations, Title 38 (38 CFR), there are several ways to established service connectedness, the most common being:
the “injury or disease resulting in disability was incurred coincident with service in the Armed Forces” (38 CFR §3.303);
a preexisting injury or disease was aggravated by active service (38 CFR §3.306);
a presumptive service connection was established by law or VA policy (38 CFR §§3.307, 3.308, 3.309); and
the condition occurred as a result of an injury or disease incurred coincident with service (38 CFR §3.310).
The compensation amount is based on a determination of the degree of disability, which is ranked from 10 to 100 percent according to guidance contained in 38 CFR Part 4. “Individual unemployability” (IU) provisions in the regulation (38 CFR §4.16a) allow certain veterans who cannot be gainfully employed due to service-connected disabilities to be compensated at the 100 percent level even though their rating does not reach 100 percent.5
Where a veteran is a rated with more than one disability, a cumulative rating is calculated according to rules contained in 38 CFR §4.25. It states that the combined rating:
… results from the consideration of the efficiency of the individual as affected first by the most disabling condition, then by the less disabling condition, then by other less disabling conditions, if any, in the order of severity. Thus, a person having a 60 percent disability is considered 40 percent efficient. Proceeding from this 40 percent efficiency, the effect of a further 30 percent disability is to leave only 70 percent of the efficiency remaining after consideration of the first disability, or 28 percent efficiency altogether. The individual is thus 72 percent disabled….
The final rating—70 percent in the example above—is determined by rounding the calculated figure to the nearest number divisible by 10, with combined values ending in 5 adjusted upward.
The base amount determined by this protocol is then, where appropriate, supplemented for beneficiaries with a spouse, dependent children, or parents. Certain service-connected conditions that require special accommodations such as loss (or loss of use) of a limb are also granted supplements. Some veterans are eligible for additional monies via “special monthly compensation” for the loss or loss of use of certain capacities—loss of a reproductive organ, for example. However, the decision to grant or maintain disability compensation is made on the basis of statutory or regulatory requirements alone and these do not include consideration of individual economic need. Rates are adjusted for inflation on a yearly basis.
The scope of VA benefits available to veterans and—in some circumstances—their families is dependent on the rating assigned to his or her disabilities. Access to hospital care and outpatient care services at VA medical center services, for example, is prioritized based on criteria set down in Public Law 104-262, the Veterans’ Health Care Eligibility Reform Act of 1996. This law grants the highest priority (priority 1) to veterans with service-connected disabilities rated 50 percent or more, or who are determined by VA to be unemployable due to service-connected conditions. These veterans, along with veterans receiving care for a service-connected disability, also receive preferred access in scheduling of hospital or outpatient medical appointments. Veterans with service-connected disabilities rated 30 percent or 40 percent are priority 2; those with service-connected disabilities rated 10 percent or 20 percent, priority 3.6 Higher priority access to medical centers is important because system constraints may greatly restrict timely access to some services for veterans.
A spectrum of other benefits also uses disability rating as at least one of the criteria for eligibility.7 Vocational rehabilitation and employment (VR&E) assistance is available to veterans with a VA service-connected disability rated at least 20 percent with an employment handicap, or rated 10 percent with a “serious handicap.” Veterans whose service-connected disabilities are rated 30 percent or more are eligible for reimbursement for certain travel costs to receive VA medical care. The Concurrent Retirement and Disability Payments program provides a 10-year phase-out of an offset
to military retired pay due to receipt of VA disability compensation for veterans whose single or combined disability rating is 50 percent or greater.
If a veteran is rated as 100 percent disabled or is deemed eligible for IU benefits, the veteran and his or family are entitled to a number of additional benefits. These include access to VA outpatient dental treatment, unlimited exchange and commissary store privileges in the United States, and eligibility to receive a waiver of some premiums for VA life insurance. In some circumstances, the surviving spouses and children of such veterans may receive so-called Dependency and Indemnity Compensation, are eligible for support for some education and training, and may participate in CHAMPVA—the Civilian Health and Medical Program of VA—which provides reimbursement for most medical expenses: inpatient, outpatient, mental health, prescription medication, skilled nursing care, and durable medical equipment. Under a special program currently in place, veterans awarded 100 percent disability compensation based upon unemployability may still request a vocational rehabilitation evaluation and, if eligible, participate in a VR&E program and receive help in getting a job. VA will continue to pay 100 percent disability compensation to a veteran who secures employment under this program until the veteran has worked continuously for at least 12 months (DVA, 2005a). An Aid and Attendance allowance is available for some veterans, veterans’ spouses, surviving spouses, and parents who are in need of regular assistance to dress themselves or take care of other needs of everyday living (38 CFR §3.352).
Thus, even a 10 percent rating for a service-connected disability grants a potentially significant increase in access to VA benefits in addition to monetary compensation.
Chapter 2 of this report, which provides background on disability compensation, contains additional information regarding the federal government’s benefits programs for veterans. Chapters 4 and 5 address two major components of most PTSD compensation and pension (C&P) evaluations: the clinical examination and the rater’s decision.
WHY PTSD COMPENSATION IS AN ISSUE TODAY
Issues regarding the provision of benefits to veterans have risen in public prominence over the past few years. While a number of factors have contributed to this increased prominence, the three that have received particular notice are the increase in the number of veterans seeking and receiving benefits, the concomitant increase in benefits expenditures, and the prospect of a large number of veterans of Operation Iraqi Freedom and Operation Enduring Freedom (OIF/OEF) entering the system. In particular, compensation claims for PTSD have attracted attention because of the increasing numbers of claims in recent years and because diagnosing PTSD is
more subjective than is the case with many of the other disorders that VA administers benefits for.
A 2005 report by the VA Office of the Inspector General summarizes the trends in PTSD claims and compensation over the past five years (DVA, 2005b):
During FYs 1999–2004, the number and percentage of PTSD cases grew significantly. While the total number of all veterans receiving disability compensation grew by only 12.3 percent, the number of PTSD cases grew by 79.5 percent, increasing from 120,265 cases in FY 1999 to 215,871 cases in FY 2004. During the same period, PTSD benefits payments increased 148.8 percent from $1.72 billion to $4.28 billion. Compensation for all other disability categories only increased by 41.7 percent. While veterans being compensated for PTSD represented only 8.7 percent of all claims, they received 20.5 percent of all compensation benefits.
The Office of Management and Budget noted that the 59.5 percent growth in VA’s budget authority from 2001 to 2007 was the second-highest increase of any agency in the federal government (OMB, 2006b).
While the growth in claims has come largely from veterans of earlier conflicts, the VA benefits system will experience continued growth because of the coming wave of veterans of OIF/OEF. As of late 2006, approximately 1.5 million members of the military had been part of at least one of these operations, and more than a third of those 1.5 million were separated from their service and eligible for veterans’ benefits at that time. An analysis reported in the New York Times in October 2006 found that nearly one in five OIF/OEF veterans had been granted disability benefits and that 35 percent of that group had been granted benefits for a mental disorder (Shane, 2006).
INTENT AND GOALS OF THE STUDY
The VA charged the committee responsible for this study with reviewing:
compensation practices for PTSD, including examining the criteria for establishing severity of PTSD as published in the VA Schedule for Rating Disabilities;
the basis for assigning a specific level of compensation to specific severity levels and how changes in the frequency and intensity of symptoms affect compensation practices for PTSD;
how compensation practices and reevaluation requirements for PTSD compare with those of other chronic conditions that have periods of remission and return of symptoms; and
strategies used to support recovery and return to function in patients with PTSD8 (Szybala, 2006).
These four general charges were operationalized into a series of issues identified as being of particular interest. These included the appropriateness of the criteria used for rating PTSD severity, the management of comorbidities in the C&P evaluation process, the role of the Global Assessment of Functioning (GAF) score in evaluating PTSD, the scientific literature regarding the length of time between the occurrence of the stressor thought to be associated with an applicant’s PTSD and the appearance of symptoms, the value of standardized testing in C&P examinations, the advisability of periodic reexamination of PTSD compensation beneficiaries, and whether compensation might influence recovery and, if so, in what ways.
The remaining chapters of this report address these topics to the extent permitted by currently available science.
RELATED INSTITUTE OF MEDICINE REPORTS
The Institute of Medicine (IOM) has published several reports that address issues directly related to this study. These are cited and in some cases summarized below.
Reports on Disability Issues
The IOM and its sister organization, the National Research Council, have written a number of reports on topics related to disability compensation. These reports have, for the most part, focused on programs administered by the Social Security Administration (SSA).
Three reports released since 2000 have particular relevance. The Dynamics of Disability (IOM and NRC, 2002) responds to an SSA request for an independent review of the agency’s research plan for the redesign of its disability-decision process. It includes a working paper that puts forth a research agenda for SSA’s disability determination for mental impairments (Kennedy, 2001). Among its findings, the report noted that there was no agreement on the definition and measurement of disability, and it indicated that there was a need to develop objective measures of both the physical and the social environment.
Improving the Social Security Disability Decision Process, which was released first as an interim report (IOM, 2006a) and then as a final report
(IOM, 2007b), offers recommendations to the SSA on how to facilitate access and use appropriate medical expertise to support the Social Security disability adjudication process as well as on how to improve the Listing of Impairments, a screening tool that the SSA uses as part of its process of determining eligibility for disability payments under the Social Security Disability Insurance and Supplemental Security Income programs.
Reports on Veterans Health and Stress Issues
As part of a larger research effort on veterans’ health issues, committees of the IOM have been working on a series of reports on the effect of psychological stress on present and former members of the military. One of those reports has been published, while the rest are still forthcoming.
The 2006 report Posttraumatic Stress Disorder: Diagnosis and Assessment (IOM, 2006b) was the first of these reports to be released. It provided responses to ten questions posed by the VA, the report’s sponsor. Seven of these questions related directly to PTSD diagnosis and assessment:
What are the accepted diagnostic criteria for PTSD?
What would an evidence-based criteria set for diagnosis of PTSD include?
What are the components of an evidence-based diagnosis of PTSD?
What would diagnostic criteria be, based on best evidence, either based on or apart from official standards?
What are useful biomarkers [for diagnosis]?
What neuropsychological evaluation or other testing should be included in an optimal evaluation of a patient for PTSD?
What constitutes optimal evaluation of a patient for PTSD?
The other three questions were related to the more general subject of psychological stressors:
What constitutes a stressor?
How should stressful events be diagnosed and documented?
How can and should a patient document a stressful event?
This report is the second in the series. A third report, expected to be released later in 2007, will focus on PTSD treatment for veterans, reviewing the literature on various treatment modalities and treatment goals for individuals with PTSD. As part of its assessment, the committee responsible for the treatment report will review the strength of the evidence on the efficacy of pharmacotherapy and psychotherapy interventions for PTSD,
identify research gaps, make suggestions for future research, and address some related issues identified by the VA.
Two other IOM committees are currently addressing subjects that are closely associated with this research effort. A committee organized under the auspices of the Gulf War and Health series of congressionally mandated studies is conducting a comprehensive review, evaluation, and summary of the peer-reviewed scientific and medical literature regarding the association between deployment-related physiologic, psychologic, and psychosocial stress and long-term health effects in Gulf War veterans.9 The report on this topic will be issued in late 2007. A second effort, being conducted at the behest of the Veterans’ Disability Benefits Commission,10 is examining broader issues regarding the medical evaluation of veterans for disability compensation. The committee responsible for this work has produced the report A 21st Century System for Evaluating Veterans for Disability Benefits (IOM, 2007a), which will be released in the summer of 2007.
Earlier IOM reports have noted that PTSD is an issue for former prisoners of war in World War II and the Korean conflict (IOM, 1992), for Vietnam veterans (IOM, 1994), and for Persian Gulf veterans (IOM, 1995, 1996) in the course of broader discussions of the health of these groups.
ORGANIZATION OF THE REPORT
The remainder of this report is organized into six other chapters plus supporting appendices. Chapter 2 provides background information on disability compensation, with a focus on mental health and veterans issues. Chapter 3 outlines the characteristics, etiology, and course of PTSD and also provides information on comorbidities, risk factors, and special considerations for veterans. Chapter 4 provides an overview of the VA’s PTSD compensation process and the conduct of PTSD compensation and pension examinations. These examinations generate the information used by raters to evaluate compensation claims and, where appropriate, determine the level of disability—a process that is set forth in Chapter 5. Chapter 6 discusses other issues that the committee was asked to consider, including the
literature regarding the effect of compensation on recovery and reexamination of veterans already receiving compensation. Chapter 7 offers general observations and recommendations.
Agendas from all the public meetings held by the Committee on Veterans’ Compensation for Post Traumatic Stress Disorder are provided in Appendix A. Appendix B contains a digest of the sections of the U.S. federal regulation relating to VA compensation of PTSD and other mental disorders (38 CFR Part 4, Subpart B). Appendix C displays the worksheets that VA provides clinicians to guide the conduct of PTSD C&P examinations. A listing of the acronyms and abbreviations used in the report is contained in Appendix D. And Appendix E provides biographic information on the committee members, consultants, and staff responsible for this study.
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DVA (U.S. Department of Veterans Affairs). 2004. VA Disability Compensation Program: Legislative History. Report prepared by Economic Systems Inc. for the VA Office of Policy, Planning and Preparedness. December 2004. [Online]. Available: www1.va.gov/op3/docs/Disability_Comp_Legislative_Histor_Lit_Review.pdf [accessed October 2, 2006].
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IOM. 1995. Health Consequences of Service During the Persian Gulf War: Initial Findings and Recommendations for Immediate Action. Washington, DC: National Academy Press.
IOM. 1996. Health Consequences of Service During the Persian Gulf War: Recommendations for Research and Information Systems. Washington, DC: National Academy Press.
IOM. 2006a. Improving the Social Security Disability Decision Process: Interim Report. Washington, DC: The National Academies Press.
IOM. 2006b. Posttraumatic Stress Disorder: Diagnosis and Assessment. Washington, DC: The National Academies Press.
IOM. 2007a. A 21st Century System for Evaluating Veterans for Disability Benefits. Washington, DC: The National Academies Press.
IOM. 2007b. Improving the Social Security Disability Decision Process: Final Report. Washington, DC: The National Academies Press.
IOM and NRC (National Research Council). 2002. The Dynamics of Disability: Measuring and Monitoring Disability for Social Security Programs. Washington, DC: National Academy Press.
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OMB (Office of Management and Budget, Executive Office of the President). 2006a. Budget of the United States, FY 2006, Department of Veterans Affairs. [Online]. Available: http:// www.whitehouse.gov/omb/budget/fy2006/veterans.html [accessed October 13, 2006].
OMB. 2006b. Fiscal Year 2007 Mid-session Review. Budget of the United States. [Online]. Available: http://www.whitehouse.gov/omb/budget/fy2007/pdf/07msr.pdf [accessed October 12, 2006].
Shane S. 2006. Data suggests vast costs loom in disability claims. The New York Times. October 11, 2006.
Szybala RL. 2006. Statement of Renée L. Szybala, Director, Compensation and Pension Service, to the National Academy of Sciences’ Institute of Medicine Committee on VA Compensation for Posttraumatic Stress Disorder, May 2, 2006. [Online]. Available: http://www.iom.edu/File.aspx?ID=34556 [accessed October 12, 2006].
VDBC (Veterans’ Disability Benefits Commission). 2006. Website Home Page. [Online]. Available: http://www.vetscommission.org/ [accessed August 4, 2006].