Conclusion: Into the 21st Century
In the course of responding to the specific tasks assigned by the Veterans’ Disability Benefits Commission, the committee encountered some themes that underlie the somewhat disparate topics. First, the Veterans Benefits Administration (VBA) is so focused on serving veterans applying for the various services it provides that there do not appear to be adequate resources for systematic analysis of how well it is providing those services (process analysis) or the impact of the services on the lives of veterans (outcome analysis), which in turn would enable the Department of Veterans Affairs (VA) to be more responsive to changes affecting its programs. Second, VBA does not have adequate resources for a systematic program of research oriented toward understanding and improving the effectiveness of its benefits programs. Third, VA is missing the opportunity to take a more veteran-centered approach to service provision across its benefits programs. Veterans with severe disabilities need coordinated care that is able to integrate their needs for medical rehabilitation, vocational rehabilitation, assistive technologies, accessible transportation and housing, education and training services, and compensation to make up for loss of earning capacity that may remain after rehabilitation. VA provides some of these services, but they are not readily accessible nor well coordinated. Addressing these issues is beyond the scope of the committee’s assignment, but we think it is worthwhile to discuss them and point to the need for them to be addressed.
NEED FOR ANALYSIS AND PLANNING
It is instructive that much of the information about the operations of the disability compensation program came from external sources or, if internal, from ad hoc panels and task forces. The effort to update the Rating Schedule in the 1990s was triggered by a 1988 report of the General Accounting Office (GAO), which found that ten of the body systems had not been updated for 10 years or more and the rest had been updated, but not comprehensively.1 Internal ad hoc reviews formed in response to perceived problems include the 1993 Blue Ribbon Panel on Claims Processing and the 2001 Claims Processing Task Force. Congress established the Veterans’ Claims Adjudication Commission of 1996, initiated the study of the management of compensation and pension (C&P) benefits claim processes for veterans by the National Academy of Public Administration in 1997, and created the current Veterans’ Disability Benefits Commission. GAO and the VA Office of the Inspector General have issued a number of reports on the operation and results of the C&P process.
Another indicator of limited planning is the insufficient capacity of VBA’s management information systems to provide data needed for planning and evaluation. Until recently, the information system on C&P disability cases—the Benefits Delivery Network (BDN)—could not provide information on the characteristics of disabilities that were not allowed and could not detect changes in aggregate grant rates or differences in these rates across regional offices. The BDN could only list up to seven diagnostic codes at a time and their rating levels, and if a veteran was granted an increase or a new service-connected disability, the historical information was overwritten. This limits analysis of trends in reopened cases, such as the impact of the progression of diabetes and the manifestation of its complications over time, which will have an unknown but large impact on program capacity and costs.
VBA is aware of the problems and has made some progress. An Office of Performance Analysis and Integrity (PA&I) was established in 2001 to consolidate data quality and analysis functions of the various VBA programs, and a data warehouse was established. VA now has an Office of Planning, Evaluation, and Preparedness, which has sponsored evaluations of some VBA programs. A 2000 evaluation of VA’s education benefit programs found that the benefit level had lagged significantly behind the rising cost of education. In 2001, an evaluation of the program for survivors of veterans with service-connected disabilities was performed, which looked at the Dependency and Indemnity Compensation program and four insurance programs.
Following a recommendation of the 1996 Veterans’ Claims Adjudication Commission, VA established an Office of the Actuary in 1999, but it does not yet produce the kinds of actuarial forecasts of the number of veterans with service-connected disabilities receiving Department of Defense (DoD) disability benefits done by the DoD Office of the Actuary.
VBA now has an information system for the C&P Service that provides much better information beginning with calendar year 2004 for planning and evaluation purposes as well as program management. The new system—Rating Board Automation (RBA 2000)—provides a more complete range of information and can produce historical data for trend analyses and forecasts. RBA 2000 can also produce information on inconsistencies in decision making.
The policy analysis group in PA&I is small, however, in relation to the analysis and planning needs of VBA.
This report also recommends a greater research effort to improve the Rating Schedule and keep it up to date (Recommendations 4-2, 4-3, 4-6, 5-3, 6-2, and 7-3). The recommended research program focuses on the evaluation and rating processes and on program outcomes. VBA does not have a large research capacity, however, nor are there adequate resources and staff to conduct policy research and to contract for research and evaluation studies relating to the adequacy of the process and outcomes of veterans benefit programs and services. Examples of the research that might be performed are described below.
Process research would focus on continuous improvement of the VBA rating system and process, including ways of increasing accuracy and reducing variability in outcomes. Examples of areas to be examined would include decision-making studies, in which the same patients are examined by several C&P examiners to understand the range and sources of variability in results, and cases would be rated by different examiners to understand the range and sources of variability in those results. Currently, most C&P examinations are performed by generalists, including those involving the worksheets for the heart, the various musculoskeletal impairments, HIV infection, and so forth, because VA believes that generalists can produce adequate reports for rating.2 This hypothesis could be tested. The use
of nurses and physician assistants under physician supervision, which is allowed, could also be tested.
Clinical Outcomes Research
Clinical outcomes research would help identify and validate the use of severity scores and disease-staging protocols used in clinical settings for rating purposes. Research on the effectiveness of using measures of individual functioning, such as activities of daily living, instrumental activities of daily living, and specific functional tests, recommended in Chapter 4, falls in this category of research, as does research on the utility of health-related quality-of-life (QOL) measures in quantifying loss in QOL not accounted for in the current Rating Schedule.
Economic Outcomes Research
Economic outcomes research is recommended in Chapter 4 to provide information on how well the criteria in the Rating Schedule can measure loss of earnings. The same research could also provide information on the adequacy of benefits in compensating for lost earning capacity. The results of this research would be a factor in revising the criteria, because it is the closest measure to loss of earning capacity available. This would not necessarily limit adjustment of the criteria to account for other losses, such as loss of QOL, but it would provide a benchmark in assessing the income security impact of disability compensation.
The committee’s scope of work was centered on the disability compensation program, but it also included consideration of the medical criteria for eligibility for ancillary services (Chapter 6). It became apparent that while VA has the collective body of services needed to maximize the potential of veterans with disabilities, the separate services are not actively coordinated, which ultimately makes them less effective. It is up to the veteran to apply for each benefit, and he or she must apply and be granted service connection to become eligible for other services. Ideally, there would be a comprehensive initial evaluation of a veteran’s needs and a case worker to assist in obtaining the applicable services. This approach would treat the veteran as a client. This would create tension with the veteran’s role as a claimant (“we would like to help you, but first you have prove you are eligible”), but this would be minimized if there were a more coordinated intake process.
In Chapter 3, we laid out a model of a rating process in which there would be rating of impairment severity, degree of disability, and loss of
QOL. Some research and analysis must be done to understand how best to determine the nonwork disability and QOL ratings and whether they can be combined—whether, for example, work disability and nonwork disability measures could be included in one Rating Schedule or would have to be rated separately, or whether it is feasible to operationalize QOL measures as a basis for compensation. Impairment ratings are based on medical findings and expert judgment, but disability evaluation requires additional information and expertise to judge what a person can do in daily life. The disability evaluation process provides the opportunity to evaluate the veteran with disabilities for the other services VA provides, such as vocational rehabilitation, employment services, education benefits, and specialized medical services (e.g., centers for spinal cord injury, traumatic brain injury, and vision impairment rehabilitation). This process would coordinate VA’s programs for each veteran and make it a more veteran-centered agency.