VA Disability Benefits: Routine Monitoring of Disability Decisions Could Improve Consistency
Published: 2005-10-20T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: The House Subcommittee on Disability Assistance and Memorial Affairs asked GAO to discuss its work on the consistency of disability compensation claims decisions of the Department of Veterans Affairs (VA). GAO has reported wide state-to-state variations in average compensation payments per disabled veteran, raising questions about decisional consistency. In 2003, GAO designated VA's disability programs, along with other federal disability programs, as high risk, in part because of concerns about decisional consistency. Illustrating this issue, GAO reported that inadequate information from VA medical centers on joint and spine impairments contributed to inconsistent regional office disability decisions.
section_title: What GAO Found
paragraphs: GAO's November 2004 report explained that adjudicators in the Department of Veterans Affairs often must use judgment in making disability compensation claims decisions. As a result, it is crucial for VA to have a system for routinely identifying the effect of judgment on decisional variations among its 57 regional offices to determine if the variations are reasonable and, if not, how to correct them. In 2002, GAO reported that state-to-state variations of as much as 63 percent in average compensation payments per disabled veteran indicated potential inconsistency. The nature of the criteria that adjudicators must apply in evaluating the degree of impairment due to mental disorders provides an example of the extent of judgment required. GAO's October 2005 report on decisions for joint and spine disabilities showed one important way to improve consistency. Specifically, regional offices often rely on VA's 157 medical centers to examine claimants and provide medical information needed to decide the claims. However, VA has found inconsistency among its medical centers in the adequacy of their joint and spine disability exam reports that regional offices need to decide these claims. As of May 2005, the percentage of exam reports containing the required information varied across the medical centers from a low of 57 percent to a high of 92 percent. This could adversely affect the consistency of disability claims decisions involving joint and spine impairments. Although VA has made substantial progress, more remains to be done to improve the level of consistency in the disability exam reports.

section_title: Letter
paragraphs: Thank you for inviting me to discuss our work on the consistency of  decisions that the Department of Veterans Affairs (VA) makes on veterans’  disability compensation claims. Ensuring that VA’s disability decisions are  consistent across the nation is vital to ensuring the integrity of VA’s  disability program. In 2002, we reported that wide variations existed  across the nation in the average compensation payments per disabled  veteran, and we recommended that VA study such indications of  inconsistency in the decision making of its 57 regional offices. As you  know, in January 2003, GAO designated VA’s disability program, along  with other federal disability programs, as high risk, in part because of  concerns about the consistency of decision making.
In December 2004, the media published data showing that the average  compensation payment per disabled veteran varied from a low of $6,710 in  Ohio to a high of $10,851 in New Mexico. In response, the Secretary asked  the Office of Inspector General in December 2004 to study the reasons for  the wide variations in average payments, and in May 2005, the Inspector  General reported its findings and made recommendations for  improvement. As the Inspector General found, much needs to be done to  ensure that VA renders consistent decisions across the nation.
As you requested, my remarks today will draw upon two GAO reports. The  first, issued in November 2004, addressed VA’s need for a systematic  approach to identifying consistency issues that need to be studied in  detail. The second report, issued on October 12, 2005, examined VA’s  efforts to achieve consistency among its medical centers in the quality of  the medical information they provide to regional offices in order to make  decisions on disability claims involving impairments of joints and the  spine. Improving the quality of the medical information for these  impairments could improve VA’s decisional consistency.
In summary, as we reported in November 2004, VA’s adjudicators often  must use judgment in making disability decisions. As a result, variation is  an inherent factor in the decision-making process. This makes it crucial  that VA have a system for routinely identifying variations among its 57  regional offices so that such variations can be studied to determine if they  are within the bounds of reasonableness and, if not, how to correct the  problem. Also, as we reported in October 2005, to achieve consistency, VA  must deal with issues involving not only its regional offices but also its 157  medical centers which conduct most of the disability examinations that  regional offices rely on to provide the medical information they need to  make disability decisions. As we reported, VA has found inconsistency  among its medical centers in the extent to which they provide regional  offices with exam reports containing all the medical information needed to  ensure that regional offices make decisions awarding the appropriate level  of benefits to veterans with joint and spine impairments. Some medical  centers consistently provide high-quality exam reports, while others do  not, which means the benefits awarded to veterans with similar joint and  spine impairments could differ, depending on which medical center  examined them. Although VA has made substantial progress in correcting  this problem, more remains to be done to ensure that all medical centers  provide exam reports containing adequate information for regional offices  to make proper decisions.
subsections: section_title: Background
paragraphs: Regardless of a veteran’s employment status or level of earnings, VA’s  disability compensation program pays monthly cash benefits to eligible  veterans who have service-connected disabilities resulting from injuries or  diseases incurred or aggravated while on active military duty. A veteran  starts the disability claims process by submitting a claim to one of the 57  regional offices administered by the Veterans Benefits Administration  (VBA). In the average compensation claim, the veteran claims about five  disabilities for which the regional office must develop the evidence  required by law and federal regulations, such as military records and  medical evidence. To obtain the required medical evidence, VBA’s regional  offices often arrange medical examinations for claimants. For example, in  fiscal year 2004, VBA’s 57 regional offices asked the 157 medical centers  administered by the Veterans Health Administration (VHA) to examine  about 500,000 claimants and provide examination reports containing the  medical information needed to decide the claim.
On the basis of the evidence developed by the regional office, an  adjudicator determines whether each disability claimed by the veteran is  connected to the veteran’s military service. Then, by applying medical  criteria contained in VA’s Rating Schedule, the adjudicator evaluates the  degree of disability caused by each service-connected disability in order to  determine the veteran’s overall degree of service-connected disability. The  degree of disability is expressed as a percentage, in increments of 10  percentage points—for example, 10 percent, 20 percent, 30 percent, and so  on, up to 100 percent disability. The higher the percentage of disability, the  higher the benefit payment received by the veteran.
If a veteran disagrees with the regional office adjudicator’s decision on  whether a disability is service-connected or on the appropriate percentage  of disability, the veteran may file a Notice of Disagreement. The regional  office then provides a further written explanation of the decision, and if  the veteran still disagrees, the veteran may appeal to VA’s Board of  Veterans’ Appeals. Before appealing to the board, a veteran may ask for a  review by a regional office Decision Review Officer, who is authorized to  grant the contested benefits based on the same case record that the  original adjudicator relied on to make the initial decision.
After appealing to the board, if a veteran disagrees with the board’s  decision, the veteran may appeal to the U.S. Court of Appeals for Veterans  Claims, which has the authority to render decisions establishing criteria  that are binding on future decisions made by VA’s regional offices as well  the board. For example, in DeLuca v. Brown, 8 Vet. App. 202 (1995), the  court held that when federal regulations define joint and spine impairment  severity in terms of limits on range of motion, VA claims adjudicators must  consider whether range of motion is further limited by factors such as pain  and fatigue during “flare-ups” or following repetitive use of the impaired  joint or spine. Previous to this decision, VA had not explicitly considered  whether such additional limitations existed because VA contended that its  Rating Schedule incorporated such considerations.
section_title: VA Needs a System for Routinely Monitoring Variations Inherent in Deciding Disability Claims
paragraphs: Because adjudicators often must use judgment when deciding disability  compensation claims, variations in decision making are an inherent  possibility. While some claims are relatively straightforward, many require  judgment, particularly when the adjudicator must evaluate (1) the  credibility of different sources of evidence; (2) how much weight to assign  different sources of evidence; or (3) disabilities, such as mental disorders,  for which the disability standards are not entirely objective and require the  use of professional judgment. Without measuring the effect of judgment on  decisions, VA cannot provide reasonable assurance that consistency is  acceptable. At the same time, it would be unreasonable to expect that no  decision-making variations would occur.
Consider, for example, a disability claim that has two conflicting medical  opinions, one provided by a medical specialist who reviewed the claim file  but did not examine the veteran, and a second opinion provided by a  medical generalist who reviewed the file and examined the veteran. One  adjudicator could assign more weight to the specialist’s opinion, while  another could assign more weight to the opinion of the generalist who  examined the veteran. Depending on which medical opinion is given more  weight, one adjudicator could grant the claim and the other could deny it.  Yet a third adjudicator might conclude that the competing evidence  provided an approximate balance between the evidence for and the  evidence against the veteran’s claim, which would require that the  adjudicator apply VA’s “benefit-of-the-doubt” rule and decide in favor of  the veteran.
An example involving mental disorders also demonstrates how  adjudicators sometimes must make judgments about the degree of severity  of a disability. The disability criteria in VA’s Rating Schedule provide a  formula for rating the severity of a veteran’s occupational and social  impairment due to a variety of mental disorders. This formula is a  nonquantitative, behaviorally oriented framework for guiding adjudicators  in choosing which of the degrees of severity shown in table 1 best  describes the claimant’s occupational and social impairment.
Similarly, VA does not have objective criteria for rating the degree to  which certain spinal impairments limit a claimant’s motion. Instead, the  adjudicator must assess the evidence and decide whether the limitation of  motion is “slight, moderate, or severe.” To assess the severity of  incomplete paralysis, the adjudicator must decide whether the veteran’s  paralysis is “mild, moderate, or severe.” The decision on which severity  classification to assign to a claimant’s condition could vary in the minds of  different adjudicators, depending on how they weigh the evidence and  how they interpret the meaning of the different severity classifications.
Despite the inherent variation, however, it is reasonable to expect the  extent of variation to be confined within a range that knowledgeable  professionals could agree is reasonable, recognizing that disability criteria  are more objective for some disabilities than for others. For example, if  two adjudicators were to review the same claim file for a veteran who has  suffered the anatomical loss of both hands, VA’s disability criteria state  unequivocally that the veteran is to be given a 100 percent disability rating.  Therefore, no variation would be expected. However, if two adjudicators  were to review the same claim file for a veteran with a mental disability,  knowledgeable professionals might agree that it would not be out of the  bounds of reasonableness for these adjudicators to diverge by 30  percentage points but that wider divergences would be outside the bounds  of reasonableness.
The fact that two adjudicators might make differing, but reasonable,  judgments on the meaning of the same evidence is recognized in the  design of the system that VBA uses to assess the accuracy of disability  decisions made by regional office adjudicators. VBA instructs the staff  who review the accuracy of decisions to refrain from charging the original  adjudicator with an error merely because they would have made a  different decision than the one made by the original adjudicator. VBA  instructs the reviewers not to substitute their own judgment in place of the  original adjudicator’s judgment as long as the original adjudicator’s  decision is adequately supported and reasonable.
Because of the inherent possibility that different adjudicators could make  differing decisions based on the same information pertaining to a specific  impairment, we recommended in November 2004 that the Secretary of  Veterans Affairs develop a plan containing a detailed description of how  VA would (1) use data from a newly implemented administrative  information system—known as Rating Board Automation 2000—to  identify indications of decision-making inconsistencies among the regional  offices for specific impairments and (2) conduct systematic studies of the  impairments for which the data reveal possible inconsistencies among  regional offices. VA concurred with our recommendation but has not yet  developed such a plan. At this point, VA has now collected 1 full year of  data using the new administrative data system, which should be sufficient  to begin identifying variations and then assessing whether such variations  are within the bounds of reasonableness.
section_title: Inconsistent Quality Of Disability Examination Reports Underscores Need to Monitor Consistency of Decisions
paragraphs: Because the existing medical records of disability claimants often do not  provide VBA regional offices with sufficient evidence to decide claims  properly, the regional offices often ask VHA medical centers to examine  the claimants and provide exam reports containing the medical  information needed to make a decision. Exams for joint and spine  impairments are among the exams that regional offices most frequently  request.
To comply with the DeLuca decision’s requirements for joint and spine  disability exam reports, VHA instructs its medical center clinicians to  make not only an initial measurement of the range of motion in the  impaired joint or spine but also to measure range of motion after having  the claimant flex the impaired joint or spine several times. This is done to  determine the extent to which repeated motion may result in pain or  fatigue that further degrades the functioning of the impaired joint or spine.  In addition, the clinician also is instructed to determine if the claimant  experiences flare-ups from time to time, and if so, how often such flare- ups occur and the extent to which they limit the functioning of the  impaired joint or spine. However, in a baseline study conducted in 2002,  VA found that 61 percent of the exam reports on joint and spine  impairments did not provide sufficient information on the effects of  repetitive movement or flare-ups to comply with the DeLuca criteria.
We reported earlier this month on the progress VA had made since 2002 in  ensuring that its medical centers consistently prepare joint and spine exam  reports containing the information required by DeLuca. We found that, as  of May 2005, the percentage of joint and spine exam reports not meeting  the DeLuca criteria had declined substantially from 61 percent to 22  percent. Much of this progress appeared attributable to a performance  measure for exam report quality established by VHA in fiscal year 2004  after both VHA and VBA had taken a number of steps to build a foundation  for improvement. This included creating the Compensation and Pension  Examination Project Office, a national office established in 2001 to  improve the disability exam process, and providing extensive training to  VHA and VBA personnel.
While VA made substantial progress in ensuring that its medical centers’  exam reports adequately address the DeLuca criteria, a 22 percent  deficiency rate indicated that many joint and spine exam reports still did  not comply with DeLuca. Moreover, in relation to the issue of consistency,  the percentage of exam reports satisfying the DeLuca criteria varied  widely across the 21 health care networks that manage VHA’s 157 medical  centers—from a low of 57 percent compliance to a high of 92 percent. It  should be noted that the degree of variation is likely even greater than  indicated by these percentages because, within any given health care  network, an individual medical center’s performance in meeting the  DeLuca criteria may be lower or higher than the combined average  performance for all the medical centers in that specific network.  Therefore, in the network that had 57 percent of its joint and spine exams  meeting DeLuca criteria, an individual medical center within that network  may have had less than 57 percent meeting the DeLuca criteria.  Conversely, in the network that had 92 percent of the exams meeting the  DeLuca criteria, an individual medical center within that network may  have had more than 92 percent satisfying DeLuca. Unless medical centers  across the nation consistently provide the information required by  DeLuca, veterans claiming joint and spine impairments may not receive  consistent disability decisions.
Further, VA has found deficiencies in a substantial portion of the requests  that VBA’s regional offices send to VHA’s medical centers, asking them to  perform disability exams. For example, VA found in early 2005 that nearly  one-third of the regional office requests for spine exams contained errors  such as not identifying the pertinent medical condition or not requesting  the appropriate exam. However, VBA had not yet established a  performance measure for the quality of the exam requests that regional  offices submit to medical centers.
To help ensure continued progress in satisfying the DeLuca criteria, we  recommended that the Secretary of Veterans Affairs direct the Under  Secretary for Health to develop a strategy for improving consistency  among VHA’s health care networks in meeting the DeLuca criteria. For  example, if performance in satisfying the DeLuca criteria continues to vary  widely among the networks during fiscal year 2006, VHA may want to  consider establishing a new performance measure specifically for joint  and spine exams or requiring that medical centers use automated  templates developed for joint and spine exams, provided an in-progress  study of the costs and benefits of the automated exam templates supports  their use. We also recommended that the Secretary direct the Under  Secretary for Benefits to develop a performance measure for the quality of  exam requests that regional offices send to medical centers.
section_title: Conclusions
paragraphs: As a national program, VA’s disability compensation program must ensure  that veterans receive fair and equitable decisions on their disability claims  no matter where they live across the nation. Given the inherent risk of  variation in disability decisions, it is incumbent on VA to ensure program  integrity by having a credible system for identifying indications of  inconsistency among its regional offices and then remedying any  inconsistencies found to be unreasonable. Until assessments of  consistency become a routine part of VA’s oversight of decisions made by  its regional offices, veterans may not consistently get the benefits they  deserve for disabilities connected to their military service, and taxpayers  may not trust the effectiveness and fairness of the disability compensation  program.
Mr. Chairman, this concludes my remarks. I would be happy to answer any  questions you or the members of the subcommittee may have.
section_title: Contact and Acknowledgments
paragraphs: For further information, please contact Cynthia A. Bascetta at (202) 512- 7101. Also contributing to this statement were Irene Chu and Ira Spears.
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