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41–916 PDF 2008

S. HRG. 110–638 

REVIEW OF VETERANS’ DISABILITY COMPENSATION: EXPERT WORK ON PTSD AND OTHER 

ISSUES 

HEARING 

BEFORE THE

COMMITTEE ON VETERANS’ AFFAIRS 

UNITED STATES SENATE 

ONE HUNDRED TENTH CONGRESS 

SECOND SESSION 

FEBRUARY 27, 2008 

Printed for the use of the Committee on Veterans’ Affairs 

( 

Available via the World Wide Web: http://www.access.gpo.gov/congress/senate 

(II) 

COMMITTEE ON VETERANS’ AFFAIRS 

DANIEL K. AKAKA, Hawaii, Chairman 

JOHN D. ROCKEFELLER IV, West Virginia 

PATTY MURRAY, Washington 

BARACK OBAMA, Illinois 

BERNARD SANDERS, (I) Vermont 

SHERROD BROWN, Ohio 

JIM WEBB, Virginia 

JON TESTER, Montana 

RICHARD BURR, North Carolina, Ranking 

Member 

ARLEN SPECTER, Pennsylvania 

LARRY E. CRAIG, Idaho 

KAY BAILEY HUTCHISON, Texas 

LINDSEY O. GRAHAM, South Carolina 

JOHNNY ISAKSON, Georgia 

ROGER F. WICKER, Mississippi 

WILLIAM E. BREW, Staff Director 

LUPE WISSEL, Republican Staff Director 

(III) 

C O N T E N T S 

FEBRUARY 27, 2008 

SENATORS 

Page 

Akaka, Hon. Daniel K., Chairman, U.S. Senator from Hawaii ........................... 1 

Murray, Hon. Patty, U.S. Senator from Washington ........................................... 2 

Burr, Hon. Richard, Ranking Member, U.S. Senator from North Carolina ....... 3 

WITNESSES 

McMahon, Joyce, Ph.D., Managing Director, Center for Health Research and 

Policy, CNA Corporation; accompanied by Eric Christensen, Ph.D., Senior 

Project Director, Center for Health Research and Policy, CNA Corporation .. 5 

Prepared statement .......................................................................................... 7 

Response to written questions submitted by Hon. Daniel K. Akaka ........... 13 

Bristow, Lonnie R., M.D., MACP, Former President, American Medical Association; accompanied by Michael Mcgeary, Senior Program Officer, Division 

of Health Sciences Policy, Institute of Medicine, National Academies ............ 16 

Prepared statement .......................................................................................... 18 

Kilpatrick, Dean G., Ph.D., Professor and Director, National Crime Victims 

Research and Treatment Center, Medical University of South Carolina ........ 21 

Prepared statement .......................................................................................... 22 

Response to written questions submitted by Hon. Daniel K. Akaka ........... 25 

Zeger, Scott L., Ph.D., Member, Committee on Evaluation of the Presumptive 

Disability Decision-Making Process for Veterans, Board on Military and 

Veterans Affairs, Institute of Medicine, The National Academies and Professor, Johns Hopkins Bloomberg School of Public Health; accompanied 

By Rick Erdtmann, M.D., Mph, Director, Medical Follow-Up Agency, Institute of Medicine, National Academies ................................................................ 26 

Prepared statement .......................................................................................... 28 

Enclosure: Improving the Presumptive Disability Decision-Making 

Process for Veterans .............................................................................. 32 

Response to written questions submitted by Hon. Daniel K. Akaka ........... 48 

(1) 

REVIEW OF VETERANS’ DISABILITY COMPENSATION: EXPERT WORK ON PTSD AND 

OTHER ISSUES 

WEDNESDAY, FEBRUARY 27, 2008 

U.S. SENATE, 

COMMITTEE ON VETERANS’ AFFAIRS, 

Washington, DC. 

The Committee met, pursuant to notice, at 9:33 a.m., in room 

562, Dirksen Senate Office Building, Hon. Daniel K. Akaka, Chairman of the Committee, presiding. 

Present: Senators Akaka, Murray, and Burr. 

OPENING STATEMENT OF HON. DANIEL K. AKAKA, CHAIRMAN, 

U.S. SENATOR FROM HAWAII 

Chairman AKAKA. The hearing will be in order. Aloha and welcome to all of you to today’s hearing. 

Disability compensation is at the heart of what our government 

offers to wounded warriors, yet many veterans and others believe 

that VA’s compensation system is fundamentally broken. To understand what significant changes, if any, are needed, the committee 

will devote significant time and energy to disability compensation. 

No one on this committee undertakes this endeavor lightly. 

As I said at an earlier hearing on compensation, the Veterans’ 

Disability Benefits Commission report is part of the road map that 

we are following to improve the system. Today is the third hearing 

in a series. The first hearing focused on the overall findings and 

recommendations in the Commission’s report. That report relied 

heavily on the expert work performed by the witnesses before us 

today. 

There were two organizations that provided the bulk of the research used by the Commission, the CNA Corporation and the Institute of Medicine. IOM did a series of studies, including a hard 

look at VA’s system for evaluating military service and PTSD. The 

recommendations in these studies have tremendous ramifications 

for servicemembers who are right now in harm’s way. IOM also 

looked at the way VA makes decisions about presumptive disabilities and how disabilities are medically evaluated and rated. IOM’s 

work has broad implications for VA’s disability compensation system. 

The Veterans’ Disability Benefits Commission asked the CNA 

Corporation for help on one essential question, whether the benefits provided to veterans and their survivors for disability and 

deaths are appropriate. The recommendations made by IOM and 

2 

CNA Corporation could potentially impact millions of veterans and 

their survivors. 

I am pleased that we have representatives of both groups here 

today to help us better understand those findings. 

In particular, there are some who question whether disability 

compensation serves as a disincentive for wellness. Given IOM’s recent report in this area, I would like to know whether this view is 

supported by the literature IOM reviewed. 

In the interest of time, I will stop here and ask the committee 

members for their statement. Senator Murray? 

STATEMENT OF HON. PATTY MURRAY, 

U.S. SENATOR FROM WASHINGTON 

Senator MURRAY. Thank you very much, Chairman Akaka, for 

holding today’s hearing to review the findings of the Veterans’ Disability Benefits Commission. This hearing is a very good opportunity for all of our committee members to better understand the 

expert work that was done for the Commission by the Institute of 

Medicine and the CNA Corporation. I want to thank all of today’s 

witnesses who provided the Commission with their medical expertise and their professional analysis. Their collective analysis was 

critical to the VDBC’s final recommendations, recommendations 

that were evidence-based and data driven. 

As most everyone here knows, the VDBC made 113 suggestions 

designed to bring the VA’s disability compensation program into 

the 21st century. They cover a wide range of issues to ensure that 

our veterans’ benefits compensate all service-disabled veterans and 

their families fairly and consistently. The men and women who 

served our country deserve a VA disability benefits system that is 

worthy of their sacrifice. As a country, we owe it to them to make 

sure that we do everything to make their transition to civilian life 

as smooth as possible, and that we compensate them for the physical and mental wounds they incurred as a result of their service. 

Unfortunately, that is not happening. The current system is outdated, and it is burdensome. It fails to successfully address the 

wide range of disabilities that impact the lives of veterans of all 

ages and rank. It is excessively complex and it all too often is just 

too slow. 

The Veterans’ Disability Benefits Commission has made a number of worthy suggestions to address those shortfalls and bring the 

disability benefits system into the 21st century. Among the most 

significant recommendations made by the Commission is to update 

the current ratings schedule and to revise the purpose of the current system, from a model that now only compensates for work disability, to a model that, instead, compensates 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. 

It is clear that a lot of work went into producing the document 

that is now before us. After two and one-half years, the VDBC produced a 500-plus-page report with 113 recommendations. This is 

the most expansive analysis of veterans’ disability benefits in more 

than 50 years. The work done by the IOM and the CNA were key 

factors in the Commission’s decision to make their recommendaVerDate Aug 31 2005 12:11 Dec 11, 2008 Jkt 000000 PO 00000 Frm 00006 Fmt 6633 Sfmt 6633 H:\PS41451\DOCS\022708.TXT SVETS PsN: PAULIN
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tions. I thank all of you for being here today and look forward to 

hearing your discussion about how you came to those conclusions. 

Thank you very much for your work. 

Chairman AKAKA. Thank you very much, Senator Murray. 

Now we will hear from our Ranking Member, Senator Burr. 

STATEMENT OF HON. RICHARD BURR, RANKING MEMBER, 

U.S. SENATOR FROM NORTH CAROLINA 

Senator BURR. Mr. Chairman, thank you. More importantly, 

thank you to our witnesses for their willingness to be here to discuss the work you performed for the Veterans’ Disability Benefits 

Commission. 

It is clear that you spent countless hours studying the benefits 

and services provided to our Nation’s veterans and thinking of 

ways to improve them, and for that, I truly want to say thank you 

on behalf of this entire committee. Your efforts helped the Disability Commission form its recommendations and they will also 

help guide this committee’s efforts to improve the lives of our Nation’s veterans. 

Before we hear your presentation, I would like to comment on a 

couple of broad themes that are raised in your report. 

First, your report highlights the lack of coordination among the 

many benefits and services that VA provides to injured veterans. 

As we all know, VA has a world class health care system, a comprehensive vocational rehabilitation and employment program, and 

a disability compensation program, among many other benefits. 

But as the Institute of Medicine found, while VA has the services 

needed to maximize the potential of veterans with disabilities 

under one roof, they are not actively coordinated and thus are not 

as effective as they could be. 

As part of a more integrated approach, the Institute of Medicine 

suggested that we move away from the current process that requires many veterans with Post Traumatic Stress Disorder to obtain a disability rating from VA before they get priority access to 

VA’s mental health services. The Institute of Medicine expressed 

the belief that, and I quote, ‘‘if it were possible to provide a path 

to treatment that did not involve seeking a disability rating, it 

would enhance opportunities for recovery and for wellness,’’ unquote. That is what it is all about. I couldn’t agree more. 

That is why I introduced the Veterans Mental Health Treatment 

First Act last month. That bill would help veterans suffering from 

PTSD get treatment before they go through any of the disability 

rating process. Under my bill, VA would provide veterans with a 

wellness stipend to help them financially as they seek and complete their treatment program. What a novel approach. All veterans would have to do is agree to comply with the treatment program and hold off on filing disability claims for a short period, 

hopefully the completion of their rehabilitation period. My goal is 

to try to change the existing mind set from one that emphasizes 

disability status to one that emphasizes wellness and restoration. 

I look forward to hearing from our witnesses today about how we 

might be able to accomplish that specific goal. 

The second important theme that these reports highlighted is the 

need to update VA’s disability compensation system. As the InstiVerDate Aug 31 2005 12:11 Dec 11, 2008 Jkt 000000 PO 00000 Frm 00007 Fmt 6633 Sfmt 6633 H:\PS41451\DOCS\022708.TXT SVETS PsN: PAULIN
4 

tute of Medicine found, the current system has not kept pace with 

society in understanding disabilities. As we will hear today, the 

studies point out that some parts of VA’s disability rating schedule 

have not been properly updated for more than six decades. And 

even the parts that have been updated are not adequate for assessing disabilities like PTSD and Traumatic Brain Injury—conditions 

that are affecting so many veterans of the War on Terror. 

One report also found that the rating schedule does not adequately compensate veterans who become seriously disabled at a 

young age and have most of their working lives ahead of them. 

This deficiency is being felt by many young veterans of the War on 

Terror, like Ted Wade, a veteran from my home State of North 

Carolina who suffered a devastating injury at the age of 25 while 

serving in Iraq. As his wife Sarah put it, ‘‘due to his injuries, Ted 

will never again get a pay raise.’’ 

In short, the findings in these reports make it very clear that 

there is an urgent need to update and modernize this system. To 

do that, the report recommended a wide range of improvements, 

such as compensating veterans for loss of quality-of-life, completely 

updating VA’s rating schedule, and developing incentives that will 

promote vocational rehabilitation and help our heroes return to 

work, which is, I think, our charge. 

With these reports and others showing us the serious deficiencies 

of the current system, we simply cannot ignore the need for modernization. We have young men and women returning home from 

war with devastating injuries and they need to come back to a system that cuts the red tape and quickly provides them the benefits 

and, more importantly, the services they need to return to a full 

and productive life. 

To start us on that path, I have been working on a bill that 

would incorporate many of the recommendations of these reports. 

In part, my bill would require the entire rating schedule to be replaced with an updated schedule. It would require VA to compensate veterans for any loss of quality-of-life caused by service-related disabilities. It would also require VA to conduct a study on 

the factors that may prevent injured veterans from achieving their 

career goals and what steps could be taken to help them overcome 

those obstacles. Also, this bill would create a new transition payment for injured veterans who were found unfit for duty. These 

payments would help cover family living expenses so an injured 

veteran would be better able to focus on rehabilitation, training, 

and, more importantly, returning to the workforce. 

As the Institute of Medicine pointed out, this type of modernization of the disability system will not be easy and may require a 

large up-front cost. In my view, it is the right thing to do, and I 

believe we shouldn’t stop this process from moving forward. 

Mr. Chairman, before I turn back over the mike to you, I want 

to mention an interesting quote that the Institute of Medicine included in the beginning of its report, and I quote, ‘‘Knowing is not 

enough. We must apply. Willing is not enough. We must do.’’ Unquote. I think it is a great reminder to all of us that we need to 

do more than just read the reports. We need to take action to fix 

the problems that have been identified by you and so many others. 

5 

Mr. Chairman, I hope we will work together to do just that, so 

that our wounded warriors will have a modern, fair, and, more importantly, a coordinated system to help them return to full and productive lives. I thank the Chair and I yield the floor. 

Chairman AKAKA. Thank you very much, Senator Burr, for your 

statement. 

I want to welcome our panel here and first welcome Dr. Joyce 

McMahon, Managing Director of the Center for Health Research 

and Policy with CNA Corporation. She is accompanied by Dr. Eric 

Christensen. 

Representing IOM is Dr. Lonnie Bristow, the Chair of the Committee on Medical Evaluation of Veterans for Disability Compensation. He is also a former President of the American Medical Association. He is accompanied by Michael McGeary. 

Also representing IOM is Dr. Dean Kilpatrick, a member of the 

Committee on Veterans’ Compensation and PTSD. He is also the 

Director of the National Crime Victims Research and Treatment 

Center at the Medical University of South Carolina. He is accompanied by Dr. David Butler. 

Finally, we have Dr. Scott Zeger, who is a member of IOM’s 

Committee on Evaluation of the Presumptive Disability Decision 

Making Process for Veterans. He is also a professor at Johns Hopkins Bloomberg School of Public Health. He is accompanied by Dr. 

Rick Erdtmann. 

Dr. McMahon, will you please begin with your statement? 

STATEMENT OF JOYCE McMAHON, PH.D., MANAGING DIRECTOR, CENTER FOR HEALTH RESEARCH AND POLICY, CNA 

CORPORATION; ACCOMPANIED BY ERIC CHRISTENSEN, 

PH.D., SENIOR PROJECT DIRECTOR, CENTER FOR HEALTH 

RESEARCH AND POLICY, CNA CORPORATION 

Ms. MCMAHON. Thank you. Chairman Akaka, Senator Burr, distinguished members, I appreciate the opportunity to testify before 

the Senate Committee on Veterans Affairs today on the subject of 

the findings and recommendations of the Veterans’ Disability Benefits Commission. This testimony is based on the findings reported 

in CNA’s final report for the Veterans’ Disability Benefits Commission. 

Our overall focus was to provide analysis regarding the appropriateness of the current benefits program for compensating for 

loss of average earnings and degradation of quality-of-life resulting 

from service-connected disabilities for veterans. In addition, the 

Commission asked us to address additional topics, including disincentives for disabled veterans to work or receive recommended 

treatment; surveys of raters and veterans’ service officers with regard to how they perceive the processes of rating claims and assisting applicants; the economic well-being and quality-of-life of survivors; comparing the VA disability compensation program to other 

Federal disability programs; evaluating offering a lump-sum option 

to some service-disabled veterans; individual unemployability, mortality, and Social Security Disability income; and finally, comparing 

DOD disability determinations to those conducted by the VA. 

I am going to briefly summarize our major findings. The other 

details are in the written testimony. 

6 

With regard to earnings comparisons for service-disabled veterans, our primary task was to address how well VA compensation 

serves to replace the average loss in earnings capacity for servicedisabled veterans, in other words, to bring them to parity. We 

looked at this overall as well as by subgroups based on the body 

system of the primary disability and on the total combined disability rating, from 10 percent to 100 percent. 

We found that for male service-disabled veterans, they are about 

at parity overall with respect to lost earnings capacity balanced by 

VA compensation at the average age of entry, which is approximately age 55. However, there are some important differences by 

subgroup. In general, those with a primary mental disability have 

lower earnings ratios than those with a primary physical disability, 

and many of the rating subgroups for those with a primary mental 

disability had earnings rates below parity. In addition, entry at a 

young age is associated with below-parity earnings ratios, especially for those who are in the severely disabled subgroups. 

The second major tasking from the Commission was to assess 

veterans’ quality-of-life degradation resulting from service-connected disability. Addressing this issue requires surveying servicedisabled veterans to estimate their average quality-of-life. We used 

health-related questions that were taken from a standardized bank 

of questions that are widely used to examine health status in the 

overall population. This allowed us to compare the results for the 

service-disabled veterans to widely published population norms. 

We found that as the degree of disability increased, in general, 

overall health declined. There were differences between those with 

physical and mental primary disabilities in terms of physical and 

mental health. For those who had a primary physical disability, 

there was a marked diminishing in the amount of the physical 

health scores that they received, but in general that did not lead 

to lowered mental health except for those who were the most severely disabled. On the other hand, having a primary mental disability led not only to lowered mental health scores, but was also 

associated with lower physical health, as well. For those with a primary mental disability, physical scores were well below the population norms for all rating groups, and those with PTSD had the 

lowest physical health scores of all. 

In essence, the earnings parity measure that I spoke of allows an 

estimate of whether the VA compensation benefits provide an implicit quality-of-life payment. There is no explicit quality-of-life 

payment, of course. If an earnings ratio is above parity, the veteran 

would be receiving an implicit positive quality-of-life payment. 

Those with a ratio less than parity effectively receive a negative 

quality-of-life payment. 

Going back to our earnings ratios, we found on average that VA 

compensation does not provide a positive quality-of-life payment 

overall, but there are implicit negative quality-of-life payments for 

severely disabled veterans who enter the system at a young age, 

and more generally for those with a mental primary disability. This 

goes along with the context that the loss of quality-of-life appears 

to be greatest for those with a mental primary disability. 

I have other findings, but I am about out of time; so I think I 

will close at this point. Thank you. 

7 

[The prepared statement of Ms. McMahon follows:] 

PREPARED STATEMENT OF JOYCE MCMAHON, PH.D., MANAGING DIRECTOR, CENTER

FOR HEALTH RESEARCH AND POLICY, CNA CORPORATION

Chairman Akaka, Senator Burr, distinguished members; I appreciate the opportunity to testify before the Senate Committee on Veterans’ Affairs today on the subject of the findings and recommendations of the Veterans’ Disability Benefits Commission (VDBC). This testimony is based on the findings reported in Final Report 

for the Veterans’ Disability Benefits Commission: Compensation, Survey Results, and 

Selected Topics, by Eric Christensen, Joyce McMahon, Elizabeth Schaefer, Ted 

Jaditz, and Dan Harris, of the CNA Corporation (CNA). Details on the specific findings discussed here can be found in the report, which is available at http:// 

www.cna.org/domestic/health care/. 

The Commission asked CNA to help assess the appropriateness of the benefits 

that the Department of Veterans Affairs (VA) provides to veterans and their survivors for disabilities and deaths attributable to military service. Our overall focus 

was to provide analyses regarding the appropriateness of the current benefits program for compensating for loss of average earnings and degradation of quality-oflife resulting from service-connected disabilities for veterans. We also evaluated the 

impact of VA compensation for the economic well-being of survivors and assessed 

their quality-of-life. 

In addition, the Commission asked us to address additional topics, including: 

• Disincentives for disabled veterans to work or to receive recommended treatment. 

• Surveys of raters and Veterans Service Officers with regard to how they perceive the processes of rating claims and assisting applicants. 

• Comparing the VA disability compensation program to other disability programs 

• Evaluating offering a lump sum option to some service-disabled veterans. 

• Individual unemployability (IU), mortality, and Social Security Disability Income 

• Comparing DOD disability determinations to those conducted by the VA. 

EARNINGS COMPARISONS FOR SERVICE-DISABLED VETERANS

Our primary task was to answer the question of how well the VA compensation 

benefits serve to replace the average loss in earnings capacity for service-disabled 

veterans. Our approach identified target populations of service-disabled veterans 

and peer or comparison groups (non-service-disabled veterans) and obtained data to 

measure earned income for each group. We also investigated how various factors 

such as disability rating, type of disability, and age impact earned income. Finally, 

we compared lifetime earned income losses for service-disabled veterans to their lifetime VA compensation, adjusting for expected mortality and discounting to present 

value terms, to see how well VA compensation replaces lost earning capacity. 

Congressional language indicates that the intent of VA compensation is to provide 

a replacement for the average impairment in earning capacity. VA compensation is 

not an individual means-tested program, although there are minor exceptions to 

this. Therefore, we focused on average losses for all service-disabled veterans and 

for subgroups. We defined the subgroups of disabled veterans, through consultation 

with the Commission, on the body system of the primary disability (16 in all) and 

on the total combined disability rating (10 percent, 20–40 percent, 50–90 percent, 

and 100 percent disabled). In addition, we further split the 50–90 percent disabled 

group into those with and without individual unemployability status (IU). After 

meeting certain disability criteria as well as providing evidence that they are unable 

to engage in substantial gainful employment, IU disabled veterans receive compensation at the 100 percent disabled level. 

To make earnings comparisons over a lifetime, it is necessary to have a starting 

point. In other words, a young service-disabled veteran will have a long period of 

lost earnings capacity during prime wage-earning years, while a veteran who enters 

into the VA disability compensation system at an older age will face reduced earnings capacity for a smaller number of years. If a veteran first becomes eligible for 

VA compensation at age 65 or older, the average expectation of lost earnings is very 

low, because a large share of individuals are retired or planning to retire soon by 

this age. The data show that the average age of entry into the VA compensation 

system is about 55 years, although many enter at a younger or older age. Also, the 

average age of entry varies somewhat across the body systems of the primary disability and combined degree of disability. 

8 

We looked at average VA compensation for all male service-disabled veterans, and 

found that they are about at parity with respect to lost earnings capacity at the average age of entry (55). We compared the discounted present value of their lifetime 

expected earnings to the earnings of their peer group (i.e., veterans who were not 

service-disabled). To calculate expected earnings parity, we took the ratio of servicedisabled earned income plus VA compensation divided by the present value of total 

expected earnings for the peer group. This figure is 0.97, which is near parity. A 

ratio of exactly 1 would be perfect parity, indicating that the earnings of disabled 

veterans, plus their VA compensation, give them the same lifetime earnings as their 

peers. A ratio of less than one would mean that the service-disabled veterans receive 

less than their peers on average, while a ratio of greater than one would mean that 

they receive more than their peers. 

We also evaluated the parity of earned income and VA compensation for servicedisabled veterans compared to the peer group by disability rating group and age at 

first entry into the VA compensation system. Our findings indicate that it is important to distinguish whether the primary disability is a physical or a mental condition. We found that there is not much difference in the results among physical body 

systems (e.g., musculoskeletal, cardiovascular), and for mental disabilities, it does 

not matter much whether the disability is for PTSD or some other mental disability. 

Examining veterans with a physical primary disability, our findings indicate that 

service-disabled veterans are generally at parity at the average age of first entry 

into VA compensation system (50 to 55 years of age). However, we observed earnings ratios substantially below parity for service-disabled veterans who were IU, 

and slightly below parity for those who were 100 percent disabled, who entered at 

a young age. Those who first entered at age 65 or older were generally above parity. 

For veterans with a mental primary disability, we found that their earnings ratios 

were generally below parity at the average age of entry, except for the severely disabled (IU and 100 percent disabled). We found that the severely disabled who enter 

at a young age are substantially below parity. Those who entered at age 65 or older 

generally were above parity, except for the 10 percent disabled group, which was 

still slightly below parity. 

To summarize the earnings ratio findings for male veterans, there is general parity overall. However, when we explored various subgroups, we found that some were 

above parity, while others were below parity. The most important distinguishing 

characteristic is whether the primary disability is physical or mental. In general, 

those with a primary mental disability have lower earnings ratios than those with 

a primary physical disability, and many of the rating subgroups for those with a 

primary mental disability had earnings rates below parity. In addition, entry at a 

young age is associated with below parity earnings ratios, especially for severely disabled subgroups. 

VETERANS’ QUALITY-OF-LIFE SURVEY RESULTS

The second principal tasking from the Commission was to assess whether the current benefits program compensates not just for loss of average earnings, but also 

for veterans’ quality-of-life degradation resulting from service-connected disability. 

Addressing this issue required collecting data from a representative sample of service-disabled veterans, which would allow us to estimate their average quality-of-life. 

To do this, we constructed, in consultation with the Commission, a survey to evaluate the self-reported physical and mental health of veterans and other related 

issues. CNAC’s subcontractor, ORC Macro, conducted the survey and collected the 

data. As with the earned income analysis, we designed the survey to collect data 

by the major subgroup. We defined subgroups by the body system of the primary 

disability and combined disability rating, and three SMC categories. We were also 

able to characterize the survey results by IU status within the 50–90 percent disabled subgroup. 

The survey utilized 20 health-related questions taken from a standardized bank 

of questions that are widely used to examine heath status in the overall population. 

These questions allowed us to calculate a physical health summary score (physical 

component summary, or PCS) and a mental health summary score (mental component summary, or MCS). This approach is widely used to measure health status in 

a variety of national surveys, and it allowed us to compare the results for the service-disabled veterans to widely published population norms. We also calculated five 

additional health subscales that also have widely published population norms. 

For evaluating the survey, we analyzed the results by subgroup similar to the 

strategy we used for comparing earnings ratios. We looked at those with a primary 

physical disability and those with a primary mental disability separately. We also 

examined the PCS and MCS scores for additional subgroups within those categories. 

9 

For the population norms, the PCS average is set at 50 points, and the norms decrease slightly with age. For the MSC scores, the population norm is quite flat at 

an average of 50, and decreases only for the oldest age categories. 

For service-disabled veterans with a primary physical disability, we found that 

their PCS measures were below population norms for all disability levels, and that 

the scores were in general lower as the disability level increased. In addition, having 

a primary physical disability was not generally associated with reduced mental 

health as measured by MCS. Mental health scores for those with a primary physical 

disability were close to population norms, although those who were severely disabled had slightly lower mental scores. 

For service-disabled veterans with a primary mental disability, we found that 

both the physical and mental component summary scores were well below population norms. This was true for each of the rating groups. This was a distinction 

from those with a primary physical condition, who (except for the severely disabled) 

did not have MCS scores below population norms. 

To summarize our overall findings, as the degree of disability increased, generally 

overall health declined. There were differences between those with physical and 

mental primary disabilities in terms of physical and mental health. Physical disability did not lead to lowered mental health in general. However, mental disability 

did appear to lead to lowered physical health in general. For those with a primary 

mental disability, physical scores were well below the population norms for all rating groups, and those with PTSD had the lowest PCS values. 

We also used the Veterans Survey to investigate other issues that the Commission 

raised. First, we investigated whether service-disabled veterans tended to not follow 

recommended medical treatments because they felt it might impact their disability 

benefits. We used a series of indirect questions to ascertain this information. We 

found that this does not appear to be an issue. 

In addition, the Commission asked us to investigate whether VA benefits created 

a disincentive to work for service-disabled veterans. Again, we used a series of indirect questions to ascertain this information. For example, a disincentive to work 

might be seen through working part-time instead of full-time, or retiring early. We 

did not find this to be a major issue, as only 12 percent of the service-disabled veterans indicated that they might work, or work more, if it were not for their VA benefits. However, it could be that these individuals felt that they would have no choice 

but to work more, if they had no VA benefits, and that it might be quite difficult 

for them to actually work more. 

COMBINING EARNINGS AND QUALITY-OF-LIFE FINDINGS FOR

SERVICE-DISABLED VETERANS

The quality-of-life measures allow us to examine earnings ratio parity measures 

in the context of quality-of-life issues. In essence, the earnings parity measures 

allow an estimate of whether the VA compensation benefits provide an implicit quality-of-life payment. If a subgroup of service-disabled veterans has an earnings ratio 

above parity, they are receiving an implicit quality-of-life payment. At parity, there 

is no quality-of-life payment, and those with a ratio less than parity are effectively 

receiving a negative quality-of-life payment. We turned next to considering the implicit quality-of-life payment in the context of the veterans’ self-reported health status. 

With regard to self-reported quality-of-life, we had multiple measures to consider, 

such as the PCS and MCS measures, and a survey question on overall life satisfaction. In addition, there is no intrinsic valuation of a PCS score of 42 compared to 

a score of 45. We know that a score of 45 reflects a higher degree of health than 

a score of 42 does, but we have no precise way to categorize the magnitude of the 

difference. To simplify the analysis, we combined the information from the PCS and 

MCS into an overall health score, with a population norm of 100 points (each scale 

had a norm of 50 points separately). Then we calculated the population percentile 

that would be attributed to the combined score. For example, for a score of 77 

points, we know that 94 percent of individuals in the age range 45 to 54 would score 

above 77. This gave us a way to calibrate our results, in terms of how the overall 

physical and mental health of the service-disabled veterans compares to population 

norms. By construction, the 50th percentile is the population norm of this measure. 

The results of this analysis confirmed our earlier finding that there are more significant health deficits for those with a primary mental disability than a primary 

physical disability. We found that overall health for those with a mental primary 

disability is generally below the 5th percentile in the typical working years for those 

who are 20 percent or more disabled (this would represent a combined score of 77). 

10 

Even for the 10 percent group, the overall health score is generally below the 20th 

percentile (a combined score of 83). 

This approach allows us to consider the implicit quality-of-life payment, based on 

the parity of the earnings ratio, compared to the overall health percentile and the 

overall life satisfaction measure (the percentage of respondents who say that they 

are generally satisfied with their overall life). We investigated this by rating groups 

and average age at first entry, separately for those with a physical primary disability compared to a mental primary disability. We discuss our findings separately 

for those with a physical primary disability and for those with a mental primary 

disability, considering the implicit quality-of-life payment, the overall health percentile and the overall life satisfaction. 

For those with a physical primary disability, the average age at first entry varied 

from 45 to 55, rising with the combined degree of disability. For 10 percent and 20– 

40 percent disability, there was a negative quality-of-life payment, although their 

overall health percentile ranged from 28 to 15 percent. For these groups, the overall 

life satisfaction ranged from 78 to 73 percent. For higher level of disability groups, 

there was a modest positive quality-of-life payment, ranging as high as $2,921 annually for the 100 percent disabled group. For the 100 percent disabled group, the 

overall health percentile was 4, meaning that 96 percent of the population would 

have a higher health score than the average score for this subgroup, and the overall 

life satisfaction was only 60 percent. 

For service-disabled veterans with a mental primary disability, we found that 

there was an implicit negative quality-of-life payment for veterans of all disability 

levels except for those designated as IU. Also, for these subgroups, the overall 

health percentile was at the 13th percentile for 10 percent disabled and at the 6th 

percentile for 20–40 percent disabled. In fact, for the higher disability groups, the 

overall health score was at or below 1 percent, meaning that 99 percent of the population would have a higher overall health score. Overall life satisfaction, even for 

the 10 percent disability level, was only 61 percent. For disability levels 50–90 percent, IU, and 100 percent disabled, the overall life satisfaction measure hovered 

around 30 percent. 

With regard to implicit quality-of-life payments, we found positive quality-of-life 

payments for those with a physical primary disability at a combined rating of 50 

to 90 percent or higher (except for IU). For those with a mental primary disability, 

we found a positive quality-of-life payment only for the IU subgroup. In comparing 

overall health percentiles and life satisfaction, however, we found that for all rating 

groups, those with a mental primary disability had lower overall health percentiles, 

and substantially lower overall life satisfaction, than those with a physical primary 

disability. Those with a mental primary disability had lower health and life satisfaction compared to those with a physical primary disability, but received less in implicit quality-of-life payments. 

To summarize, we found that VA compensation is about right overall relative to 

earnings losses based on comparison groups for those at the average age at first 

entry. But the earnings ratios are below parity for severely disabled veterans who 

enter the system at a young age and more generally below parity among subgroups 

for those with a mental primary disability. Earnings ratios tend to be above parity 

for those who enter the VA system at age 65 or older. On average, VA compensation 

does not provide a positive implicit quality-of-life payment. Finally, the loss of quality-of-life appears to be greatest for those with a mental primary disability. 

EARNINGS AND QUALITY-OF-LIFE FINDINGS FOR SURVIVORS

We computed earnings profiles for survivors using a methodology analogous to 

that used for service-disabled veterans. We calculated earnings income by age group 

and compared these earnings levels to the earnings of surviving spouses in the general population. Segmenting by age group is critical as 69 percent of survivors are 

65 or more years old. 

We also constructed and conducted a survey for survivors to assess how their selfreported health compared to population norms. We focused our comparisons on female survivors and their peers from the Current Population Survey (CPS). We were 

asked to explore how well Dependency and Indemnity Compensation (DIC) provided 

a partial replacement for lost earnings attributed to the loss of a servicemember or 

veteran. 

The earnings comparisons show that on average survivors generally have lower 

earnings than their civilian peer groups, but that the combination of earned income 

plus VA compensation is as high as, or higher than, the average earned income of 

their peer groups at every age. In addition, based on our survey results, 90 percent 

11 

of the respondents said that they were satisfied with DIC. We concluded that DIC 

appears to provide an adequate replacement for lost earnings for survivors. 

The health differences among survivors and their peers are not as dramatic as 

the health differences were for service-disabled veterans and their peers, but there 

are some departures from population norms. The PCS for survivors is below population norms for age 55 and over, and the MCS is below population norms for ages 

35 to 64. Those survivors who provided substantive care to a disabled veteran (4 

or more hours per day, 5 days a week, for 2 or more years) appeared to suffer some 

negative effects on physical health and participation in social activities. 

RATERS AND VSOS SURVEY RESULTS

The Commission asked us to survey VBA rating officials and accredited veterans 

service officers (VSOs) of National Veterans Service Organizations (NVSOs) to gather insights from those who work most closely with the benefits determination and 

claims rating process. Through consultation with the Commission, we constructed 

separate (but largely parallel) surveys for raters and VSOs. The surveys focused on 

the challenges in implementing the benefits determination and claims rating process 

and perspectives on how the process works. Training, proficiency on the job, and resource availability and usage were among the issues examined. 

The overall assessment indicated that the benefits determination process is 

viewed as difficult to use. Many VSOs find it difficult to assist in the benefits determination process. In addition, VSOs report that most veterans and survivors find 

it difficult to understand the determination process and difficult to navigate through 

the required steps and provide the required evidence. Most raters and VSOs agreed 

that veterans have unrealistic expectations of the claims process and benefits. 

Raters and VSOs noted that additional clinical input would be useful, especially 

from physicians and mental health professionals. Raters felt that the complexity of 

claims was rising over time, and that additional resources and time to process 

claims would help. Some raters felt that they were not adequately trained or that 

they lacked enough experience. They viewed mental claims, especially PTSD, as requiring more judgment and subjectivity and as being more difficult and time-consuming compared to physical claims. Many raters indicated that the criteria for IU 

are too broad and that more specific decision criteria or evidence would help in deciding IU claims. 

VA DISABILITY COMPENSATION PROGRAM COMPARED TO OTHER DISABILITY PROGRAMS

The Commission was interested in operational aspects of the veterans’ disability 

compensation program and asked us to compare VA’s program with other Federal 

disability compensation programs to determine whether there are any useful practices that VA could adopt to improve its own operations. Our first task was to identify the major criticisms of operations in the VA disability program. We reviewed 

a variety of sources that discussed problems with VA performance, including reports 

from the Government Accountability Office (GAO), reports from the VA Office of the 

Inspector General (OIG), congressional testimony, and the results of the Commission’s site visits. 

After identifying the major criticisms of VA, we spoke with the relevant VA staff 

to get additional information on the areas being criticized. We interviewed individuals who worked in VBA’s Compensation and Pension Service, VBA’s Office of Employee Development and Training, the Board of Veterans’ Appeals, and the Office 

of the General Counsel. We discussed specific aspects of VA operations that were 

identified as problematic and the approaches that the other disability programs take 

in those areas. 

Except for the very important issue of timeliness, VA does not appear to be underperforming in comparison with other disability programs. Recent training improvements seem promising for improving VA timeliness in the long term, but effects will 

not be seen for a while. Some of VA’s problems with timeliness could be the result 

of a complex program design, with multiple disabilities per claim, the need to determine service connection (sometimes many years after separation), and the need to 

assign a disability rating to each disability. 

OPTION FOR A LUMP SUM ALTERNATIVE

The Commission asked us to explore options for replacing the current annuity 

benefits stream for some service-disabled veterans with a lump sum alternative. We 

looked at this from the perspective of the potential benefits and costs both to the 

VA and to service-disabled veterans, and with respect to potential implementation 

barriers. We also investigated how other countries use a lump sum alternative for 

their service-disabled veterans. We focused on exploring possible options for those 

12 

at the lowest disability levels (10 to 20 percent). In addition, we determined that 

this would be most feasible for body systems where rating changes were infrequent, 

as re-rating might generate the need to recalculate lump sum payments or provide 

an annuity. 

For the VA, the anticipated benefits of a lump sum derive primarily from the potential for reduced administrative interactions (which might lead to speedier claims 

processing) and savings in compensation and administrative costs. If the lump sum 

were optional, this would increase the choices open to service-disabled veterans. Finally, there are a number of concerns about how the lump sum amounts would be 

determined, what would happen if a veteran’s condition worsened after he/she had 

taken a lump sum, and whether veterans would use a lump sum ‘‘wisely’’ or not. 

We looked at Australia’s, Canada’s, and the United Kingdom’s disability compensation systems for their service-disabled veterans, all of which utilize some 

version of a lump sum alternative. These countries generally use an annuity system 

to compensate for ‘‘economic’’ losses, and reserve the lump sum for compensating for 

‘‘non-economic’’ or quality-of-life losses. Canada and the UK use lump sums to compensate for lost quality-of-life, while Australia offers the veteran a choice between 

an annuity and a lump sum. 

We made a number of simplifying assumptions and selected a small number of 

examples to simulate how a lump sum program might be implemented. We found 

that the VA could obtain net savings, but a lump sum option would be costly up 

front, taking between 17 and 25 years for the VA to achieve net savings. In addition, we identified a number of institutional issues that would pose execution challenges. 

IU AND MORTALITY

The Commission asked us to conduct an analysis of those receiving the individually unemployable (IU) designation. This designation is for those who do not have 

a 100 percent combined rating but whom VA determines to be unemployable. The 

designation enables them to receive disability compensation at the 100 percent level. 

Overall 8 percent of those receiving VA disability compensation have IU, but 31 

percent of those with PTSD as their primary diagnosis have IU status. Ideally, if 

the rating schedule works well, the need for IU will be minimal because those who 

need 100 percent disability compensation will get it from the ratings schedule. The 

fact that 31 percent of those with PTSD as their primary condition have IU may 

be an indication that the ratings schedule does not work well for PTSD. 

Another concern is the rapid growth in the number of veterans designated as IU— 

from 117,000 in 2000 to 223,000 in 2005. This represents a 90 percent increase, an 

increase that occurred while the number of disabled veterans increased 15 percent 

and the total number of veterans declined by 8 percent. The issue is whether disabled veterans were taking advantage of the system, using IU status to increase 

their disability compensation. The data suggest that this was not the case. While 

there has been some increase in the prevalence of getting IU status for certain rating-and-age combinations, the vast majority of the increase in the IU population is 

explained by demographic changes (specifically the aging of the Vietnam cohort) in 

the veteran population. 

We also used mortality rates to determine whether IU recipients were taking advantage of the system. If those with IU had higher mortality rates than those without IU, it would appear to identify clinical differences between those with and without IU. Our findings confirm that those with IU status have higher mortality rates 

than those rated 50–90 percent without IU, although IU mortality rates are less 

than for the 100 percent disabled. 

COMPARISON OF DOD/VA DISABILITY RATINGS

Due to concern with consistency of DOD and VA disability ratings, the Commission asked CNAC to study the issue. We first looked to see how much overlap there 

was between the two systems. We found that roughly four-fifths of those who receive a DOD disability rating end up in the VA compensation system in less than 

2 years. 

Next we explored whether DOD and VA gave approximately the same combined 

disability rating. On average, we found that service-disabled veterans received substantially higher ratings from VA than from DOD. The question is why? First, VA 

rates more conditions than DOD does: on average VA rates about three more conditions per person than DOD does. Second, we found that even at the individual diagnosis level, VA gives higher ratings than DOD does on average. For some codes, the 

average rating from DOD is slightly higher than from VA. But for others, such as 

13 

mental diagnostic codes, the average rating from VA is substantially higher than 

the rating from DOD. 

Note that while we found differences in combined and individual ratings given by 

DOD and VA, we make no judgment as to the correctness of the ratings in either 

system. We have neither the data nor the clinical expertise to make such judgments. 

What we have done is point out aspects of the VA and DOD disability systems that 

differ. 

OVERALL OPTIONS AND RECOMMENDATIONS

One issue that emerges from the data concerns service-disabled veterans with a 

mental primary disability. Their overall health percentiles and overall life satisfaction percentiles are far below those with physical primary disabilities at the same 

rating level. Their earnings in general are well below those with physical primary 

disabilities. The data clearly indicate that their life experience is less satisfying 

than that of their counterparts. It is important to consider how veterans’ programs 

could be made more effective at benefiting this group of veterans. However, there 

is no current metric to translate the quality-of-life losses documented in the Veterans Survey into dollars. 

There are several options for addressing the lack of earnings parity where it exists and for compensation for lost quality-of-life. Earnings parity of those with mental conditions could be improved through higher ratings for mental conditions or 

special monthly compensation similar to that currently paid for other conditions. 

However, using higher ratings would require re-rating all of those with a mental 

disability. Earnings parity for the severely disabled who enter the system at ‘‘young’’ 

ages could be improved by making disability compensation levels a function of age 

at first entry into the disability system or through a special monthly compensation. 

Another issue is the IU designation that many veterans receive because they are 

unemployable. If the purpose of this designation truly relates to employment, there 

could be a maximum eligibility age reflecting typical retirement patterns. If the purpose is to correct for rating schedule deficiencies, an option is to correct the ratings 

schedule so that fewer need to be artificially rated 100 percent through IU. 

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. DANIEL K. AKAKA TO

THE CNA CORPORATION

Question 1. Please elaborate on the assertion that VA does not appear to be 

underperforming in comparison with other disability programs. 

Response. The Commission was interested in operational aspects of the veterans’ 

disability compensation program and asked us to compare VA’s program with other 

Federal disability compensation programs. Our focus was limited to comparisons 

with Federal programs paying monetary benefits to disabled individuals, including 

Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI) 

under the Social Security Administration (SSA), Workers’ Compensation under the 

Federal Employees’ Compensation Act (FECA), disability retirement for Federal employees under the Federal Employee Retirement System (FERS) and the Civil Service Retirement System (CSRS), and DOD’s Disability Evaluation System (DES). 

Unfortunately, we found that there were no formal evaluations of the effectiveness 

of specific practices in the other programs we examined, in the areas identified as 

problematic for VA. This limited our ability to do meaningful comparisons across the 

programs. 

We also found that there are many differences across the various disability programs in terms of purpose, administrative processes, eligibility, benefits, and size. 

These differences may also limit the potential applicability for VA of lessons from 

the other programs. For example, each disability program has different administrative processes for filing claims and making appeals. The various disability compensation programs also have different criteria for determining eligibility and benefit levels, and different purposes of the monetary compensation, varying from partial or full replacement of earnings to an income supplement, or even to compensation for a shortened career. The amount and type of information needed for each 

program are important determinants of how difficult and time-consuming it is to 

process and resolve a claim. 

For any disability compensation program, three important measures of performance in claims processing are timeliness, accuracy, and consistency. In addition, we 

considered issues involving training, productivity standards, and staff turnover. 

14 

Timeliness 

Beginning with timeliness, we noted that the time required to decide and resolve 

a claim depends on how complex the design of the program is. For example, although the VA program does not need to know a claimant’s earnings history, it does 

need to determine service connection and severity for each disability, and each claim 

can have multiple disabilities. 

Compared to the other disability programs, VA performance in terms of timeliness 

was poor. The average time for VA to complete a claim (without appeals) in FY2006 

was 177 days. In comparison, the average for SSDI was 88 days in FY2006, and 

OPM staff reported that the FERS/CSRS average is currently 38 days. In general, 

the FECA and DES programs also reported shorter times to adjudication than the 

VA average. But because of the differences across programs in the work required 

to process a claim, it is difficult to say whether VA’s timeliness problems are due 

to the complex nature of its disability decisions, or to other factors. VA should evaluate what stages of their claims process are contributing most to the total processing 

time. 

With respect to specific strategies to improve timeliness, VA makes use of ‘‘Tiger 

Teams’’ to deal with cases that are designated as high priority, such as very longstanding cases or cases where the veteran is very old or terminally ill. But because 

the success of those teams comes from the fact that they are made up of the most 

experienced staff, unfortunately the Tiger Team approach is not something that VA 

can replicate on a larger scale (i.e., there are not enough experienced employees to 

staff a large number of Tiger Teams). VA might also consider SSA’s new Quick Disability Determination (QDD) process, which uses a predictive model to identify cases 

with a high probability of being granted benefits and then trying to act on those 

cases within 20 days. 

Accuracy 

Accuracy is another major dimension of the quality of claims processing. VA’s accuracy rate in 2006 was 88 percent. Accuracy is based on whether all issues in the 

claim were addressed, whether the claim was developed in compliance with the Veterans Claims Assistance Act, and whether the rating decision, effective date, and 

payment date were correct. VA’s accuracy was slightly below the overall accuracy 

rate for SSDI, which was 96 percent. However, the programs have different claims 

processing requirements. VA has to rate the severity of a disability, creating more 

potential for error than the yes-or-no disability decision that is required for SSDI. 

We were unable to obtain overall accuracy rates for the other programs. However, 

in comparing other programs’ practices with VA’s, the only practice that is substantively different from VA’s is SSA’s practice of focusing on reviewing the most 

error-prone type of cases. 

Consistency 

Measuring consistency is difficult, and none of the programs currently has a 

measure of consistency of the level that GAO recommends (examining disability decisions with multivariate analysis, controlling for multiple factors, and in-depth 

independent review of statistically selected case files). It is currently impossible to 

compare consistency across programs. 

Possible ways to improve consistency might include standardizing training for raters, improving standardization of medical examinations, and consolidating the rating process into fewer locations. VA disability compensation claims are currently 

processed in 57 Regional Offices (ROs), and GAO has recommended that VA consolidate some of its disability compensation operations as one way to improve claim 

processing quality and reduce variation across regional offices. VA reports that it 

does in fact have plans to consolidate some of its disability claims processing in the 

future. However, this might create less in-person access for some veterans. 

SSA has a similar regional variation to that observed for the VA. The other programs face fewer consolidation issues or concerns, because they are much smaller 

programs and have fewer offices and locations for processing claims. 

Training issues 

VA has also been criticized regarding staff training. However, examination of the 

other disability programs shows that VA is not lagging behind in its training efforts. 

None of the other programs seems to have any formal evaluation of their training. 

VBA has recently focused on increasing the standardization of training. No other 

disability program has VA’s level of standardization. 

Staff turnover 

For the VA program, high staff turnover is viewed as creating a problem for the 

quality of claims processing. But it is not clear that the 1-year attrition rate for VA 

15 

disability examiners differs from the rate for all new Federal employees. However, 

minimizing turnover is especially important for VA because of the lengthy training 

time required for claims processing. GAO has recommended that it might be useful 

for the VA to take steps to quantify the reasons that raters resign. In any event, 

VA is not the only disability program facing the problem of high staff turnover, 

which has been identified as a particularly difficult issue for SSA. The other disability compensation programs reported similar staff turnover concerns. 

Summary of comparisons across programs 

Except for timeliness, we found no evidence that VA was under-performing in 

comparison with other disability programs. Some of VA’s problems with timeliness 

could be the result of a complex program design, with multiple disabilities per 

claim, the need to determine service connection (sometimes many years after separation), and the need to assign a disability rating to each disability. For VA to improve timeliness, it first needs to evaluate the stages of the claims process that are 

contributing most to the total elapsed time required to complete a claim. 

Question 2. IOM made a distinction between overall quality-of-life, and physical 

limitations that impair a veteran beyond the workplace. Did CNA make a similar 

distinction in its survey? In other words, did CNA consider overall physical limitations and quality-of-life as independent concepts? 

Response. CNA evaluated two scales to describe quality-of-life outcomes for disabled veterans. These scales were the same scales that have been used in a wide 

variety of research across the years, which enabled us to compare results for disabled veterans to widely-established population norms. First, we calculated a physical health score based on answers to a subset of the questions. We also calculated 

a mental health score based on answers to a different subset of the questions. Our 

‘‘overall’’ quality-of-life assessment was based on adding together these two scores, 

and weighting them equally—in other words, we counted the physical assessment 

and the mental assessment as equally important. So to specifically answer the question, the overall quality-of-life measure we calculated was composed of two separate 

subcomponents—one based on physical limitations, and one based on mental limitations. 

We also asked other questions on the survey, such as questions about the respondents’ overall satisfaction with life. We did not fold these questions into a quality-of-life measure, because there were no equivalent population norms that the respondents’ answers could be compared to. 

Question 3. Can you please describe what additional resources raters felt would 

be helpful as they adjudicated claims for compensation? 

Response. The survey findings identified several issues related to the benefits determination process. 

• Both raters and VSOs identified additional clinical input on rating teams as potentially useful, especially from physicians of appropriate specialties and from mental health professionals. VSOs identified rehabilitation specialists and medical 

records specialists as other potentially useful sources of input. 

• There is a relatively wide range of perceived training adequacy, perceived proficiency in knowledge, skills and abilities (KSAs), KSAs relevant to the performance 

of the rater’s role, and years of rating experience among rating officials that appears 

to be related to raters’ abilities to implement the process and their ease at rating 

and deciding claims. Raters who feel less well-trained or less proficient and those 

who have fewer years of rating experience generally find the process more problematic. 

• Raters’ perceptions regarding their training adequacy and their KSA proficiency 

are both somewhat related to their perceptions of the availability of the resources 

they need to decide a claim such as computer system support, information and evidence, time, and administrative/managerial and clerical support. As perceived training adequacy and KSA proficiency increase, so does perceived resource availability. 

• In many respects, rating or deciding mental disorder claims is more problematic 

than rating or deciding physical condition claims. Raters and VSOs see claims with 

mental disorder issues, especially PTSD, as requiring more judgment and subjectivity than claims with physical condition issues. Raters and VSOs indicated that 

it is less likely that mental disorder issue claims rated by different raters at the 

same VA Regional Office would receive similar ratings, and that deciding the various criteria of a claim is more problematic for mental disorder than for physical 

condition claims. 

• Rating physical conditions in several body systems or subsystems also appears 

problematic. Raters identified neurological and convulsive disorders, musculoskeletal disorders (especially involving muscles), and disorders of special sense orVerDate Aug 31 2005 12:11 Dec 11, 2008 Jkt 000000 PO 00000 Frm 00019 Fmt 6633 Sfmt 6621 H:\PS41451\DOCS\022708.TXT SVETS PsN: PAULIN
16 

gans (especially eyes), as the most difficult and time consuming physical conditions 

to rate. 

• A significant majority of raters indicate that more specific decision criteria or 

more specific evidence regarding individual unemployability (IU) would be helpful 

and that the criteria for IU are too broad. 

• Time to rate or decide a disability claim is a scarce resource and a major challenge for raters. Time appears to be most challenging when raters are deciding complex claims, and raters report that claims getting more complex over time. 

• A large majority of raters reported that they had insufficient time to rate or 

otherwise decide a claim, and both raters and VSOs reported that there was too 

much emphasis on speed relative to accuracy. 

• Obtaining needed evidence, especially given the challenge and scarcity of time 

and the insufficiency of many medical examinations (in particular from private examiners, according to raters) is a challenge in its own right. 

• Raters reported that the use of standardized assessment tools and more specific 

criteria for rating and deciding mental health issues—especially PTSD—would be 

useful. 

• The process is difficult for most veterans and survivors to understand and navigate. Assisting clients to understand the process and the evidence needed for it is 

a major challenge for VSOs. A majority of VSOs further report that they disagree 

that the process is satisfactory to most of their clients. Most raters and VSOs believe veterans have unrealistic expectations of the claims process and the benefits 

they should receive. 

• Overall, most raters and VSOs report that they believe that the claims rating 

process generally arrives at a fair and right decision for veterans. Further, in general, raters and VSOs assessed the performance of their VSOs (and each other) as 

good; however, most raters reported that they believe VSOs inappropriately coach 

their clients. 

Question 4. The Veterans’ Disability Benefits Commission recommended that VA 

explore developing a tool to assess quality-of-life due to disability. This quality-oflife scale could either be incorporated into the current rating criteria or assessed 

independently. Which do you believe is preferable? Are there precedents from other 

disability compensation systems that might be instructive? 

Response. We do not aware of precedents to guide this decision. In our opinion, 

it would be more appropriate to keep the quality-of-life scale as a separate element. 

If the quality-of-life were to be incorporated into the current rating criteria, this 

would add another complexity to the rating system of compensation that is already 

quite difficult for veterans to understand. The current system of compensation is to 

make up for lost earnings capacity. It would be best not to layer another different 

purpose on top of that until we understand more about which categories of disabled 

veterans will be entitled to a quality-of-life adjustment, and how that adjustment 

will be determined (e.g., based on average quality-of-life, based on combined disability rating, based on combined disability rating and primary type of disability, 

etc.). 

Chairman AKAKA. Thank you. Thank you very much, Dr. 

McMahon. 

Now we will hear from Dr. Bristow. 

STATEMENT OF LONNIE R. BRISTOW, M.D., MACP, FORMER 

PRESIDENT, AMERICAN MEDICAL ASSOCIATION; ACCOMPANIED BY MICHAEL McGEARY, SENIOR PROGRAM OFFICER, DIVISION OF HEALTH SCIENCES POLICY, INSTITUTE 

OF MEDICINE, NATIONAL ACADEMIES 

Dr. BRISTOW. Thank you, Mr. Chairman. Chairman Akaka, 

Ranking Member Burr, and other Members of the Committee, my 

name is Lonnie Bristow. As you have heard, I am a physician and 

I have served as the President of the American Medical Association. I am joined on this panel today by Drs. Dean Kilpatrick and 

Scott Zeger, who will introduce themselves shortly. But on their behalf, let me thank you for the opportunity to testify about the work 

that our three Institute of Medicine, or IOM, committees have been 

engaged in. 

17 

My task today is to present the recommendations of the IOM 

committee that I chaired, which was asked to evaluate the VA’s 

schedule for rating disabilities and related matters. Dr. Kilpatrick 

will follow me to speak about his committee’s work, which focused 

on Post Traumatic Stress Disorder, which is a particular challenge 

for the VA to evaluate. And Dr. Zeger will conclude our panel’s 

presentation by briefing you on the findings of his committee, 

which was asked to offer its perspective on the scientific considerations that must underlie the question of whether a health outcome 

should be presumed to be connected to military service. 

We each have submitted our written testimony for the record, 

which we will summarize in our presentations here. Afterwards, of 

course, we will be happy to answer the Committee’s questions. 

In my time remaining, I will quickly list our key findings and 

recommendations concerning the VA rating schedule and be glad to 

go into more detail about any of them during the question period. 

Our committee found that the statutory purpose of disability 

compensation, which is to compensate for the average loss of earning capacity, is an unduly restrictive rationale for the program and 

it is inconsistent with the current or modern concept of disability. 

The committee recommends that the VA compensate for three consequences of service-connected injuries and diseases: First, for work 

disability, which is currently does; second, the loss of ability to engage in usual life activities other than work, what disability experts today call functional limitations; and third, for the loss in 

quality-of-life. 

Concerning the ratings schedule, the committee found that the 

schedule is not as current medically as it could and should be. It 

found that the actual relationship of the rating levels to the average loss of earning capacity was not known at the time of our assessment. Also, the schedule does not evaluate impact on the veteran’s ability to function in everyday life and the schedule does not 

evaluate the loss in quality-of-life. 

Our committee, therefore, recommends that VA immediately update the current ratings schedule medically, beginning with those 

body systems that have gone the longest without a comprehensive 

update, and adopt a system for keeping that schedule up to date 

medically. 

Second, VA should establish an external Disability Advisory 

Committee to provide advice during the updating process. 

And third, as part of updating the schedule, it should move to 

the ICD and DSM diagnostic classification systems. 

Fourth, it should investigate the relationship between the ratings 

and actual earnings to see the extent to which the ratings schedule 

is compensating for loss of earnings on average and adjust that rating criteria to reduce any disparities that are found. 

Fifth, it should compensate for functional limitations on usual 

life activities to the extent that the rating schedule does not. 

And sixth, it should develop a method of measuring the loss of 

quality-of-life, and where that schedule does not adequately compensate for it, VA should adopt a method for doing so. [Lights went 

off.] 

The committee also reviewed individual unemployability, or IU, 

and our main finding concerning IU is that it is not something that 

18 

can be determined on medical grounds alone. Therefore, our committee recommends that VA conduct vocational assessments as 

well as medical evaluations in determining eligibility for IU. 

This concludes my remarks and I want to thank you again for 

the opportunity to testify and for testing my vision. [Laughter.] 

I would be happy to address any questions you might have about 

our report subsequently. 

[The prepared statement of Dr. Bristow follows:] 

PREPARED STATEMENT OF LONNIE BRISTOW, M.D., CHAIR, COMMITTEE ON MEDICAL

EVALUATION OF VETERANS FOR DISABILITY BENEFITS, BOARD ON MILITARY AND

VETERANS HEALTH, INSTITUTE OF MEDICINE, THE NATIONAL ACADEMIES

Good morning, Chairman Akaka, Ranking Member Burr, and Members of the 

Committee. My name is Lonnie Bristow. I am a physician and a Navy veteran, and 

I have served as the president of the American Medical Association. I’m joined on 

this panel by Drs. Dean Kilpatrick and Scott Zeger, who will introduce themselves 

shortly. On their behalf, thank you for the opportunity to testify about the work of 

our Institute of Medicine (IOM) committees. Established in 1970 under the charter 

of the National Academy of Sciences, the IOM provides independent, objective advice to the Nation on improving health. 

My task today is to present to you the recommendations of the IOM committee 

I chaired, which was asked to evaluate the VA Schedule for Rating Disabilities and 

related matters. Dr. Kilpatrick will follow me to speak about his committee’s work, 

which focused on Post Traumatic Stress Disorder, which is a particular challenge 

for the VA top evaluate. Dr. Zeger will conclude our panel’s presentation by briefing 

you on the findings of his committee, which was asked to offer its perspective on 

the scientific considerations underlying the question of whether a health outcome 

should be presumed to be connected to military service. 

I had the great pleasure and honor of chairing the IOM Committee on Medical 

Evaluation of Veterans for Disability Compensation, which was established at the 

request of the Veterans’ Disability Benefits Commission and funded by the Department of Veterans Affairs (VA). 

UPDATING THE BASIS FOR DISABILITY COMPENSATION

Our report, A 21st Century System for Evaluating Veterans for Disability Benefits, which was issued last July, makes a number of important recommendations regarding the VA Rating Schedule and related matters. Our first recommendation is 

to broaden the purpose of the VA disability compensation program, which currently 

is to compensate for average loss of earning capacity, or work disability. We recommend that VA also compensate for loss of ability to engage in the usual activities 

of everyday life other than work and, if possible, for diminished quality-of-life. We 

recognize that legislative action will be required to change the statutory purpose of 

the disability compensation program, but doing so would bring the compensation 

program in line with our current understanding that disability has broad effects (see 

attached figure 4–1 from the report). 

ASSESSING THE RATING SCHEDULE

When the Committee reviewed the Rating Schedule, we found that: 

• Although it is called the Schedule for Rating Disabilities, it currently evaluates 

degree of impairment (i.e., loss of a body part or function) rather than degree of disability (i.e., limits on a person’s ability to function at work or in life). 

• Even in rating degree of impairment, the Schedule is not as current medically 

as it could and should be. 

• The relationship of the rating levels to average loss of earning capacity is not 

known. 

• The Schedule does not evaluate impact on a veteran’s ability to function in everyday life. 

• The Schedule does not evaluate loss of quality-of-life. 

Accordingly, we made a series of recommendations to update and revise the Rating Schedule. 

19 

UPDATING THE RATING SCHEDULE

First, the committee recommends that VA should immediately update the current 

Rating Schedule, beginning with those body systems that have gone the longest 

without a comprehensive update (i.e., the orthopedic part of the musculoskeletal system, the neurological system, and the digestive system). Revisions of the remaining 

systems could be done on a rolling basis—several a year—after which, VA should 

adopt a system for keeping the Schedule up to date medically. Also, VA should establish an external disability advisory committee to provide advice during the updating process. 

As part of updating the Rating Schedule, VA should move to the International 

Classification of Diseases (ICD) and Diagnostic and Statistical Manual of Mental 

Disorders (DSM) diagnostic classification systems that are used in today’s health 

care systems, including VA’s. 

EVALUATING TRAUMATIC BRAIN INJURY

We were asked by your staff about improving the criteria for Traumatic Brain Injury, or TBI. TBI is an excellent example of where the rating criteria in the Schedule need to be updated in accord with current medical knowledge and practice. 

TBI is rated under diagnostic code 8045, ‘‘Brain disease due to trauma,’’ which 

was last updated substantively in 1961. Today, we understand much better how concussions from blast injuries can affect cognition even though there is no evident 

physical injury. In Iraq, many servicemembers have been subjected to multiple improvised explosive device blasts. The current criteria emphasize physical manifestations, such as paralysis and seizures. The Rating Schedule recognizes that symptoms such as headache, dizziness, and insomnia are common in brain trauma but 

limits them to a 10 percent rating. It is time to review how to properly evaluate 

and rate TBI in light of current medical knowledge, along with the rest of the neurological conditions, most of which have not been revised since 1945. 

RELATING THE RATING SCHEDULE TO AVERAGE LOSS OF EARNINGS

In addition to updating the Schedule medically, VA should investigate the relationship between the ratings and actual earnings to see the extent to which the Rating Schedule as revised is compensating for loss of earnings on average. This would 

build on the analyses done by the CNA Corporation at the body system level but 

use samples large enough to study the most prevalent conditions being rated. Just 

38 conditions account for two-thirds of the compensation rating decisions. If VA 

finds disparities in average earnings, for example, that veterans with a mental disorder rated 70 percent earn substantially less on average than veterans rated 70 

percent for other kinds of disabilities, it could adjust the rating criteria to narrow 

the gap. 

COMPENSATING FOR NON-WORK-RELATED FUNCTIONAL LIMITATIONS

The Committee recommends that VA compensate for non-work disability, defined 

as functional limitations on usual life activities, to the extent that the Rating Schedule does not. To do this, VA should develop a set of functional measures—e.g., ADLs 

(activities of daily living), IADLs (instrumental activities of daily living)—and specific performance measures, such as time to ambulate a certain distance, or ability 

to do specific work-related tasks in both physical domains (e.g., climbing stairs or 

gripping) and cognitive domains (e.g., communicating or coordinating with other 

people). After the measures are validated in the disability compensation population, 

VA should conduct a study of functional capacity among applicants to see how well 

the revised Rating Schedule compensates for loss of functional capacity. There may 

be a close correlation between the rating levels based on impairment and degree of 

functional limitations (i.e., the higher the rating, the more functional capacity is 

limited), in which case the Rating Schedule compensates for both impairment and 

functional loss. But if the correlation is not high or does not exist, VA should develop a mechanism to compensate for loss of function that exceeds degree of impairment. This could be done by including functional criteria in the Rating Schedule or 

by rating function separately, with compensation based on the higher of the two ratings. 

COMPENSATING FOR LOSS OF QUALITY OF LIFE

The Committee also recommends that VA compensate for loss of quality-of-life. 

We realize that quality-of-life assessment is relatively new and still at a formative 

stage, which makes this recommendation conditional on further research and development. VA should develop a tool for measuring quality-of-life validly and reliably 

20 

in the veteran population, and then VA should conduct research to determine the 

extent to which the Rating Schedule might already account for loss in quality-oflife. We might find that veterans with the lowest quality-of-life already have the 

highest percentage ratings, but if not, VA should develop a procedure for evaluating 

and rating loss of quality-of-life of veterans with disabilities where it exceeds the 

degree of disability based on impairment and functional limitations determined according to the Rating Schedule. 

EVALUATING INDIVIDUAL UNEMPLOYABILITY

The Committee also reviewed individual unemployability, or IU, which has been 

a fast-growing part of the compensation program. Our main finding concerning IU 

is that it is not something that can be determined on medical grounds alone. IU 

is based on an evaluation of the individual veteran’s capacity to engage in a substantially gainful occupation, rather than on the Rating Schedule, which is based 

on the average impairment of earnings concept. Thus the determination of IU must 

consider occupational as well as medical factors. To analyze IU claims, raters have 

medical evaluations from medical professionals and other medical records but usually they do not have comparable functional capacity or vocational evaluations from 

vocational experts. Therefore, the Committee recommends that, in addition to medical evaluations by medical professionals, VA require vocational assessment in the 

determination of eligibility for individual unemployability benefits. Raters should receive training on how to interpret findings from vocational assessments for the evaluation of individual unemployability claims. 

OTHER RECOMMENDATIONS

The Committee made additional recommendations on issues other than the VA 

Schedule for Rating Disabilities, which I am not reviewing today. They can be found 

in our report and our recommendations for improving the medical examination and 

rating processes were presented to you by our staff director, Michael McGeary, on 

February 14 (for example, mandating the use of the on-line medical examination 

templates and having medical consultants to advise the raters on medical evidence). 

This concludes my remarks. Thank you for the opportunity to testify. I would be 

happy to address any questions the Subcommittee might have. 

FIGURE 4–1 The consequences of an injury or disease. 

From: A 21st Century System for Evaluating Veterans for Disability Benefits. National Academies Press, 2007. 


41916b9.eps
21 

Chairman AKAKA. Thank you. Thank you very much, Dr. 

Bristow. I would tell you that your vision is 20/20. [Laughter.] 

Let me say that all of your full statements will be included in 

the record. 

Now we will hear from Dr. Kilpatrick. 

STATEMENT OF DEAN G. KILPATRICK, PH.D., PROFESSOR AND 

DIRECTOR, NATIONAL CRIME VICTIMS RESEARCH AND 

TREATMENT CENTER, MEDICAL UNIVERSITY OF SOUTH 

CAROLINA 

Mr. KILPATRICK. Thank you, Mr. Chairman and Members of the 

Committee, for the opportunity to testify on behalf of the Committee on Veterans Compensation for Post Traumatic Stress Disorder. Last June, we completed this report, ‘‘PTSD Compensation 

in Military Service,’’ and I understand that this is available to you. 

We had several conclusions that I would like to summarize. 

First, we had testimony that was presented to committee indicating that clinicians often feel pressured to severely constrain the 

time they devote to doing the compensation and pension examination that is used and is really the basis for making the disability 

determinations. These exams may last as little as 20 minutes, even 

though the protocol suggested in a best practice manual developed 

by the National Center for PTSD in the VA can take 3 hours or 

more to complete. The committee believed that the key to proper 

administration of the VA’s PTSD compensation program is a thorough C&P examination conducted by an experienced and welltrained mental health professional. Many of the problems and 

issues with the current process can be addressed by consistently allocating and applying the time and resources needed for a thorough 

examination. 

The VA, for a second point, establishes a rating for the level of 

disability associated with service-connected disorders through a review that uses the information gathered in the C&P examinations 

and criteria set forth in the schedule for rating disabilities. Currently, the same set of criteria are used for rating all mental disabilities. They focus on symptoms from schizophrenia, mood, and 

anxiety disorders. 

Our committee found that these criteria are at best a crude and 

overly general instrument for the assessment of PTSD disability. 

We recommended that new criteria be developed and applied that 

specifically address PTSD symptoms and associated disability problems that are firmly grounded in the standards set out in the DSM 

used by mental health professionals. The committee also recommended that PTSD-specific training for both clinicians and raters be done in order to promote more accurate, consistent, and uniform disability ratings. 

The VA asked the committee to address whether it would be advisable to establish a set schedule for reexamining veterans who receive compensation for PTSD. We concluded that it is not appropriate to require across-the-board periodic reexaminations and recommended that reexamination be done only on a case-by-case basis 

when there are sound reasons to expect that major changes in disability status might occur. 

22 

We based this conclusion on two reasons. First, there are finite 

resources, both personnel and money, to conduct PTSD exams; and 

we believe these should be focused on the performance of uniformly 

high-quality and timely initial exams. Second, across-the-board 

periodic reexaminations are not required for other mental disorders 

or mental conditions. We felt there was no scientific justification 

for singling out PTSD disability for special action and we thought 

that doing so might stigmatize those veterans by implying that 

their condition requires extra scrutiny. 

The Veterans’ Disability Benefits Commission subsequently recommended that the VA should conduct PTSD reevaluations every 

two to 3 years. This, I think, is an honest disagreement from two 

committees that were looking at the same thing. There are advantages and disadvantages to both of these approaches that our two 

groups put forward, but the important thing is for the VA to give 

these both careful consideration when they formulate their policy. 

I believe that if periodic PTSD reexaminations are implemented, 

this should not be done until there are sufficient resources to ensure that every veteran gets a first-rate C&P exam done by a welltrained mental health professional conducted in a timely fashion. 

With respect to the issue that has been raised about whether 

compensation for PTSD is a disincentive for veterans receiving or 

benefiting from treatment or therapy, our committee concluded 

that there is little direct evidence that receiving compensation or 

seeking it has negative effects on treatment outcome. This is reviewed substantially in our report. 

We also received testimony in the committee which indicated 

that compensation seeking, or people who were service-connected 

for PTSD, was shown to be unrelated to clinical outcome or treatment response in a number of randomized clinical trials that had 

been done to treat PTSD that had been conducted by the VA. 

Our committee also reached a whole series of other recommendations regarding the conduct of VA’s compensation and pension system for PTSD that are outlined in the body of our report and I appreciate your attention and would be happy to answer questions at 

the appropriate time. 

[The prepared statement of Mr. Kilpatrick follows:] 

PREPARED STATEMENT OF DEAN G. KILPATRICK, PH.D., DISTINGUISHED UNIVERSITY

PROFESSOR, DIRECTOR, NATIONAL CRIME VICTIMS RESEARCH AND TREATMENT CENTER, MEDICAL UNIVERSITY OF SOUTH CAROLINA AND MEMBER, COMMITTEE ON VETERANS’ COMPENSATION FOR POST TRAUMATIC STRESS DISORDER, INSTITUTE OF

MEDICINE AND NATIONAL RESEARCH COUNCIL, THE NATIONAL ACADEMIES

Good morning, Mr. Chairman and Members of the Committee. My name is Dean 

Kilpatrick and I am Distinguished University Professor in the Department of Psychiatry and Behavioral Sciences and Director of the National Crime Victims Research and Treatment Center at the Medical University of South Carolina. Thank 

you for the opportunity to testify on behalf of the members of the Committee on Veterans’ Compensation for Post Traumatic Stress Disorder. This committee was convened under the auspices of the National Research Council and the Institute of 

Medicine. Our committee’s work was requested by the Department of Veterans Affairs, which provided funding for the effort. Its work was also presented to and used 

by the congressionally-constituted Veterans Disability Benefits Commission. 

Last June, our committee completed its report—entitled PTSD Compensation and 

Military Service—which addresses potential revisions to the Schedule for Rating 

Disabilities in the context of a larger review of how VA administers its PTSD compensation program. I am pleased to be here today to share with you the content of 

that report, the knowledge I’ve gained as a clinical psychologist and researcher on 

23 

traumatic stress, and my experience as someone who previously served as a clinician at the VA. 

I will begin with some background information on Post Traumatic Stress Disorder. Briefly described, PTSD is a psychiatric disorder that can develop in a person 

after a traumatic experience. Someone is diagnosed with PTSD if, in response to 

that traumatic experience, he or she develops a cluster of symptoms that include: 

• reexperiencing the traumatic event as reflected by distressing recollections, 

memories, nightmares, or flashbacks; 

• avoidance of anything that reminds them of the traumatic event; 

• emotional numbing or feeling detached from other people; 

• hyperarousal as reflected by trouble sleeping, trouble concentrating, outbursts 

of anger, and having to always be vigilant for potential threats in the environment; 

and 

• impairment in social or occupational functioning, or clinically significant distress. 

PTSD is one of an interrelated and overlapping set of possible mental health responses to combat exposures and other traumas encountered in military service. It 

has been described as one of the signature wounds of the most recent Iraq conflicts. 

Although PTSD has only been an official diagnosis since the 1980’s, the symptoms 

associated with it have been reported for centuries. In the U.S., expressions including shell shock, combat fatigue, and gross stress reaction have been used to label 

what is now called PTSD. 

Our committee’s review of the scientific literature regarding PTSD led it to draw 

some conclusions that are relevant to this hearing. It found abundant evidence indicating that PTSD can develop at any time after exposure to a traumatic stressor, 

including cases where there is a long time interval between the stressor and the 

recognition of symptoms. Some of these cases may involve the initial onset of symptoms after many years of symptom-free life, while others may involve the manifestation of explicit symptoms in persons with previously undiagnosed PTSD. The determinants of delayed-onset PTSD are not well understood. The scientific literature 

does not identify any differences material to the consideration of compensation between these delayed-onset or delayed-identification cases and those chronic PTSD 

cases where there is a shorter time interval between the stressor and the recognition of symptoms. 

Our review also identified several areas where changes to VA’s current practices 

might result in more consistent and accurate ratings for disability associated with 

PTSD. 

There are two primary steps in the disability compensation process for veterans. 

The first of these is a compensation and pension, or C&P, examination. These examinations are conducted by VA mental health professionals or outside professionals who meet certain education and licensing requirements. Testimony presented to our committee indicated that clinicians often feel pressured to severely 

constrain the time that they devote to conducting a PTSD C&P examination—sometimes to as little as 20 minutes—even though the protocol suggested in a best practice manual developed by the VA National Center for PTSD can take 3 hours or 

more to properly complete. The committee believes that the key to proper administration of VA’s PTSD compensation program is a thorough C&P clinical examination 

conducted by an experienced mental health professional. Many of the problems and 

issues with the current process can be addressed by consistently allocating and applying the time and resources needed for a thorough examination. The committee 

also recommended that a system-wide training program be implemented for the clinicians who conduct these exams in order to promote uniform and consistent evaluations. 

The second primary step in the compensation process for veterans is a rating of 

the level of disability associated with service-connected disorders identified in the 

clinical examination. This rating is performed by a VA employee using the information gathered in the C&P exam and criteria set forward in the Schedule for Rating 

Disabilities. Currently, the same set of criteria is used for rating all mental disorders. They focus on symptoms from schizophrenia, mood, and anxiety disorders. 

The committee found that the criteria are at best a crude and overly general instrument for the assessment of PTSD disability. We recommended that new criteria be 

developed and applied that specifically address PTSD symptoms and that are firmly 

grounded in the standards set out in the Diagnostic and Statistical Manual of Mental Disorders used by mental health professionals. 

Our committee also suggested that VA take a broader and more comprehensive 

view of what constitutes PTSD disability. In the current scheme, occupational impairment drives the determination of the rating level. Under the committee’s recVerDate Aug 31 2005 12:11 Dec 11, 2008 Jkt 000000 PO 00000 Frm 00027 Fmt 6633 Sfmt 6621 H:\PS41451\DOCS\022708.TXT SVETS PsN: PAULIN
24 

ommended framework, the psychosocial and occupational aspects of functional impairment would be separately evaluated, and the claimant would be rated on the 

dimension on which he or she is more affected. We believe that the special emphasis 

on occupational impairment in the current criteria unduly penalizes veterans who 

may be capable of working, but significantly symptomatic or impaired in other dimensions, and thus it may serve as a disincentive to both work and recovery. This 

recommendation is consistent with the Dole-Shalala Commission’s suggestion to add 

quality-of-life payments to compensation. 

Research reviewed by the committee indicates that disability compensation does 

not in general serve as a disincentive to seeking treatment. While some beneficiaries 

will undoubtedly understate their improvement in the course of pursuing compensation, the scientific literature suggests that such patients are in the minority, and 

there is some evidence that disability payments may actually contribute to better 

treatment outcomes in some programs. The literature on recovery indicates that it 

is influenced by several factors, and the independent effect of compensation on recovery is difficult to disentangle from these. 

Determining ratings for mental disabilities in general and for PTSD specifically 

is more difficult than for many other disorders because of the inherently subjective 

nature of symptom reporting. In order to promote more accurate, consistent, and 

uniform PTSD disability ratings, the committee recommended that VA establish a 

specific certification program for raters who deal with PTSD claims, with the training to support it, as well as periodic recertification. Rater certification should foster 

greater confidence in ratings decisions and in the decisionmaking process. 

At VA’s request, the committee addressed whether it would be advisable to establish a set schedule for re-examining veterans receiving compensation for PTSD. We 

concluded that it is not appropriate to require across-the-board periodic reexaminations for veterans with PTSD service-connected disability. The committee instead 

recommended that reexamination be done only on a case-by-case basis when there 

are sound reasons to expect that major changes in disability status might occur. 

These conclusions were based on two considerations. First, there are finite resources—both funds and personnel—to conduct C&P examinations and determine 

disability ratings. The committee believes that resources should be focused on the 

performance of uniformly high-quality C&P clinical examinations. It believes that 

allocating resources to such examinations—in particular, to initial C&P evaluations—is a better use of resources than periodic, across-the-board reexaminations. 

Second, as the committee understands it, across-the-board periodic reexaminations 

are not required for other mental disorders or medical conditions. The committee’s 

review of the literature on misreporting or exaggeration of symptoms by PTSD 

claimants yielded no justification for singling out PTSD disability for special action 

and thereby potentially stigmatizing veterans with the disability by implying that 

their condition requires extra scrutiny. 

I understand that the Veterans Disability Benefits Commission subsequently recommended that VA should conduct PTSD reevaluations every 2–3 years to gauge 

treatment effectiveness and encourage wellness. Since the Commission report was 

released after the end of our work, my committee did not address the disparity in 

our recommendations. I know that our committee and the Commission both want 

veterans to receive fair treatment and the finest care, and I consider this to be an 

honest difference of opinion on how to best achieve those goals. There are advantages and disadvantages to the approaches that our two groups put forward, and 

the important thing is for VA to give these careful consideration when they formulate their policy. I believe that—if periodic reexaminations are implemented—this 

should not be done until there are sufficient resources to insure that every veteran 

gets a first-rate initial C&P exam in a timely fashion. 

To summarize, the committee identified three major changes that are needed to 

improve the compensation evaluation process for veterans with PTSD: 

• First, the C&P exam should be done by mental health professionals who are 

adequately trained in PTSD and who are allotted adequate time to conduct the 

exams. 

• Second, the current VA disability rating system should be substantially changed 

to focus on a more comprehensive measure of the degree of impairment, disability, 

and clinically significant distress caused by PTSD. The current focus on occupational impairment serves as a disincentive for both work and recovery. 

• Third, the VA should establish a certification program for raters who deal with 

PTSD clams. 

Our committee also reached a series of other recommendations regarding the conduct of VA’s compensation and pension system for PTSD that are detailed in the 

25 

body of our report. I have provided copies of this report as part of my submitted 

testimony. 

Thank you for your attention. I will be happy to answer your questions. 

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. DANIEL K. AKAKA TO THE

DEAN G. KILPATRICK, PH.D., DISTINGUISHED UNIVERSITY PROFESSOR, DIRECTOR, 

NATIONAL CRIME VICTIMS RESEARCH AND TREATMENT CENTER, MEDICAL UNIVERSITY OF SOUTH CAROLINA AND MEMBER, COMMITTEE ON VETERANS’ COMPENSATION

FOR POST TRAUMATIC STRESS DISORDER, INSTITUTE OF MEDICINE AND NATIONAL

RESEARCH COUNCIL, THE NATIONAL ACADEMIES

Question 1. Dr. Kilpatrick, IOM also stated that PTSD can develop anytime after 

exposure to a traumatic stressor. IOM found abundant scientific evidence indicating 

that PTSD can develop at any time after exposure to a traumatic stressor, including 

cases where there is a long interval between the stressor and the recognition of 

symptoms. Can you please elaborate further on this topic? 

Response. The National Academies’ Committee on Veterans’ Compensation for 

Post Traumatic Stress Disorder—of which I was a member—addressed this topic in 

detail on pages 101–105 of our 2007 report PTSD Compensation and Military Service. Quoting the report: 

Determining whether an apparent case of delayed-onset PTSD is actually 

delayed poses challenges in both clinical and research settings. The difficulty can be attributed to several factors. Foremost, it is rare that a careful longitudinal assessment has been conducted, with data collection beginning soon after exposure to a stressor and continuing long enough to establish (1) the developmental trajectory of PTSD symptoms, (2) the documentation of diagnostic criteria, and (3) the full diagnostic assessment itself. Such 

information is needed to determine with some degree of confidence how long 

after exposure symptoms occurred, which and when individual diagnostic 

criteria manifested, and when and under which version of the DSM all diagnostic criteria for the PTSD diagnosis were met. Additionally, there exists 

a subpopulation of veterans with PTSD who do not seek mental health 

treatment services or compensation from the Department of Veterans Affairs at the time of the onset of the disease. When such veterans present 

with PTSD symptoms for treatment or compensation evaluation long after 

their military service, what appears to be ‘‘delayed onset’’ PTSD may actually be a delayed diagnosis of a disorder that has been present for a substantial period of time. 

Some individuals exposed to potentially traumatic events, including war 

zone stressors, develop subthreshold PTSD—that is, they meet some of the 

[DSM IV-TR] B, C, and D criteria for PTSD*** but not all, or they fall 

one or two symptoms short of meeting full diagnostic criteria. Such individuals may not have a history of full PTSD, but with slight increases in 

symptomatology these cases can cross the diagnostic threshold to become 

full PTSD. Thus, what appears to be a new, delayed-onset case may actually be someone who for years has experienced symptoms just short of the 

benchmark criteria required for PTSD diagnosis and who becomes a case 

due to a small increase in symptomatology. (p. 102) 

* * * 

Delayed-onset PTSD is consistently observed, albeit in a fraction of the 

overall PTSD cases, and data indicate that delayed-onset PTSD is perhaps 

more common among those exposed to war—related trauma than among 

those exposed to other kinds of trauma Some cases of delayed-onset PTSD 

are symptomatic individuals who do not meet all the criteria of PTSD. 

* * * A number of factors have been found to be associated with the delayed onset of PTSD in previously undiagnosed individuals, including the 

occurrence of negative life events, decline in self esteem, ethnicity, and negative health changes. These factors have been shown to exacerbate symptoms in those with existing PTSD as well * * *. (p. 104) 

The report elaborates on this information and provides citations to several peerreviewed scientific papers that support these observations and conclusions. 

Question 2. Dr. Kilpatrick, can you please explain the importance of providing a 

guaranteed level of benefits that would take explicit account of the nature of chronic 

PTSD by providing a safety net for those who might be asymptomatic for periods 

of time? 

26 

Response. PTSD Compensation and Military Service notes that ‘‘some researchers 

have speculated that veterans may be reluctant to acknowledge therapeutic gains 

because they believe that this may lead VA to lower their disability rating and thus 

lower their benefits’’ (p. 182). VA asked the committee to recommend strategies for 

reducing disincentives and maximizing incentives for achieving optimal mental functioning for veterans. Among the responses formulated by the committee was a recommendation that the VA consider instituting a set, long-term minimum level of 

benefits that would be available to any veteran with service-connected PTSD at or 

above some specified rating level without regard to that person’s state of health at 

a particular point in time after the C&P examination. Our report offers this reasoning in support of that recommendation: 

Regulation already specifies an analogous approach for other disorders, 

including conditions whose symptoms may remit and relapse over time. 

Multiple sclerosis, for example, has a minimum rating of 30 percent without 

regard to whether the condition is disabling at the moment that the subject 

is evaluated. However, rather than being limited to a particular minimum 

rating, the committee suggests that the VA consider what minimum benefits level—where ‘‘benefits’’ comprise compensation and other forms of assistance, such as priority access to VA medical treatment—would be most 

likely to promote wellness. It is beyond the scope of the charge to the committee to specify the particular set of benefits that would be most appropriate or the level[s] of impairment that would trigger provision of these 

benefits. This would require a careful consideration of the needs of the population, of the new incentives that the policy change would create, of the 

possible effects on compensation outlays and demand for other VA resources, and of how to maintain fairness with respect to other conditions 

that have a remitting/relapsing nature. 

Providing a guaranteed minimum level of benefits would take explicit account of the nature of chronic PTSD by providing a safety net for those who 

might be asymptomatic for periods of time. A properly designed set of benefits could eliminate uncertainty over future timely access to treatment and 

financial support in times of need and would in part remove the incentive 

to ‘‘stay sick’’ that some suggest is a flaw of the current system. 

(p. 185–186) 

Chairman AKAKA. Thank you very much, Dr. Kilpatrick. 

Now we will hear from Dr. Scott Zeger. 

STATEMENT OF SCOTT L. ZEGER, PH.D., PROFESSOR, JOHNS 

HOPKINS BLOOMBERG SCHOOL OF PUBLIC HEALTH; ACCOMPANIED BY RICK ERDTMANN, M.D., MPH, DIRECTOR, 

MEDICAL FOLLOW-UP AGENCY, INSTITUTE OF MEDICINE, 

NATIONAL ACADEMIES 

Dr. ZEGER. Thank you, Chairman Akaka, Ranking Member Burr, 

and Senator Murray. I appreciate the chance to be here with you 

today. I am Scott Zeger, professor of biostatistics at Johns Hopkins 

University, and was a member of the IOM committee that recently 

authored this report, ‘‘Improving the Presumptive Disability Decision Making Process for Veterans.’’ On behalf of the committee 

members and our Chair, Dr. Samet, I am pleased to present a summary of our findings to you. 

Our committee worked for a year with two goals, first to describe 

the current process for making presumptive decisions for veterans, 

and second to propose a more sound scientific framework for making those decisions in the future. 

Veterans who have been injured by their service are owed appropriate health care and disability compensation. As one of the most 

eloquent VSO witnesses to our committee told us, ‘‘Americans don’t 

leave their wounded soldiers behind.’’ When scientific information 

is incomplete, Congress or the Department of Veterans Affairs may 

27 

elect to make a presumption of service connection so that a group 

of veterans may be appropriately compensated. 

Our committee studied past presumptions and identified shortcomings in the current process. These include poor tracking of soldiers’ exposures—sometimes due to secrecy—and inadequate surveillance of veterans’ illnesses. We detected varying approaches to 

synthesizing evidence on the health consequences of military service and a lack of transparency of the VA decisionmaking process. 

Our committee has recommended a more scientific approach that 

would include the following components: A new process for nominating exposures or health conditions for presumptions that would 

be open to all stakeholders; a revised process for evaluating scientific information on whether an exposure causes a health condition in veterans; a transparent evidence-based decisionmaking 

process by the VA; better tracking of the exposures of military personnel and of the illnesses of the veterans; and an organizational 

structure to support this process. 

We specifically proposed the creation of two panels. The first 

would be called the Advisory Committee to the VA that would assemble and give priority to the exposures and health conditions 

proposed for possible presumptive evaluation. Nominations would 

come from veterans and other stakeholders. The second panel 

would be a Scientific Review Board, an independent body not unlike the IOM, that would evaluate the strength of the evidence that 

the health condition is caused by the military exposure. 

The VA would then use explicit criteria to render a decision to 

establish a presumption or not, and since better data is the means 

to achieve better decisions, the Scientific Review Board would also 

be responsible to monitor DOD and VA information on the health 

of veterans as it accumulates over time and to nominate new exposures or health conditions for consideration for presumptions. 

In proposing causation as the target for inference, the committee 

recognizes that both causation and association have been used in 

recent practice. Our focus on cause rather than association is to 

identify the right target, not to set a higher evidentiary standard. 

Also, by focusing on the causal target, the committee calls for a 

broad interpretation of all sources of evidence, not only empirical 

evidence usually relied on when establishing association. The committee recommends that the VA decide in favor of a presumption 

when a causal relationship is more likely than not as assessed by 

the Science Review Board. 

The committee recognizes that action by Congress is needed to 

implement our plan to create the two panels and to assure that we 

fulfill our commitment to veterans by more accurately tracking 

their military exposures and their health outcomes after their distinguished service on behalf of us all. 

Thanks for the opportunity to speak to you today and I would be 

happy to address questions that you might have. 

[The prepared statement of Mr. Zeger follows:] 

28 

PREPARED STATEMENT OF SCOTT L. ZEGER, PH.D., MEMBER, COMMITTEE ON EVALUA- TION OF THE PRESUMPTIVE DISABILITY DECISION-MAKING PROCESS FOR VETERANS, BOARD ON MILITARY AND VETERANS AFFAIRS, INSTITUTE OF MEDICINE, THE NA- TIONAL ACADEMIES AND FRANK HURLEY-CATHARINE DORRIER CHAIR AND PRO- FESSOR, DEPARTMENT OF BIOSTATISTICS, THE JOHNS HOPKINS BLOOMBERG SCHOOL

OF PUBLIC HEALTH

Good afternoon Senator Akaka and Members of the Senate Committee on Veterans’ Affairs. I am Scott L. Zeger, Professor of Biostatistics from Johns Hopkins 

University in Baltimore, Maryland, a member of the Institute of Medicine Committee who recently authored the report, Improving the Presumptive Disability Decision-Making Process for Veterans. On behalf of Dr. Jonathan Samet, our Committee 

Chair, and the rest of the 16 members who represent a diversity of scientific and 

medical disciplines, I am pleased to present a summary of our key findings to you 

today. 

Our Institute of Medicine Committee worked for a year to describe the current 

process for making presumptive decisions for veterans who have health conditions 

arising from military service and to propose a more sound scientific framework for 

making such presumptive decisions in the future. 

To address its charge, the Committee met with many stakeholders: past and 

present staffers from Congress, the Veterans Administration (VA), the Institute of 

Medicine, veteran’s service organizations, and individual veterans. The Department 

of Defense (DOD) gave the Committee information about how it tracks exposures 

and health conditions of personnel. The Committee attempted to formally capture 

how the current approach works and completed a series of case studies to identify 

‘‘lessons learned’’. The Committee also considered how information is obtained on 

the health of veterans and how exposures during military service can be linked to 

any health consequences via scientific investigation. It gave substantial attention to 

the process by which information can best be synthesized to determine if a particular exposure causes a risk to health. 

Veterans who have been injured by their service, whether their injury appears 

during service or afterwards, are owed appropriate health care and disability compensation. For some medical conditions that develop after military service, the scientific information needed to determine that the health condition was caused by 

their service may be incomplete. In such a situation, Congress or the Department 

of Veterans Affairs (VA) may elect to make a ‘‘presumption’’ of service-connection 

so that a group of veterans can be appropriately compensated. Presumptions are 

made in order to reach decisions in the face of unavailable or incomplete information. 

Presumptions were first established in 1921. More recently, several presumptions 

have been made about Agent Orange exposure during service in Vietnam and 

around the health risks sustained by military personnel in the first Persian Gulf 

War. 

The present approach to presumptive disability decision-making largely flows 

from the Agent Orange Act of 1991, which started a model for decision-making that 

is still in place. In that law, Congress asked the VA to contract with an independent 

organization, the Institute of Medicine, to review the scientific evidence for the 

health effects of Agent Orange. Subsequently, the Institute of Medicine has produced reports on Agent Orange, evaluating whether there is evidence that Agent 

Orange is associated with various health outcomes. The Institute of Medicine provides its reports to the VA, which then acts through its own internal decision-making process to determine if a presumption is to be made. 

The case studies conducted by the Committee probed this process. The case studies pointed to a number of difficulties that need to be addressed in any future approach: 

• Lack of information on exposures received by military personnel and inadequate 

surveillance of veterans for service-related illnesses. 

• Gaps in information because of secrecy. 

• Varying approaches to synthesizing evidence on the health consequences of military service. 

• In the instance of Agent Orange, classification of evidence for association but 

not for causation. 

• A failure to quantify the effect of the exposure during military service, particularly for diseases with other risk factors and causes. 

• A general lack of transparency of the presumptive disability decision-making 

process. 

The Committee discussed in great depth the optimum approach to establishing a 

scientific foundation for presumptive disability decision-making, including the methVerDate Aug 31 2005 12:11 Dec 11, 2008 Jkt 000000 PO 00000 Frm 00032 Fmt 6633 Sfmt 6621 H:\PS41451\DOCS\022708.TXT SVETS PsN: PAULIN
29 

ods used to determine if exposure to some factor increases risk for disease. This assessment and the findings of the case studies led to recommendations to improve 

the process: 

• As the case studies demonstrated, Congress could provide a clearer and more 

consistent charge on how much evidence is needed to make a presumption. There 

should be clarity as to whether the finding of an association in one or more studies 

is sufficient or the evidence should support causation. 

• Due to lack of clarity and consistency in congressional language and VA’s 

charges to the committees, IOM committees have taken somewhat varying approaches since 1991 in reviewing the scientific evidence, and in forming their opinions on the possibility that exposures during military service contributed to causing 

a health condition. Future committees could improve their review and classification 

of scientific evidence if they were given clear and consistent charges and followed 

uniform evaluation procedures. 

• The internal processes by which the VA makes it presumptive decisions following receipt of an IOM report have been unclear. VA should adopt transparent 

and consistent approaches for making these decisions. 

• Adequate exposure data and health condition information for military personnel 

(both individuals and groups) usually have not been available from DOD in the past. 

Such information is one of the most critical pieces of evidence for improving the determination of links between exposures and health conditions. Approaches are needed to assure that such information is systematically collected in an ongoing fashion. 

All of these improvements are feasible over the longer term and are needed to ensure that the presumptive disability decision-making process for veterans is based 

on the best possible scientific evidence. Decisions about disability compensation and 

related benefits (e.g., medical care) for veterans should be based on the best possible 

documentation and evidence of their military exposures as well as on the best possible information. A fresh approach could do much to improve the current process. 

The Committee’s recommended approach (see Figure GS–1 attached) has several 

parts: 

• an open process for nominating exposures and health conditions for review; involving all stakeholders in this process is critical; 

• a revised process for evaluating scientific information on whether a given exposure causes a health condition in veterans; this includes a new set of categories to 

assess the strength of the evidence for causation, and an estimate of the numbers 

of exposed veterans whose health condition can be attributed to their military exposure; 

• a consistent and transparent decision-making process by VA; 

• a system for tracking the exposures of military personnel (including chemical, 

biological, infectious, physical and psychological stressors), and for monitoring the 

health conditions of all military personnel while in service and after separation; and 

• an organizational structure to support this process. 

To support the Committee’s recommendations, we suggest the creation of two panels. One is an Advisory Committee (advisory to VA), that would assemble, consider 

and give priority to the exposures and health conditions proposed for possible presumptive evaluation. Nominations for presumptions could come from veterans and 

other stakeholders as well as from health tracking, surveillance and research. The 

second panel would be a Science Review Board, an independent body, which would 

evaluate the strength of the evidence (based on causation) which links a health condition to a military exposure and then estimates the fraction of exposed veterans 

whose health condition could be attributed to their military exposure. The Science 

Review Board’s report and recommendations would go to the VA for its consideration. The VA would use explicit criteria to render a decision by the VA Secretary 

with regard to whether a presumption would be established. In addition, the Science 

Review Board would monitor information on the health of veterans as it accumulates over time in the DOD and VA tracking systems, and nominate new exposures 

or health conditions for evaluation as appropriate. 

This Committee recommends that the following principles be adopted in establishing this new approach: 

1. Stakeholder inclusiveness 

2. Evidence-based decisions 

3. Transparent process 

4. Flexibility 

5. Consistency 

6. Causation, not just association, as the target for decision making. 

30 

The last principle needs further discussion, as it departs from the current approach. In proposing causation as the target, the Committee had concern that the 

approach of relying on association, particularly if based on findings of one study, 

could lead to ‘‘false-positive’’ presumptions. The Committee calls for a broad interpretation of evidence to judge whether a factor causes a disease in order to assure 

that relevant findings from laboratory studies are adequately considered. The Committee also recommends that benefits be considered when there is at least a 50 percent likelihood of a causal relationship, and does not call for full certainty on the 

part of the Science Review Board. 

The Committee suggests that its framework be considered as the model to guide 

the evolution of the current approach. While some aspects of the approach may appear challenging or infeasible at present, feasibility would be improved by the provision of appropriate resources to all of the participants in the presumptive disability 

decision-making process for veterans and future methodological developments. Veterans deserve to have these improvements accomplished as soon as possible. 

The Committee recognized that action by Congress will be needed to implement 

its proposed approach. Legislation to create the two panels is needed and Congress 

should also act to assure that needed resources are available to create and sustain 

exposure and health tracking for service personnel and veterans. Many of the 

changes proposed by the Committee could be implemented now, even as steps are 

taken to move the DOD and VA toward implementing the model recommended. Veterans deserve to have an improved system as soon as possible. 

Thank you for the opportunity to testify. I would be happy to address any questions the Subcommittee might have. 

31 

FIGURE GS–1 (IOM 2007) Proposed Framework for Future Presumptive Disability 

Decision-Making Process for Veterans. 

a Includes research for classified or secret activities, exposures, etc. 

b Includes veterans, Veterans Service Organizations, federal agencies, scientists, 

general public, etc. cThis committee screens stakeholders’ proposals and research in support of evaluating evidence for presumptions and makes recommendations to the VA Secretary 

when full evidence review or additional research is appropriate. dThe board conducts a two-step evidence review process (see report text for further detail). eFinal presumptive disability compensation decisions are made by the Secretary, 

Department of Veterans Affairs, unless legislated by Congress. 


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ENCLOSURE: IMPROVING THE PRESUMPTIVE DISABILITY DECISION-MAKING PROCESS

FOR VETERANS


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RESPONSES TO WRITTEN QUESTIONS SUBMITTED BY HON. DANIEL K. AKAKA TO SCOTT

L. ZEGER, PH.D., MEMBER, COMMITTEE ON EVALUATION OF THE PRESUMPTIVE DIS- ABILITY DECISION-MAKING PROCESS FOR VETERANS, BOARD ON MILITARY AND VET- ERANS AFFAIRS, INSTITUTE OF MEDICINE, THE NATIONAL ACADEMIES AND FRANK

HURLEY-CATHARINE DORRIER CHAIR AND PROFESSOR, DEPARTMENT OF BIOSTATIS- TICS, THE JOHNS HOPKINS BLOOMBERG SCHOOL OF PUBLIC HEALTH

Thank you for the opportunity to speak to your Committee on February 27, 2008 

on the important question of how to use the best available science in the VA’s presumption process as detailed in our Institute of Medicine report of the Committee 

on Evaluation of the Presumptive Disability Decision-Making Process for Veterans. 

I am writing in response to your letter of March 3, 2008, that provided two questions in follow-up of my testimony. Attached, please find my responses. 

I appreciated the opportunity to speak to the Committee. Please do not hesitate 

to contact our Committee’s Chair, Dr. Jonathan M. Samet, or me if we can be of 

further assistance as you consider and use the report. 

Question 1. Dr. Zeger, I am interested in hearing about your Committee’s recommended new process for VA to follow in establishing presumptions. To aid the 

Committee in its understanding of this proposed approach, please take an existing 

issue—establishment of a presumption in the case of possible Agent Orange exposure for veterans who served off the coast of Vietnam—and describe how the Committee’s recommended approach would be applied. 

Response. The Committee calls for a prospectively implemented evidence-based 

approach that could have provided needed data and information on Agent Orange 

exposure in the Vietnam War, had it been in place at the time. The Committee’s 

report calls for improved exposure surveillance during wartime deployment. Had 

such a system been in place during the Vietnam War, we might have the relevant 

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tions in Vietnam, rather than having to speculate about them half a century later 

and make an exposure presumption. Having established a legal presumption regarding exposure to Agent Orange, the issue of shipboard exposure is less of a scientific 

question and more one of legal construction of the law and implementing regulations 

The first step in the process would be for a specific issue or concern (i.e., potential 

exposure and potential resulting health condition) to be presented to the Advisory 

Committee. This could come from two general sources. (1) surveillance data and/or 

research results produced by VA, DOD, public health agencies or academicians and 

(2) nominations from an individual (e.g., veteran, veteran’s family), a group (e.g., 

VSOs), Federal agencies, academicians or general public. VA staff serving the Advisory Committee would quickly compile as much information as they could to present 

to the Advisory Committee. The Advisory Committee is envisioned as a screening 

group and would review the available information to make a determination whether 

there was enough evidence to request a full scientific review by the Science Review 

Board. If the Advisory Committee determined there was not enough evidence, it 

could recommend additional research be conducted to establish the strength of a 

causal relationship between the potential exposure and potential resulting health 

condition. If the Advisory Committee determined there was enough evidence, it 

would recommend to the VA Secretary that a full scientific review of the evidence 

be conducted by the Science Review Board. 

The next step in the process would be for the VA Secretary to issue a specific 

charge to the standing Science Review Board. In addition, the VA Secretary may 

decide that additional research and/or surveillance data should be generated for the 

specific potential exposure and potential resulting health condition. 

The Science Review Board (SRB), with the assistance of its associated staff, would 

conduct a comprehensive evidence review of the strength of the causal relationship 

between the potential exposure and potential resulting health condition. The SRB 

would make a determination and classify the strength of causal evidence into one 

of four categories: Sufficient, Equipoise and Above, Below Equipoise or Against. The 

category of Equipoise and Above signifies that the health condition was at least as 

likely as not to be caused by the potential exposure. If the SRB classified the 

strength of causal evidence as Sufficient or as Equipoise and Above, the SRB would 

then move to the calculation of the service-attributable fraction. The calculation of 

the service-attributable fraction is independent of the classification of the strength 

of evidence for causation, would be of value in decision-making by the VA, and can 

only be accomplished when required data and information are available. In an instance in which data and information were not available to calculate service-attributable fraction, the SRB would only report its classification of the strength of causal 

evidence between the potential exposure and potential resulting health condition. 

The SRB would report its findings to the VA Secretary. 

The VA Secretary would initiate the VA’s presumption consideration process following receipt of the SRB report. VA would make a compensation decision, and the 

final decision would be made by the VA Secretary (unless legislated by Congress). 

The Committee believes that this process would be more efficient and consistent 

than the current one. The Advisory Committee, VA staff to the Advisory Committee, 

Science Review Board and its associated staff would all be established entities. The 

current process requires that new scientific review committees are assembled each 

time a new concern or study charge is given by VA. As evidenced by presumptions 

established to date, there have been different approaches in evidence evaluation and 

classification as well as how and which scientific evidence has been used in establishing presumptions. 

Question 2. Dr. Zeger, with respect to presumptive disability decision-making, 

IOM recommended a standard of ‘‘causal effect.’’ In some cases, servicemembers 

may have been subjected to multiple potential exposures of uncertain dosage. If causation is unclear, does your Committee believe that a showing of increased incidence 

of certain disabilities in the subject group should be a basis for a presumption of 

service-connection? 

Response. Our committee recommends that the presumptive process focus on the 

question: does the exposure cause the disease or condition in question. Empirical association such as an increased incidence of disease in an exposed group is one source 

of evidence in favor of causation, but so is relevant biological knowledge about the 

mechanisms by which an exposure might cause the disease is also relevant. Our recommendation to focus on cause rather than association is not raising the evidentiary 

bar for a presumption. Rather, it broadens the scope of relevant evidence to be considered. The committee further recommended that presumptions be found when all 

of the relevant evidence, carefully considered by a panel of experts, leads them to 

conclude that the causal connection is at least as likely as not. This relatively low 

50 

threshold of evidence accommodates many of the uncertainties that exist in presumption cases. By refocusing on the question of cause, by considering all of the relevant evidence and by establishing a threshold of at least as likely as not together 

with available service-attributable fraction data, the Committee believes that the 

VA can achieve the appropriate if delicate balance between society’s commitment to 

its veterans and the use of public’s resources. 

The charge to our Committee did not specifically ask the Committee to address 

‘‘multiple potential exposures of uncertain dosage’’ in establishing causation and, as 

such, this is not specifically addressed in the Committee’s report. The current presumptive disability decision-making process establishes presumptions for individual 

health conditions related to exposure from one specific agent (with the exception of 

Congress’ Gulf War presumptions of undiagnosed illnesses). However, our Committee recognized that each Servicemember will be exposed to different agents during their service in garrison and in the field. The Committee’s approach could be 

used to evaluate multiple potential exposures. If the Science Review Board (SRB) 

determined that the evidence demonstrated that it was at least as likely as not that 

multiple potential exposures caused a specific health condition, then the SRB would 

classify that specific, defined situation as Equipoise and Above. The SRB would submit its report to the VA Secretary, and the VA would make compensation and final 

decisions to establish or not establish a presumption in such an instance. 

Chairman AKAKA. Thank you very much, Dr. Zeger. 

Now we will have rounds of questions by the Committee. 

My first question is directed to Dr. Kilpatrick. Dr. Kilpatrick, 

IOM found that disability payments may actually contribute to better treatment outcomes. Can you please explain that further? 

Mr. KILPATRICK. Well, there is sort of a lore out there that basically says, veterans who get compensation for PTSD have no incentive to seek treatment and they have no incentive to get better because they are, in essence, being compensated for being sick. The 

committee received testimony from several individuals and reviewed research that indicated that basically there was not any 

strong evidence to suggest that. 

There were anecdotes to that, but actually some of the research 

that we reviewed indicated that, first of all, there was no difference 

between people who got compensation versus not in terms of responding well to treatment, and something that people don’t look 

at sometimes is that it appeared that maybe some veterans might 

seek compensation to be able to access treatment. In other words, 

the VA, as we understood it, has to prioritize eligibility based on 

some criteria. One of those criteria is: that if you were service-connected for PTSD or other things above 50 percent, I believe it is, 

that puts you at a higher priority to receive treatment. 

So, on one level, people might have to seek out disability just to 

be able to get treatment. On the other hand, there was some testimony that we got that was done of veterans who said that they felt 

validated when they were having a problem and they went to the 

VA and the VA said, we agree that you have a service-connected 

problem, and so in that case, they might feel better about themselves in addition to being able to access the treatment. 

Chairman AKAKA. Thank you. Dr. McMahon, you heard the 

IOM’s response to my previous question. I now turn to you. You 

surveyed veterans about how disability payments impact their willingness to follow medical treatment. Can you describe for the committee the results of this survey? What do the results suggest 

about the relationship between disability compensation and medical treatment, especially treatment for PTSD? 

Ms. MCMAHON. I will certainly try to shed some light based on 

the survey questions that we used. We approached this through a 

51 

series of indirect questions. We didn’t just directly ask veterans if 

they did not seek treatment or if they had terminated treatment 

because they were perhaps fearful of losing their benefits. So we 

set up a series of indirect questions to ask them about their treatment plans and ask them about the therapy they might receive and 

then approach this in an indirect manner. 

The substance of our finding was we found virtually no evidence 

of any systematic desire on the veterans’ parts to avoid treatment 

or to curtail treatment because of the fear of losing their benefits. 

And in fact, if you want to address this, the exact number—— 

Mr. CHRISTENSEN. Yes. The actual number was less than half of 

one percent of all veterans essentially had behavior that reflected 

not following treatment or not getting treatment or not seeing it 

through to the end because they were concerned about their benefits. 

Chairman AKAKA. Thank you for that response, Dr. Christensen. 

Dr. Bristow, one significant recommendation made by the Commission is to expand the concept of disability to include limitations 

in daily living and loss of quality-of-life. Please describe IOM’s 

evaluation of these concepts. 

Dr. BRISTOW. The rating schedule as it was originally developed 

was framed in a society that was largely agrarian and so the emphasis was upon whether or not an individual’s physical limitations 

impeded their ability to work, often in farm work. Society has 

changed considerably over the almost 100 years since the schedule 

began to evolve and it is clear that when an individual suffers a 

disability, there is more impact on their life than just their ability 

to earn a living. Such things as their ability to interact with their 

family, with their loved ones, with their neighbors, and to enjoy the 

everyday living activities that most of us sort of take for granted 

can be severely hampered. 

When we talk about quality-of-life, we are talking about the individual’s perception of their well-being in several domains—the 

physical, the psychological, social and economic. What do we mean 

by that? We are talking about how an individual sees themselves 

in terms of, ‘‘Am I fitting in with what I would normally expect to 

be able to do.’’ 

Now, there has been social scientific research in this area for almost 20 years, in evaluating a person’s quality-of-life. If I may take 

a moment, a study was done in Ontario, Canada, involving some 

12,000 disabled workers in a workers’ compensation program. They 

made a series of approximately 84 videos of individuals who had 

various disabilities going through the ordinary activities of daily 

life. These videos depicted the impact of being blind, for example, 

on being able to prepare your own breakfast, being able to get 

about in your home. 

They made a series of 84 such videos, and then they showed four 

or five of those videos to each of these 12,000 individuals, never 

showing a video that contained the same disability that the disabled person had, but other disabilities. Then, they asked those individuals to rate what sort of impact on their perception of life it 

would be if you had that type of disability—from zero, which they 

considered to be perfectly normal, up to 100, which was death. 

They also took at the same time some 300 normal individuals in 

52 

Ontario who had no disability and put them through the same 

process of viewing four or five of these videos each and saying, 

‘‘What would it mean to you if you were blind and had to try to 

shave,’’ as depicted on the videos. From that, they were able to construct a measure of the loss of quality-of-life for various disabilities 

in those particular workers’ compensation programs. 

Now, what we need in the VA is a similar approach—not for 

workers’ compensation, but—for the impact on a veteran’s life, and 

we need to have comparable studies that would assess how veterans who are disabled perceive themselves and how veterans who 

are not disabled perceive themselves if they were to have this disability and to be able to construct from that measures of the impact 

on the quality-of-life for veterans who are disabled. 

What my committee is recommending is that once that has been 

done, then go back to the rating schedule to see how well the rating schedule is, in fact, reflecting that impact on quality-of-life for 

the various disabilities that veterans have. And, if it turns out that 

the rating schedule is already—as Dr. McMahon said, factoring 

that in in some way—fine; all well and good. But, if it is not, then 

we believe our Nation needs to take steps to include that factor; because quality-of-life is recognized now to be much more important 

to a person than we were able to perceive 80 years ago. 

Chairman AKAKA. Thank you very much, Dr. Bristow. 

Senator Burr? 

Senator BURR. Thank you, Mr. Chairman. 

Dr. Kilpatrick, I want to make sure I understood you correctly 

in something that you said, because I thought it was a little bit different, maybe, from the testimony. You stated that somebody needed to have a disability established before you felt they would get 

the proper treatment within the VA system. Did I accurately reflect 

what you said? 

Mr. KILPATRICK. Well, let me tell you what I meant. What I 

meant to say is that it was our understanding that the VA does 

prioritize treatment if there are not enough resources in the health 

care system for the VA to treat all veterans, if they all came forward at the same time for treatment. There would not be sufficient 

resources to do that. Therefore, there is a priority system, which 

differs for veterans of different wars; but, it also filters in the level 

of service connection that you have, which is one thing that moves 

you up or down the priority list in terms of getting you in for treatment. 

So therefore, it is possible that some of the recent veterans may 

have—I mean, they are first priority to get in; but, for example, 

some Vietnam veterans might not be first priority to get in, yet 

they would have a higher priority depending on the level of disability for PTSD that they had. 

Senator BURR. Clearly past veterans have gone through disability ratings. They filed their disability claims. They have probably been re-rated numerous times, and I think we are certainly 

focused on this new starting point for today’s warrior and how the 

system needs to reflect not only technology in the delivery of care, 

but their expectations. 

The challenging thing, especially as it relates to PTSD and other 

mental disabilities, is that I think most clinicians know that the 

53 

first 6 months is the most crucial time of intense rehabilitation, of 

intense treatment, yet it is proven within the system you don’t 

even get a disability determination in 6 months, at the earliest, 

and likely it extends much past that. 

The focus of our attention is how do we take these young warriors and put them in intense rehabilitation in hopes that when 

they come out the other end, the disability is better or it is gone. 

As a matter of fact, I am troubled because the Inspector General’s 

report in 2005 found that, generally, once a PTSD rating was assigned, it was increased over time until the veteran was paid 100 

percent. Now, I have got to be clear. My objective is to make sure 

that the initial rating after treatment goes down, hopefully; and if 

it doesn’t, we have a system that, in the future, will account for 

quality-of-life and for loss of work. 

I have difficulty with the VA model today, because it seems like 

you come in one side and you go out another side sicker than when 

you came in. That is not health care. Health care is designed to 

make one better. So, I would only caution you on that statement. 

I think I am less concerned with what their rating is for disability 

when that disability determination is made. I am more concerned 

that when they are seen, if they believe that there is a need for 

mental health services, that we get them in that program; that we 

do everything to keep them in that program; that we make sure 

any financial challenges that a family has, we overcome, so that 

the service personnel’s focus is on treatment. The most important 

thing for me right now is treatment; and on the back end, we can 

make a more accurate evaluation of the disability, the degree of the 

disability, and consequently, what the compensation should be. 

Clearly, I am alarmed at what the Inspector General found, and 

that is, if we enter them into the system, if we don’t get them the 

type of services that they need up front, the outcome today is that 

eventually they become 100 percent disabled. I think our objective 

ought to be to make sure that nobody reaches 100 percent, because 

we have got the services in place to change their course, yet 100 

percent is there in case everything that we collectively try fails. 

Let me move to you, Dr. Bristow, for a second because I am curious as to where Chairman Akaka went, and I am having a difficult 

time distinguishing. I see the two areas, quality-of-life and the 

work disability, and I am having a hard time separating qualityof-life from the non-work disability, because I guess I put myself 

in a category that I am not disabled. When my wife says, ‘‘Change 

that light bulb,’’ 3 weeks later when I haven’t changed that light 

bulb—if I were disabled, it is a quality-of-life issue: that I see that 

I can’t physically do it. There are some things that I am limited 

in doing, non-work-related, that had I not had the disability, I 

could do. I could respond. 

Help me distinguish these two, because I think my concern is 

that the more you split the categories, the more difficult it is for 

us to come to a system and to design something that is reflective 

of the balance that we need. 

Dr. BRISTOW. Yes, sir, Senator. Let me try to do that. I would 

say that the non-work-related disabilities that we are referring to 

are measurable disabilities—how much time does it take you to 

climb a flight of stairs? How well can you carry out certain funcVerDate Aug 31 2005 12:11 Dec 11, 2008 Jkt 000000 PO 00000 Frm 00057 Fmt 6633 Sfmt 6602 H:\PS41451\DOCS\022708.TXT SVETS PsN: PAULIN
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tions that are common to everyday life? Those are measurable, as 

I said, speed, dexterity, that sort of thing. 

When we speak of quality-of-life, we are speaking instead of the 

individual’s perception of themselves, and as I said, how they fit 

into this world. That is not the same thing as whether or not you 

can lift a 50–pound load from the floor repetitively over the course 

of 5 minutes. 

So, one is non-work-related. It is not something that you are engaged in in your occupation, but it impacts how quickly can you get 

to work if you have difficulty with ambulation, how much difficulty 

is there in getting dressed in the morning. Those are the non-workrelated disabilities. I would consider them measurable or at least 

estimable. 

The quality-of-life issues, on the other hand, are such things as, 

‘‘I can’t put my arms around my kid who is growing up because I 

don’t have an arm.’’ That is not measurable; it is a self-perception. 

What we are saying is that in the modern world’s concept of disability, it is recognized that that is something that should be taken 

into consideration. Workers’ compensation systems in a number of 

areas are attempting to take into consideration quality-of-life 

changes as a result of a disability. I believe it can be safely said 

that the Veterans Administrations in Canada and in Australia are 

attempting to take into account the quality-of-life impact from a 

disability and to develop some form of compensation for that. 

Senator BURR. I appreciate your comments, as I do from all of 

you, and I hope you understand why we are going into such depth. 

We have got a system that hasn’t changed in 50 years. The historical precedent that is set is that we may not change this for another 50 years. So, hopefully we design it in a way that it accommodates those things that we can’t anticipate we are going to run 

into, but also that it reflects where we are technologically, where 

we are from a standpoint of our commitment, our promise, our obligation. My hope is that we get it right or that we come as close 

as humanly possible, and that is why I commend the Chairman 

and his willingness to take on as much input into this, because it 

is an extremely important course that we take. 

I apologize. My time has run out and I think the Chair is going 

to have another round, I feel certain. 

Chairman AKAKA. Thank you very much, Senator Burr. 

Dr. Zeger, let me just move back to more of the structure. Can 

you please explain the relationship between the Advisory Committee, the Science Review Board, and VA? Should VA be required 

to follow the recommendations of these new panels? 

Dr. ZEGER. Thank you, Mr. Chairman. The committee was not so 

bold as to recommend that the VA must do something, because it 

recognizes that the VA and Congress have the responsibility for establishing the exact process and the decision about a particular 

presumption. What we did ask, however, is that a more scientific 

basis be put in place so that the best evidence is brought to the 

decision that the VA and Congress make. There are two parts of 

the process we see opportunity for revision. 

The first is a way to prioritize the many potential presumptions 

that arise. The committee believes that we should encourage affected veterans to come forward with their health or exposure conVerDate Aug 31 2005 12:11 Dec 11, 2008 Jkt 000000 PO 00000 Frm 00058 Fmt 6633 Sfmt 6602 H:\PS41451\DOCS\022708.TXT SVETS PsN: PAULIN
55 

cerns; we need a place where VSOs may bring concerns of the community. So, the first Advisory Committee would be a place that 

would receive a range of potential nominations for presumptions, 

would prioritize them, and put some into a scientific process. 

The Science Review Board would be the place where the best 

available evidence would be gathered and assessed and then recommendations would be made to the VA. The VA would have the 

responsibility for the ultimate decision about the presumption, or 

Congress in the cases where it is involved. 

Chairman AKAKA. Thank you very much. 

Dr. McMahon, CNA’s quality-of-life study found that mental disability does appear to lead to lower physical health, but physical 

disability does not lead to lower mental health. To some, this might 

seem counterintuitive. We generally understand that physical disability is often associated with lower mental health. Is this true for 

veterans and non-veterans alike? 

Ms. MCMAHON. We looked at the issue of the health scores separately for physical and mental health scores from the results of the 

survey, and what we found for those who had a primary physical 

disability—and let me just back up and clarify. Veterans may have 

a number of different disabilities. We categorize them by the primary disability being physical or mental. So, for those who had a 

primary physical disability, what we found is that for those with 

a reasonably low rating of disability, up to, say, 50 percent, they 

did not appear to have a mental score that was different from the 

norm of the population in general. So, they did not have a mental 

score that reflected a difference from the general civilian population. 

On the other hand, for those who were severely disabled with a 

primary physical disability—say an 80 percent or 100 percent disability—they did show that they had below average mental health 

scores, as well. So, it is their disability on the physical side was associated with a loss of the mental score, as well. 

On the other hand, for those who had a primary mental disability, we were surprised to see that at every rating category, 

there was a loss in both the physical and the mental health scores 

compared to the overall population norms. That was not something 

we anticipated. 

Chairman AKAKA. Dr. McMahon, CNA’s analysis found that a 

higher number of those designated as individually unemployable 

suffer from disabilities such as PTSD. CNA’s report states that this 

suggests a failure of the VA rating schedule. In your opinion, what 

changes should be made to the rating schedule to correct the overreliance on IU? What changes should be made to the criteria for 

IU? 

Ms. MCMAHON. Well, we did look at IU and one of the findings 

we had is that, overall, 8 percent of those receiving VA disability 

compensation have IU, but 31 percent of those with PTSD as their 

primary diagnosis had an IU designation. We concluded from this 

that there was an indication that the rating schedule was not 

working well for PTSD and that many of the people who had PTSD 

were having to come back and say, we have an inability to work 

and we need a higher rating. So, that suggested to us that the ratVerDate Aug 31 2005 12:11 Dec 11, 2008 Jkt 000000 PO 00000 Frm 00059 Fmt 6633 Sfmt 6602 H:\PS41451\DOCS\022708.TXT SVETS PsN: PAULIN
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ing was not working well enough for that group of people and possibly for others, as well. 

What you would do to address that, I think, could occur in a 

number of ways. One suggestion is that if people are unable to 

work, even though they don’t have a 100 percent rating in this 

area, that possibly they are not being rated correctly. I am not a 

clinician. I can’t say exactly how I would rate someone with PTSD 

to do this, but I can say that we did review this issue. With the 

survey of our raters and VSOs, we asked these people how they felt 

about the rating process, and they particularly indicated that they 

found the claims becoming more complex. They found that it was 

much more difficult to rate a mental disability than a physical disability, other things being equal, and in particular, PTSD was the 

hardest to be objective about. There was a subjectivity to the evaluation that troubled them, that led to some inconsistencies, perhaps. And so they spoke up for the need for more time and especially more clinical input from physicians and mental health practitioners to assist them in making that determination for PTSD. 

And I think when you weave these stories together, it is an indication that the process needs to be addressed, that the raters are 

not comfortable with what they are being asked to do. They need 

more assistance. They need more time to consider this kind of 

claim in particular and that might lead to a better outcome. 

Chairman AKAKA. Senator Burr? 

Senator BURR. Dr. McMahon, thank you very much. I was fascinated with your statement that physical disabilities didn’t lead to 

mental deficiencies, but mental disabilities did lead to physical deficiencies. I think that is sort of at the heart of what I have tried 

to drive, and that is: with that known, the focus—especially on 

mental disabilities—should be treatment as quickly and as effectively as we possibly can. Because I think the data proves and your 

study proves that that leads to a physical deficiency if, in fact, we 

don’t thoroughly address the mental disability that exists. And as 

we look at one, a primary objective of making a veteran better 

when they leave than when they came in; and two, how do we 

eliminate the slide in the future of one who continually gets worse. 

Well, clearly to inject the physical side into it, you now have a veteran that is affected in multiple ways. 

You mentioned that veterans who become severely disabled at a 

young age may have a long period of lost earnings. I mentioned 

Sarah Wade earlier, and as she put it, ‘‘Ted will never again get 

a pay raise.’’ For these young severely disabled veterans, you found 

that they are substantially below parity in terms of compensating 

for their lost earnings. Would you walk us through your suggestions for how you would make sure that young severely wounded 

warriors, like Ted, are being adequately compensated in the future? 

Ms. MCMAHON. I would be happy to do that. I believe that when 

we looked at the parity of the disabled veterans, we found that the 

average age of entry into the VA system is about at age 55, and 

to put it as simply as possible, someone coming in at that point has 

had a fairly long job history so far in their lives and now the disabling condition has become something that they can no longer 

cope with quite so well. And so they come into the VA system and 

57 

then we look at what that says for the compensation over their expected lifetime. This is a lifetime look that we took in terms of the 

compensation. 

So, for the young veteran who has become severely disabled at 

a young age, they are facing an entire lifetime of having an inability to completely participate in the workforce as compared to their 

peers that are able to do this in a normal fashion. So, they are 

looking at a long period of years when they are disadvantaged in 

terms of their work capabilities, and that is what leads to some of 

the disparity that we see. It is not a system that expects you perhaps to come in at age 25 and be there for the rest of your life. 

As for the question of how you would deal with that, it is possible 

that you could deal with it partly by having a compensation that 

would depend on the age of entry. Another possibility would be to 

have a special compensation element for those people who came in 

at a very young age to reflect that condition. 

I think another thing that I would want to say is that I also view 

that the better solution is treatment and getting the person to be 

well-adjusted to life and able to contribute as much as they can. 

It does seem to me that you don’t want to simply say, well, we will 

give you more money if, in fact, what you can do is give more treatment to help people. And I think in particular with PTSD, that 

treatment is crucial and getting treatment that is thorough and 

adequate as well as you can to give people the best chance as possible to return to a normal life is a very important aspect of it. 

Senator BURR. Let me ask you, about 30 percent of our veterans 

with service-related disabilities are also military retirees who by 

definition would be eligible for DOD retirement benefits, including 

an annuity, health insurance for their entire family, access to taxfree shopping at commissaries and exchanges. Now, specifically for 

those retirees with less disabling conditions: did your study address 

whether they, on average, work less than veterans who do receive 

these benefits? I hope you understand what I am trying to analyze. 

Ms. MCMAHON. I do understand, and we did not look at that 

issue. I can’t give you an answer on that. 

Senator BURR. Is that something important for us to look at as 

we try to construct something that truly reflects what fair compensation is, and by the way, to eliminate disincentives that may 

exist in the system? I am not suggesting to take things away from 

people, but to identify disincentives that need to be balanced. 

Ms. MCMAHON. Partly, I would say that this becomes a policy 

issue, and my comments on this are not based so much on an analysis of findings but just in terms of other kinds of policy assessments that have been made over time. If you view your retirement 

benefit as being something that you have earned, then it is something that is yours, that you own—it is sort of like you have paid 

into a system and received it. It is somewhat like having a retirement system in the civilian market where you may have paid into 

a fund and then that money is yours at the end. And so in that 

sense, it is not really a compensation, it is a retirement fund that 

you have built up. 

In that sense, what we looked at in the study was strictly based 

on income-earning ability and compensation. We did not address, 

and I can’t think how we could have addressed the issue of various 

58 

retirement funds that individuals acquire in various ways other 

than the obvious one with the military. So, that is just not something that we were able to bring into the picture. 

Senator BURR. Dr. Bristow, do you want to add something to 

that? 

Dr. BRISTOW. Yes, sir. Thank you, Senator. Our committee was 

quite interested in this issue but from the other end of the spectrum, in that, particularly in the IU program, the Veterans Administration is prohibited from taking into account the age of the individual who applies and does not make any allowance for how long 

this person would be expected to be able to be employed in the future. Our committee, in fact, has recommended that research studies should be done to see whether or not that is an appropriate policy, and I think what I have heard today suggests to me even more 

so that it really should be done. There should be some reasonable 

accounting taken for the age of the individual and what is projected 

to be their likelihood of employability over a period of time. 

Ms. MCMAHON. And I would follow up with that. We also looked 

at unemployability that way and one of the things we noted is that 

this payment, once achieved, can be received indefinitely, whereas 

most people have retired by a certain age. And so this concept of 

considering the age of the individual with regard to the benefit received is something that we addressed, as well. 

Senator BURR. Well, I genuinely want to say how grateful I am 

to all of you for your willingness to be here. The Chairman has 

been very gracious with me on the clock. I want to ask all of you, 

I will have additional questions—— 

Chairman AKAKA. We will do another round. 

Senator BURR. The Chairman says he is going to do another 

round. I will probably have additional questions beyond that, as 

well, and they may not all be tomorrow. They may be as we work 

through the construction of where it is we need to go. And I hope 

all of you will make yourselves available to help us as we try to 

construct what we believe is the most appropriate path forward. 

Chairman AKAKA. Thank you very much, Senator Burr. We will 

have another round here. 

Dr. Kilpatrick, IOM recently published a report on the effectiveness of the best approaches for treating PTSD. Did IOM reach any 

conclusions on whether or not cognitive therapy is readily available 

to veterans? 

Mr. KILPATRICK. That was not our committee, but I am generally 

familiar with that report and my recollection is that in terms of 

cognitive behavioral therapy, they identified one treatment, which 

was prolonged exposure, that said that it really met the gold standard test of having then multiple studies that were replicated for effectiveness for PTSD. I think there are some other treatments that 

some of us think are probably very close to that level of gold standard, as well, and I believe that the committee determined that 

many VA mental health professionals have not been trained in 

those particular treatments. 

And so to that extent, I believe they would say that there is a 

shortage of trained clinicians to provide those treatments in the 

VA, which the VA, in fairness, is working on and I know has training programs and is also trying to hire new mental health profesVerDate Aug 31 2005 12:11 Dec 11, 2008 Jkt 000000 PO 00000 Frm 00062 Fmt 6633 Sfmt 6602 H:\PS41451\DOCS\022708.TXT SVETS PsN: PAULIN
59 

sionals. But I think where we stand right now is that the most effective treatment that was identified is not readily available to 

every veteran at every VA. 

Chairman AKAKA. Dr. McMahon, CNA found that service-disabled veterans with serious mental disabilities earn less in every 

age group and rating group than veterans with physical disabilities. What do you believe accounts for this difference? Should veterans with mental disabilities receive higher ratings to compensate 

for their lower earnings? 

Ms. MCMAHON. I am not completely certain, of course, what 

makes the difference, but I can speculate a little bit about what I 

think is a reasonable interpretation of that finding. I think with 

physical disability, it is often something that can be compensated 

for, not in money terms in this context, but compensated for in 

other ways. It may be that there is an artificial limb that is provided. It may be that there is an accommodation of a workspace 

that is changed or stairs are replaced by an elevator or something 

like that which allows a person to be able to work more effectively. 

In addition, people can recognize what the physical limitation is 

and perhaps find ways to work around it in a fairly straight-forward fashion. I didn’t say that well. 

When you are dealing with a condition that is a mental disability, I don’t think it is as easy to understand how to accommodate the person in that circumstance. I don’t think it is a visible 

thing, such as I have lost a limb or I need to have someone help 

me come up the stairs or something of that nature. And so I think 

it is harder for the accommodation to be made for that person. It 

is just not easily recognized what is needed to make them fit well 

into the work environment so readily. 

In terms of compensation, should there be extra compensation, I 

would say that I view it as one of two things. Either you find a way 

to treat the person so that they are able to be accommodated into 

the workforce in a better fashion or you have to recognize that we 

are not able to make that accommodation, and then in that sense, 

yes, they would need an additional compensation. 

Chairman AKAKA. Dr. Bristow—— 

Dr. BRISTOW. Yes, sir? 

Chairman AKAKA [continuing]. Can you please explain the importance of VA beginning to use the ICD and DSM classification systems that are used in today’s health care systems? 

Dr. BRISTOW. Yes, sir, I would be happy to. In fact, this will 

apply to the last question that you raised with Dr. McMahon. 

The ICD coding system and the DSM coding system allow for the 

most precise definition of a state of disease in a given individual. 

What VA is currently using is extraordinarily imprecise and, in 

fact, even when they acknowledge what the diagnosis correctly is, 

in the area of mental illness, which is a glaring example, administratively, VA has decided we will decide all mental illness in terms 

of its disability using the same set of criteria, and those criteria 

that have been selected do not fit well with many mental illnesses. 

They may fit very well with a person who has got schizophrenia, 

but they have very minimal application to a person who has PTSD. 

If they were using DSM as a coding system, DSM provides and 

identifies where the problems are being manifested in that given 

60 

individual. It would then be a lot easier to say, well, if the person 

is having these manifestations, that indicates a severer level of disability than using a broad-brush which has very little application 

to where the problems are for this specific illness. 

So, it is imperative, in my opinion and in the opinion of our Committee, that VA move to using the same coding classification that 

is being used all over the world—that is being used within the VA’s 

health care system itself. It is just that when they leave VA’s 

health service and transfer the information over, it is recoded into 

something terribly archaic, and that negatively impacts the ability 

of the disability system, which wants to do the right thing; but it 

makes it very hard for them to do the right thing when they are 

using the wrong tool. 

Chairman AKAKA. Thank you very much, Dr. Bristow. 

I will call on Senator Burr, though I have one more question to 

ask all of our witnesses. I will do that after he is done. 

Senator BURR. Dr. Bristow, I want to call on your Presidency of 

the AMA to ask you, is it healthy for the Chairman to drink such 

a large cup of Starbuck’s coffee? [Laughter.] 

I am not sure I can figure out how you could make it through 

this hearing having drunk that whole thing. 

You know, I am reminded as I sat here that we have done a tremendous job with homelessness in this country, and that is both 

sides, the veterans’ side but also the general public side. There is 

one thing that we learned extremely early in it and we are still 

having a difficulty implementing. We can do a great job at providing a roof and walls to an individual, but without the wraparound services, you can’t put somebody permanently in housing. 

It takes the wrap-around services to treat the other conditions that 

they run into that make them permanent from a standpoint of 

being in a home. 

So, I hope all of you understand why I have been so insistent 

about making sure that we provide the services. It is not just, how 

do we get the disability right. It is how do we provide the level of 

health care so that, hopefully, the disability goes down over time, 

if that is possible. 

Dr. McMahon, I want to ask you one last question. The VDBC 

noted, and I quote them, ‘‘it is commonly acknowledged that the 

disability compensation program compensates for injuries and diseases that do not impair earnings capacity but have negative consequences for veterans,’’ and I would only ask you, were you able 

to draw any conclusions along those lines? 

Ms. MCMAHON. I am going to be very candid and say I am not 

exactly certain what context that is taken from. Our mandate was 

to look for those things that had an impact on the ability to earn 

and to look at what compensation consequences there were, and 

that was really the thing that drove our considerations. I suspect 

that this is something that I would understand better if I could 

read more of the context surrounding the statement. 

Senator BURR. We will ask it in a written follow-up question and 

try to point to you—— 

Ms. MCMAHON. That would be better. Thank you. 

Senator BURR [continuing]. Exactly the context that it was in, 

and again, I want to—yes, sir, Dr. Bristow? 

61 

Dr. BRISTOW. Very quickly, I think that a good example of the 

VA’s efforts, good faith efforts in that direction would be compensation for loss of procreative organs, which have obviously nothing to 

do with a person’s earnings capacity, but it is a recognition once 

again of an attempt to go into the area of quality-of-life, which is 

important. 

If I can sneak in one last little quick statement? Our committee 

felt it is going to be important as we go forward to give each applying veteran a more complete evaluation than they currently have 

been receiving; not only a compensation and pension evaluation, 

and a medical evaluation, but they really should have a vocational 

evaluation when they first apply, so as to be able to inform that 

veteran and help that veteran decide how can they emphasize the 

‘‘ability’’ part of disability rather than the ‘‘dis’’ part. Find out what 

they can do to help them return to normal, to as much normalcy 

as possible, and that can only be done if we provide that type of 

service when they first apply. Yes, you have these impairments, 

but you also have these potentials, and maybe we can help you go 

to school to work on some of your strengths. If we can do this, it 

will help that veteran get the most out of life. 

Mr. KILPATRICK. Senator Burr, I just wanted to clarify, as well, 

that our committee, whereas it was focusing on the disability process, noted that there was a separation between the disability determination and encouragement and involvement in just what Dr. 

Bristow was talking about. And as a mental health professional 

who treats PTSD, I would say that we all think that veterans 

should get access to the best mental health services possible. There 

might be a difference of opinion about whether being involved in 

a disability for PTSD would affect that or not. I don’t think our 

committee felt that it would. 

But clearly, we are in agreement that services in the VA should 

change its procedures and what not, and laws if necessary, to make 

sure that everybody does have access to the best mental health 

services because it benefits society, obviously, not just the veterans, 

to be in a situation where they improve as much as they can, 

where they get over the terrible things that have happened to them 

and that they can live as productive a life and as happy a life as 

possible. 

Senator BURR. I appreciate that, and I hope you understand 

where I am getting that. I am not sure that it is good enough for 

us to say, it is available. I think our policy has to facilitate people 

to take advantage of it. It is not just about access. It is about accepting that pathway of treatment and rehabilitation. 

I am somewhat passionate about it because I look at the data 

and the data suggests the model we currently have, which provides 

access for many if not a majority of the veterans, does not work. 

I am not suggesting that that is something that is reflective of 

something we have done wrong or the system has done wrong. It 

is the fact that veterans for possibly a host of reasons have not entered into the system with the intent that the system will make 

them better. I truly believe if they believed that, they would be in 

it. 

So, shouldn’t we try something different? Shouldn’t we create the 

incentive to get them in, because you—the medical professionals— 

62 

tell us that if we are in there, you know what? The outcome is different. So, I think this is a process of how do you get the disability 

side correct, but also how do you take the delivery side and make 

it work for veterans. 

Again, I thank each and every one of you. 

Chairman AKAKA. Thank you, Senator Burr. 

Here is my last question. I am continuing to try to get from the 

source—which you are—to VA, to find out whether everything was 

done that needed to be done in this area. So, my question to the 

four of you is, is there anything—anything at all, either in your report or from your overall work for the Commission—which is not 

included in the report or is not reflected in the way you intended 

it to be? Dr. McMahon? 

Ms. MCMAHON. I believe that the Commission was extremely receptive to the work that we did and I do not believe that there is 

anything that they did not consider that we put forward to them. 

It was a remarkable experience—dealing with 13 Commissioners 

who had their own points of view—but I think, in the end, we were 

able to give them what they asked for and they reflected that very 

well in their report. 

Chairman AKAKA. Thank you. Dr. Bristow? 

Dr. BRISTOW. Thank you, Mr. Chairman. I believe the Commission did an outstanding job. I would say that I am not certain that 

the Commission quite grasped one aspect that my committee was 

trying to put forward, and that is the Veterans Administration has 

available to it an enormous mine of information upon which we 

can, when properly mined, base evidence-based decisions, evidencebased programs that best serve our veterans. It currently would be 

enhanced if we had the right sort of coding system, and once that 

is in place, begin to utilize the information that is right there. We 

have a treasure trove of potential information which needs to be 

mined that will allow us to best use our resources. We can find out 

what is the best way to provide services by utilizing the research 

opportunities that are just begging to be used. 

Chairman AKAKA. Thank you. Mr. Kilpatrick? 

Mr. KILPATRICK. I would say that our committee did a very thorough job of identifying areas of difficulty and then coming up with, 

I think, some common sense ways to reform the process of compensation and, as I mentioned previously, to further integrate the 

disability part of the VA with the health care and treatment delivery and rehabilitation part of the VA. 

I think that although our committee sort of tangentially discussed this, I mean, what I see as one of the big challenges is that 

for PTSD, we do have some effective treatments now. We always 

need more research. I mean, I couldn’t be a researcher and not say 

that we need more research, but we need more—we do need more 

research, but we do have some things that work now. I think we 

need more studies to look at—to evaluate efficacy and effectiveness. 

I think we also—the VA is going to need to do even more than it 

is doing now to make sure that we have well-trained mental health 

professionals who are up to date in evidence-based treatments and 

assessment procedures. 

Chairman AKAKA. Thank you. Dr. Zeger? 

63 

Dr. ZEGER. Yes. Thank you. I would like to report that our committee was very impressed by the degree to which General Scott 

and the Commissioners were interested in our committee process. 

We had the good fortune of meeting with some of them in San Antonio when we had open hearings for VSOs and veterans. It would 

have been much better had it been in Hawaii, of course, but it was 

very nice to be with them in San Antonio. I am particularly 

pleased—I know the committee is—that the Commission has accepted all of the recommendations that we have put forward to 

them and we are now looking forward to seeing a transition toward 

a more scientific basis for presumptions. 

Chairman AKAKA. Well, thank you so much for your responses. 

This has been a great hearing, and as I mentioned, I look upon all 

of you here as a source that will help VA do its job better. We are 

looking forward to trying to support what needs to be done to improve the programs that we have to help our veterans. 

So, in closing, let me say thank you very much, all of you, for 

appearing before us today. 

The hearing is adjourned. 

[Whereupon, at 11:03 a.m., the committee was adjourned.] 

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