DOD and VA: Preliminary Observations on Efforts to Improve Care Management and Disability Evaluations for Servicemembers
Published: 2008-02-27T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: In February 2007, a series of Washington Post articles about conditions at Walter Reed Army Medical Center highlighted problems in the Army's case management of injured servicemembers and in the military's disability evaluation system. These deficiencies included a confusing disability evaluation process and servicemembers in outpatient status for months and sometimes years without a clear understanding about their plan of care. These reported problems prompted various reviews and commissions to examine the care and services to servicemembers. In response to problems at Walter Reed and subsequent recommendations, the Army took a number of actions and DOD formed a joint DOD-VA Senior Oversight Committee. This statement updates GAO's September 2007 testimony and is based on ongoing work to (1) assess actions taken by the Army to help ill and injured soldiers obtain health care and navigate its disability evaluation process; and to (2) describe the status, plans, and challenges of DOD and VA efforts to implement a joint disability evaluation system. GAO's observations are based largely on documents obtained from and interviews with Army, DOD, and VA officials. The facts contained in this statement were discussed with representatives from the Army, DOD, and VA.
section_title: What GAO Found
paragraphs: Over the past year, the Army significantly increased support for servicemembers undergoing medical treatment and disability evaluations, but challenges remain. To provide a more integrated continuum of care for servicemembers, the Army created a new organizational structure--the Warrior Transition Unit--in which servicemembers are assigned key staff to help manage their recovery. Although the Army has made significant progress in staffing these units, several challenges remain, including hiring medical staff in a competitive market, replacing temporarily borrowed personnel with permanent staff, and getting eligible servicemembers into the units. To help servicemembers navigate the disability evaluation process, the Army is increasing staff in several areas, but gaps and challenges remain. For example, the Army expanded hiring of board liaisons to meet its goal of 30 servicemembers per liaison, but as of February 2008, the Army did not meet this goal at 11 locations that support about half of servicemembers in the process. The Army faces challenges hiring enough liaisons to meet its goals and enough legal personnel to help servicemembers earlier in the process. To address more systemic issues, DOD and VA promptly designed and are now piloting a streamlined disability evaluation process. In August 2007, DOD and VA conducted an intensive 5-day exercise that simulated alternative pilot approaches using previously-decided cases. This exercise yielded data quickly, but there were trade-offs in the nature and extent of data that could be obtained in that time frame. The pilot began with "live" cases at three treatment facilities in the Washington, D.C. area in November 2007, and DOD and VA may consider expanding the pilot to additional sites around July 2008. However, DOD and VA have not finalized their criteria for expanding the pilot beyond the original sites and may have limited pilot results at that time. Significantly, current evaluation plans lack key elements, such as an approach for measuring the performance of the pilot--in terms of timeliness and accuracy of decisions--against the current process, which would help planners manage for success of further expansion.

section_title: Letter
paragraphs: We are pleased to be here today as you examine issues related to meeting  the critical needs of returning wounded warriors. At present, over 30,000  servicemembers have been wounded in Operations Enduring Freedom and  Iraqi Freedom. Due to improved battlefield medicine, those who might  have died in past conflicts are now surviving, many with multiple serious  injuries such as amputations, traumatic brain injury (TBI), and post- traumatic stress disorder (PTSD). Beyond adjusting to their injuries,  returning servicemembers can face additional challenges within the  military. In February 2007, a series of Washington Post articles about  conditions at Walter Reed Army Medical Center highlighted problems in  the Army’s management of care for injured servicemembers and in the  military’s disability evaluation system.
Since that time, various reviews and high-level commissions have  identified substantial weaknesses in the care that servicemembers receive  and the disability evaluation systems that they must navigate. For  example, in March 2007, the Army Inspector General identified numerous  issues with the Army’s disability evaluation system and related care,  including a failure to meet timeliness standards for determinations,  inadequate training of staff, and the lack of standardized operations and  structure to care for returning servicemembers. Similarly, reports from  several commissions highlighted long delays and confusion that ill or  injured servicemembers experience as they navigate the military disability  evaluation system, and their distrust of a process perceived to be  adversarial. The commissions referred to prior GAO work, including a  March 2006 report in which GAO found that the services were not meeting  Department of Defense (DOD) timeliness goals for processing disability  cases and that neither DOD nor the services systematically evaluated the  consistency of disability decisions. In October 2007, the Veterans’  Disability Benefits Commission reported significant differences in  disability ratings between DOD and the Department of Veterans Affairs  (VA)—with VA often assigning higher ratings than DOD.
In response to the deficiencies reported by the media, the Army took  several actions including, most notably, initiating the development of the  Army Medical Action Plan in March 2007. The plan, designed to help the  Army become more patient-focused, includes tasks for establishing a  continuum of care and service, automating portions of the disability  evaluation system, and maximizing coordination of efforts with VA.
In May 2007, DOD established the Wounded, Ill, and Injured Senior  Oversight Committee (Senior Oversight Committee) to bring high-level  attention to addressing the problems associated with the care and  treatment of returning servicemembers. The committee is co-chaired by  the Deputy Secretaries of Defense and Veterans Affairs and also includes  the military service secretaries and other high-ranking officials within  DOD and VA. To conduct its work, the Senior Oversight Committee  established workgroups that have focused on specific areas including the  disability evaluation system. In particular, under the direction of the  Senior Oversight Committee, DOD and VA are piloting a joint disability  evaluation system.
In September 2007, we testified before this subcommittee on our  preliminary observations with respect to Army, DOD, and VA efforts to  improve health care and disability evaluations for servicemembers. Our  testimony today provides an update on these efforts and focuses on our  ongoing work to (1) assess actions taken by the Army to help ill and  injured soldiers obtain health care and navigate its disability evaluation  process, and (2) describe the status, plans, and challenges of DOD’s and  VA’s efforts to implement a joint disability evaluation system. Our  testimony is based on documents obtained from and interviews with  Army, DOD, and VA officials. Specifically, we reviewed staffing data  related to case management and disability evaluation initiatives  established in the Army Medical Action Plan. We did not verify the  accuracy of these data; however, we interviewed agency officials  knowledgeable about the data, and we determined that they were  sufficiently reliable for the purposes of this statement. We visited several  Army sites—Walter Reed Army Medical Center (Washington, D.C.), Forts  Sam Houston and Hood (Texas), Fort Lewis (Washington), and Forts  Benning and Gordon (Georgia)—to talk with Army officials about efforts  to improve the health care and the disability evaluation system for  servicemembers and obtain views from servicemembers about how these  efforts are affecting them. In addition, we reviewed the results of Army  efforts to obtain servicemembers’ opinions about the Warrior Transition  Unit and the disability evaluation process. We also spoke with officials  from DOD and VA to learn about their plans for implementing and  evaluating the disability evaluation pilot. Our findings are preliminary. It  was beyond the scope of our work for this statement to review the efforts  underway in other military services. We discussed the facts contained in  this statement with Army officials, and we incorporated their comments  where appropriate. Our work, which began in July 2007, is being  conducted in accordance with generally accepted government auditing  standards. Those standards require that we plan and perform the audit to  obtain sufficient, appropriate evidence to provide a reasonable basis for  our findings and conclusions based on our audit objectives. We believe  that the evidence obtained provides a reasonable basis for our findings  and conclusions based on our audit objectives.
In summary, the Army continues to increase support to servicemembers  undergoing medical treatment and disability evaluations, but faces  challenges reaching or maintaining its goals. To provide a more integrated  continuum of care for servicemembers, the Army has developed a new  organizational structure called Warrior Transition Units. Within each unit,  a servicemember is assigned to a team of three key staff—a primary care  manager, a nurse case manager, and a squad leader—who manage the  servicemember’s care. Since September 2007, the Army has made  considerable progress in staffing this structure, increasing the number of  staff assigned to key positions by almost 75 percent. However, shortfalls  continue to exist in some areas—11 of the 32 U.S. Warrior Transition Units  had less than 90 percent of needed staff for one or more key positions. In  addition, the Army is facing other challenges, which include replacing  borrowed staff in key positions with permanently assigned staff without  disrupting the continuity of care for servicemembers and moving  additional eligible servicemembers into the units without exacerbating  existing staff shortfalls in some locations. Furthermore, another emerging  challenge is the Army’s ability to gather reliable and objective data on how  well the units are meeting servicemembers’ needs.
Some servicemembers may not recover sufficiently to return to duty. To  support servicemembers who must undergo a fitness for duty assessment  and disability evaluation, the Army is reducing caseloads and expanding  hiring of key staff responsible for helping servicemembers navigate the  process. For example, for evaluation board liaisons who help  servicemembers track the process, the Army established an average  caseload goal of 30 servicemembers per board liaison and hired more  board liaisons to help meet this goal. However, almost one-third of  treatment locations—which support about half of servicemembers in the  disability evaluation process—have not met this goal. In addition, the  Army assigned 18 additional legal staff to support the disability evaluation  process in June 2007; however, current staffing levels are still insufficient  for widespread legal support early in the process. The Army has other  efforts underway to improve servicemembers’ ability to navigate the  disability process, such as conducting standardized briefings about the  evaluation process, but reliable data on the effectiveness of these and  other efforts are not yet available.
To address issues with both DOD and VA disability evaluations, including  untimely and inconsistent decisions and servicemember frustration, the  agencies have designed, and are piloting, a streamlined disability  evaluation process. DOD and VA moved quickly to design and implement  the pilot for eventual expansion to all servicemembers. To obtain the data  for determining the pilot design and supporting the implementation  decision, DOD and VA conducted an intensive 5-day exercise that  simulated four alternative pilot approaches using previously-decided  cases. While the simulation was a formal exercise and yielded useful  information, the short time frames necessitated trade-offs between moving  quickly and doing a more thorough evaluation, such as using a small  number of cases instead of a larger number that better represented the  relative workloads of the military services. DOD and VA began “live”  implementation of the pilot—using actual cases—at three treatment  facilities in the Washington, D.C. area in November 2007. DOD and VA may  consider expanding the pilot to a few sites outside the Washington, D.C.  area around July 2008, but have yet to finalize their criteria for expanding  implementation beyond the original sites. Further, some key metrics, such  as the timeliness and accuracy of final DOD and VA decisions, might lag  behind expansion time frames and dates for reporting on pilot progress to  Congress. To date, DOD’s and VA’s pilot evaluation plan lacks key  elements, such as an approach for measuring the performance of the  pilot—for example, in terms of timeliness, accuracy, and consistency of  decisions—against the current process, and for surveying and measuring  satisfaction of pilot participants.
subsections: section_title: Background
paragraphs: DOD and VA offer health care benefits to active duty servicemembers and  veterans, among others. Under DOD’s health care system, eligible  beneficiaries may receive care from military treatment facilities or from  civilian providers. Military treatment facilities are individually managed by  each of the military services—the Army, the Navy, and the Air Force.  Under VA, eligible beneficiaries may obtain care through VA’s integrated  health care system of hospitals, ambulatory clinics, nursing homes,  residential rehabilitation treatment programs, and readjustment  counseling centers. VA has organized its health care facilities into a  polytrauma system of care that helps address the medical needs of  returning servicemembers and veterans, in particular those who have an  injury to more than one part of the body or organ system that results in  functional disability and physical, cognitive, psychosocial, or  psychological impairment. Persons with polytraumatic injuries may have  injuries or conditions such as TBI, amputations, fractures, and burns.
Over the past 6 years, DOD has designated over 30,000 servicemembers  involved in Operations Iraqi Freedom and Enduring Freedom as wounded  in action. Servicemembers injured in these conflicts are surviving injuries  that would have been fatal in past conflicts, due, in part, to advanced  protective equipment and medical treatment. The severity of their injuries  can result in a lengthy transition from patient back to duty, or to veteran  status. Initially, most seriously injured servicemembers from these  conflicts, including activated National Guard and Reserve members, are  evacuated to Landstuhl Regional Medical Center in Germany for  treatment. From there, they are usually transported to military treatment  facilities in the United States, with most of the seriously injured admitted  to Walter Reed Army Medical Center or the National Naval Medical Center.  According to DOD officials, once they are stabilized and discharged from  the hospital, servicemembers may relocate closer to their homes or  military bases and are treated as outpatients by the closest military or VA  facility.
As part of the Army’s Medical Action Plan, the Army has developed a new  organizational structure—Warrior Transition Units—for providing an  integrated continuum of care for servicemembers who generally require at  least 6 months of treatment, among other factors. Within each unit, the  servicemember is assigned to a team of three key staff and this team is  responsible for overseeing the continuum of care for the servicemember.  The Army refers to this team as a “Triad,” which consists of a (1) primary  care manager—usually a physician who provides primary oversight and  continuity of health care and ensures the quality of the servicemember’s  care; (2) nurse case manager—usually a registered nurse who plans,  implements, coordinates, monitors, and evaluates options and services to  meet the servicemember’s needs; and (3) squad leader—a  noncommissioned officer who links the servicemember to the chain of  command, builds a relationship with the servicemember, and works along  side the other parts of the Triad to ensure the needs of the servicemember  and his or her family are met. The Army established 32 Warrior Transition  Units, to provide a unit in every medical treatment facility that has 35 or  more eligible servicemembers. The Army’s goal is to fill the Triad  positions according to the following ratios: 1:200 for primary care  managers; 1:18 for nurse case managers at Army medical centers that  normally see servicemembers with more acute conditions and 1:36 for  other types of Army medical treatment facilities; and 1:12 for squad  leaders.
Returning injured servicemembers must potentially navigate two different  disability evaluation systems that generally rely on the same criteria but  for different purposes. DOD’s system serves a personnel management  purpose by identifying servicemembers who are no longer medically fit for  duty. The military’s process starts with identification of a medical  condition that could render the servicemember unfit for duty, a process  that could take months to complete. The servicemember is evaluated by a  medical evaluation board (MEB) to identify any medical conditions that  may render the servicemember unfit. The member is then evaluated by a  physical evaluation board (PEB) to make a determination of fitness or  unfitness for duty. If found unfit, and the unfit conditions were incurred in  the line of duty, the PEB assigns the servicemember a combined  percentage rating for those unfit conditions using VA’s rating system as a  guideline, and the servicemember is discharged from duty. This disability  rating, along with years of service and other factors, determines  subsequent disability and health care benefits from DOD. For  servicemembers meeting the minimum rating and years of duty thresholds,  monthly disability retirement payments are provided; for those not  meeting these thresholds, a lump-sum severance payment is provided.
As servicemembers in the Army navigate DOD’s disability evaluation  system, they interface with staff who play a key role in supporting them  through the process. MEB physicians play a fundamental role as they are  responsible for documenting the medical conditions of servicemembers  for the disability evaluation case file. In addition, MEB physicians may  require that servicemembers obtain additional medical evidence from  specialty physicians such as a psychiatrist. Throughout the MEB and PEB  process, a physical evaluation board liaison officer serves a key role by  explaining the process to servicemembers, and ensuring that the  servicemembers’ case files are complete before they are forwarded for  adjudication. The board liaison officer informs servicemembers of board  results and of deadlines at key decision points in the process. The military  also provides legal counsel to servicemembers in the disability evaluation  process. The Army, for example, provides them with legal representation  at formal board hearings. The Army will provide military counsel, or  servicemembers may retain their own representative at their own expense.
In addition to receiving benefits from DOD, veterans may receive  compensation from VA for lost earning capacity due to service-connected  disabilities. Although a servicemember may file a VA claim while still in  the military, he or she can only obtain disability compensation from VA as  a veteran. VA will evaluate all claimed conditions, whether they were  evaluated previously by the military service’s evaluation process or not. If  the VA finds that a veteran has one or more service-connected disabilities  with a combined rating of at least 10 percent, VA will pay monthly  compensation. The veteran can claim additional benefits over time, for  example, if a service-connected disability worsens.
To improve the timeliness and resource utilization of DOD’s and VA’s  separate disability evaluation systems, the agencies embarked on a  planning effort of a joint disability evaluation system that would enable  servicemembers to receive VA disability benefits shortly after leaving the  military without going through both DOD’s and VA’s processes. A key part  of this planning effort included a “table top” exercise whereby the  planners simulated the outcomes of cases using four potential options that  incorporated variations of following three elements: (1) a single,  comprehensive medical examination to be used by both DOD and VA in  their disability evaluations; (2) a single disability rating performed by VA;  and (3) incorporating a DOD-level evaluation board for adjudicating  servicemembers’ fitness for duty. Based on the results of this exercise,  DOD and VA implemented the selected pilot design using live cases at  three Washington, D.C.-area military treatment facilities including Walter  Reed Army Medical Center in November 2007. Key features of the pilot  include (see fig. 1):    a single physical examination conducted to VA standards as part of the    disability ratings prepared by VA, for use by both DOD and VA in  determining disability benefits; and    additional outreach and non-clinical case management provided by VA  staff at the DOD pilot locations to explain VA results and processes to  servicemembers.
section_title: The Army Continues to Increase Support to Servicemembers Undergoing Medical Treatment and Disability Evaluation, but Faces Challenges Reaching Stated Goals
paragraphs: The Army has made strides increasing key staff positions in support of  servicemembers undergoing medical treatment as well as disability  evaluation, but faces a number of challenges to achieving or maintaining  stated goals. Although the Army has made significant progress in staffing  its Warrior Transition Units, several challenges remain, including hiring  medical staff in a competitive market, replacing temporarily borrowed  personnel with permanent staff, and getting eligible servicemembers into  the units. With respect to supporting servicemembers as they navigate the  disability evaluation process, the Army has reduced caseloads of key  support staff, but has not yet reached its goals and faces challenges with  both hiring and meeting current demands of servicemembers in the  process.
subsections: section_title: Army Has Made Considerable Progress in Staffing Its Warrior Transition Units, but Faces Shortfalls and Other Challenges
paragraphs: Since September 2007, the Army has made considerable progress in  staffing its Warrior Transition Units, increasing the number of staff  assigned to Triad positions by almost 75 percent. As of February 6, 2008,  the Army had about 2,300 personnel staffing its Warrior Transition Units.  In February 2008, the Army reported that its Warrior Transition Units had  achieved “full operational capability,” which was the goal established in  the Army’s Medical Action Plan. The Warrior Transition Units reported  that they had met this goal even though some units had staffing shortages  or faced other challenges.
The Army’s January 2008 assessment defined full operational capability across a wide  variety of areas identified in the Army’s Medical Action Plan, not just personnel fill. For  example, the assessment included whether facilities and barracks were suitable and  whether a Soldier and Family Assistance Center was in place and providing essential  services. In addition, the commander assessed whether the unit could conduct the mission- essential tasks assigned to it. As a result, such ratings have both objective and subjective  elements, and the Army allows commanders to change the ratings based on their judgment.
Location (size of Warrior Transition  Unit population)
Fort Hood, Texas (957)
Walter Reed Army Medical Center,  Washington, D.C. (674)
Fort Lewis, Washington (613)
Fort Campbell, Kentucky (596)
Fort Drum, New York (395)
Fort Polk, Louisiana (248)
Fort Knox, Kentucky (243)
Fort Irwin & Balboa, California (89)
Fort Belvoir, Virginia (43)
Fort Huachuca, Arizona (41)
Redstone Arsenal, Alabama (17)
The Army is confronting other challenges, as well, including replacing  borrowed staff in Triad positions with permanently assigned staff without  disrupting the continuity of care for servicemembers. We previously  reported in September 2007 that many units were relying on borrowed  staff to fill positions—about 20 percent overall. This practice has  continued; in February 2008, about 20 percent of Warrior Transition Unit  staff continued to be borrowed from other positions. Army officials told  us that using borrowed staff was necessary to get the Warrior Transition  Units implemented quickly and has been essential in staffing units that  have experienced sudden increases in servicemembers needing care. Army  officials told us that using borrowed staff is a temporary solution for  staffing the units, and these staff will be transitioned out of the positions  when permanent staff are available. Replacing the temporary staff will  result in turnover among Warrior Transition Unit staff, which can disrupt  the continuity of care provided to servicemembers.
Another lingering challenge facing the Army is getting eligible  servicemembers into the Warrior Transition Units. In developing its approach,  the Army envisioned that servicemembers meeting specific criteria, such as  requiring more than 6 months of treatment or having a condition that requires  going through the Medical Evaluation Board process, would be assigned to  the Warrior Transition Units. Since September 2007, the Warrior Transition  Unit population has increased by about 80 percent—from about 4,350 to  about 7,900 servicemembers. However, although the percentage of eligible  servicemembers going through the Medical Evaluation Board process who  were not in a Warrior Transition Unit has been cut almost in half since  September 2007, more than 2,500 eligible servicemembers were not in units,  as of February 6, 2008. About 1,700 of these servicemembers (about 70  percent) are concentrated in ten locations. (See table 2.)
Warrior Transition Unit commanders conduct risk assessments of eligible  servicemembers to determine if their care can be appropriately managed  outside of the Warrior Transition Unit. These assessments are to be  conducted within 30 days of determining that the servicemember meets  eligibility criteria. For example, a servicemember’s knee injury may  require a Medical Evaluation Board review—a criterion for being placed in  a Warrior Transition Unit—but the person’s unit commander can  determine that the person can perform a desk job while undergoing the  medical evaluation process. According to Army guidance, servicemembers  eligible for the Warrior Transition Unit will generally be moved into the  units, that it will be the exception, not the rule, for a servicemember to not  be transferred to a Warrior Transition Unit. Army officials told us that the  population of 2,500 servicemembers who had not been moved into a  Warrior Transition Unit consisted of both servicemembers who had just  recently been identified as eligible for a unit but had not yet been  evaluated and servicemembers whose risk assessment determined that  their care could be managed outside of a unit. Officials told us that  servicemembers who needed their care managed more intensively through  Warrior Transition Units had been identified through the risk assessment  process and had been moved into such units. As eligible personnel are  brought into the Warrior Transition Units, however, it could exacerbate  staffing shortfalls in some units. To minimize future staffing shortfalls,  Army officials told us that they are identifying areas where they anticipate  future increases in the number of servicemembers needing care in a  Warrior Transition Unit and would use this information to determine  appropriate future staffing needs of the units.
Another emerging challenge is gathering reliable and objective data to  measure progress. A central goal of the Army’s efforts is to make the  system more servicemember- and family-focused and the Army has  initiated efforts to determine how well the units are meeting  servicemembers’ needs. To its credit, the Army has developed a wide  range of methods to monitor its units, among them a program to place  independent ombudsmen throughout the system as well as town hall  meetings and a telephone hotline for servicemembers to convey concerns  about the Warrior Transition Units. Additionally, through its Warrior  Transition Program Satisfaction Survey, the Army has been gathering and  analyzing information on servicemembers’ opinions about their nurse case  manager and the overall Warrior Transition Unit. However, initial response  rates have been low, which has limited the Army’s ability to reliably assess  satisfaction. In February 2008, the Army started following up with  nonrespondents, and officials told us that these efforts have begun to  improve response rates. To obtain feedback from a larger percentage of  servicemembers in the Warrior Transition Units, the Army administered  another satisfaction survey in January 2008. This survey, which also  solicited servicemembers’ opinions about components of the Triad and  overall satisfaction with the Warrior Transition Units, garnered a more  than 90 percent response rate from the population surveyed. While  responses to the survey were largely positive, the survey is limited in its  ability to accurately gauge the Army’s progress in improving  servicemember satisfaction with the Warrior Transition Unit, because it  was not intended to be a methodologically rigorous evaluation. For  example, the units were not given specific instructions on how to  administer the survey, and as a result, it is not clear the extent to which  servicemembers were provided anonymity in responding to the survey.  Units were instructed to reach as many servicemembers as possible within  a 24-hour period in order to provide the Army with immediate feedback on  servicemembers’ overall impressions of the care they were receiving.
section_title: Despite Hiring Efforts, Army Faces Challenges Providing Sufficient Staff to Help Servicemembers Navigate the Disability Evaluation Process
paragraphs: Injured and ill servicemembers who must undergo a fitness for duty  assessment and disability evaluation rely on the expertise and support of  several key staff—board liaisons, legal personnel, and board physicians— to help them navigate the process. Board liaisons explain the disability  process to servicemembers and are responsible for ensuring that their  disability case files are complete. Legal staff and medical evaluation board  physicians can substantially influence the outcome of servicemembers’  disability evaluations because legal personnel provide important counsel  to servicemembers during the disability evaluation process, and evaluation  board physicians evaluate and document servicemembers’ medical  conditions for the disability evaluation case file.
With respect to board liaisons, the Army has expanded hiring efforts and  met its goals for reducing caseloads at most treatment facilities, but not at  some of the facilities with the most servicemembers in the process. In  August 2007, the Army established an average caseload target of 30  servicemembers per board liaison. As of February 2008, the Army had  expanded the number of board liaisons by about 22 percent. According to  the Army, average caseloads per liaison have declined from 54  servicemembers at the end of June 2007 to 46 at the end of December  2007. However, 11 of 35 treatment facilities continue to have shortages of  board liaisons and about half of all servicemembers in the disability  evaluation process are located at these 11 treatment facilities. (See fig. 2.)  Due to their caseloads, liaisons we spoke with at one location had  difficulty making appointments with servicemembers, which has  challenged their ability to provide timely and comprehensive support.
The Army plans to hire additional board liaisons, but faces challenges in  keeping up with increased demand. According to an Army official  responsible for staff planning, the Army reviews the number of liaisons at  each treatment facility weekly and reviews Army policy for the target  number of servicemembers per liaison every 90 days. The official also  identified several challenges in keeping up with increased demand for  board liaisons, including the increase in the number of injured and ill  servicemembers in the medical evaluation board process overall, and the  difficulty of attracting and retaining liaisons at some locations. According  to Army data, the total number of servicemembers completing the medical  evaluation board process increased about 19 percent from the end of 2006  to the end of 2007.
In addition to gaps in board liaisons, according to Army documents,  staffing of dedicated legal personnel who provide counsel to injured and ill  servicemembers throughout the disability evaluation processes is  currently insufficient. Ideally, according to the Army, servicemembers  should receive legal assistance during both the medical and physical  evaluation board processes. While servicemembers may seek legal  assistance at any time, the Office of the Judge Advocate General’s policy is  to assign dedicated legal staff to servicemembers when their case goes  before a formal physical evaluation board. In June 2007, the Army assigned  18 additional legal staff—12 Reserve attorneys and 6 Reserve paralegals— to help meet increasing demands for legal support throughout the process.  As of January 2008, the Army had 27 legal personnel—20 attorneys and 7  paralegals—located at 5 of 35 Army treatment facilities who were  dedicated to supporting servicemembers primarily with the physical  evaluation board process. However, the Office of the Judge Advocate  General has acknowledged that these current levels are insufficient for  providing support during the medical evaluation board process, and  proposed hiring an additional 57 attorneys and paralegals to provide legal  support to servicemembers during the medical evaluation board process.  The proposed 57 attorneys and paralegals include 19 active-duty military  attorneys, 19 civilian attorneys, and 19 civilian paralegals. On February 21,  2008, Army officials told us that 30 civilian positions were approved,  consisting of 15 attorneys and 15 paralegals.
While the Army has plans to address gaps in legal support for  servicemembers, challenges with hiring and staff turnover could limit their  efforts. According to Army officials, even if the plan to hire additional  personnel is approved soon, hiring of civilian attorneys and paralegals may  be slow due to the time it takes to hire qualified individuals under  government policies. Additionally, 19 of the 57 Army attorneys who would  be staffed under the plan would likely only serve in their positions for a  period of 12 to 18 months. According to a Disabled American Veterans  representative with extensive experience counseling servicemembers  during the evaluation process, frequent rotations and turnover of Army  attorneys working on disability cases limits their effectiveness in  representing servicemembers due to the complexity of disability  evaluation regulations.
With respect to medical evaluation board physicians, who are responsible  for documenting servicemembers medical conditions, the Army has mostly  met its goal for the average number of servicemembers per physician at  each treatment facility. In August 2007, the Army established a goal of one  medical evaluation board physician for every 200 servicemembers. As  with the staffing ratio for board liaisons, the ratio for physicians is  reviewed every 90 days by the Army and the ratio at each treatment facility  is reviewed weekly, according to an Army official. As of February 2008, the  Army had met the goal of 200 servicemembers per physician at 29 of 35  treatment facilities and almost met the goal at two others.
Despite having mostly met its goal for medical evaluation board  physicians, according to Army officials, the Army continues to face  challenges in this area. For example, according to an Army official,  physicians are having difficulty managing their caseload even at locations  where they have met or are close to the Army’s goal of 1 physician for 200  servicemembers due not only to the volume of cases but also their  complexity. According to Army officials, disability cases often involve  multiple conditions and may include complex conditions such as TBI and  PTSD. Some Army physicians told us that the ratio of servicemembers per  physician allows little buffer when there is a surge in caseloads at a  treatment facility. For this reason, some physicians told us that the Army  could provide better service to servicemembers if the number of  servicemembers per physician was reduced from 200 to 100 or 150.
In addition to increasing the number of staff who support this process, the  Army has reported other progress and efforts underway that could further  ease the disability evaluation process. For example, the Army has reported  improving outreach to servicemembers by establishing and conducting  standardized briefings about the process. The Army has also improved  guidance to servicemembers by developing and issuing a handbook on the  disability evaluation process, and creating a web site for each  servicemember to track his or her progress through the medical evaluation  board. Finally, the Army told us that efforts are underway to further  streamline the process for servicemembers and improve supporting  information technology. For example, the Army established a goal to  eliminate 50 percent of the forms required by the current process. While  we are still assessing the scope, status, and potential impact of these  efforts, a few questions have been raised about some of them. For  example, according to Army officials, servicemembers’ usage of the  medical evaluation board web site has been low. In addition, some  servicemembers with whom we spoke believe the information presented  on the web site was not helpful in meeting their needs.
One measure of how well the disability evaluation system is working does  not indicate that improvements have occurred. The Army collects data and  regularly reports on the timeliness of the medical evaluation board  process. While we have previously reported that the Army has few internal  controls to ensure that these data were complete and accurate, the Army  recently told us that they are taking steps to improve the reliability of  these data. We have not yet substantiated these assertions. Assuming  current data are reliable, the Army has reported not meeting a key target  for medical evaluation board timeliness and has even reported a negative  trend in the last year. Specifically, the Army’s target is for 80 percent of the  medical evaluation board cases to be completed in 90 days or less, but the  percent that met the standard declined from 70 percent in October through  December 2006, to 63 percent in October through December 2007.
Another potential indicator of how well the disability evaluation process is  working is under development. Since June 2007, the Army has used the  Warrior Transition Program Satisfaction Survey to ask servicemembers  about their experience with the disability evaluation process and board  liaisons. However, according to Army officials in charge of the survey,  response rates to survey questions related to the disability process were  particularly low because most surveyed servicemembers had not yet  begun the disability evaluation process. The Army is in the process of  developing satisfaction surveys that are separate from the Warrior  Transition Unit survey to gauge servicemembers’ perceptions of the  medical and physical evaluation board processes.
section_title: DOD-VA Joint Disability Evaluation Process Pilot Geared Toward Quick Implementation, but Pilot Evaluation Plans Lack Key Elements
paragraphs: DOD and VA have joined together to quickly pilot a streamlined disability  evaluation process, but evaluation plans currently lack key elements. In  August 2007, DOD and VA conducted an intensive 5-day “table top”  exercise to evaluate the relative merits of four potential pilot alternatives.  Though the exercise yielded data quickly, there were trade-offs in the  nature and extent of data that could be obtained in that time frame. In  November 2007, DOD and VA jointly initiated a 1-year pilot in the  Washington, D.C. area using live cases, although DOD and VA officials told  us they may consider expanding the pilot to other locations beyond the  current sites around July 2008. However, pilot results may be limited at  that and other critical junctures, and pilot evaluation plans currently lack  key elements, such as criteria for expanding the pilot.
subsections: section_title: Selection of Pilot Design Based on Formal but Quick 5-day Exercise
paragraphs: Prior to implementing the pilot in November 2007, the agencies conducted  a 5-day “table top” exercise that involved a simulation of cases intended to  test the relative merits of 4 pilot options. All the alternatives included a  single VA rating to be used by both agencies. However, the exercise was  designed to evaluate the relative merits of certain other key features, such  as whether DOD or VA should conduct a single physical examination, and  whether there should be a DOD-wide disability evaluation board, and if so,  what its role would be. Ultimately, the exercise included four pilot  alternatives involving different combinations of these features. Table 3  summarizes the pilot alternatives.
The simulation exercise was formal in that it followed a pre-determined  methodology and comprehensive in that it involved a number of  stakeholders and captured a broad range of metrics. DOD and VA were  assisted by consultants who provided data collection, analysis, and  methodological support. The pre-determined methodology involved  examining previously decided cases, to see how they would have been  processed through each of the four pilot alternatives. The 33 selected  cases intentionally reflected decisions originating from each of the military  services and a broad range and number of medical conditions. Participants  in the simulation exercise included officials from DOD, each military  service, and VA who are involved in all aspects of the disability evaluation  processes at both agencies. Metrics collected included case outcomes  including the fitness decision, the DOD and VA ratings, and the median  expected days to process cases. These outcomes were compared for each  pilot alternative with actual outcomes. In addition, participants rank  ordered their preference for each pilot alternative, and provided feedback  on expected servicemember satisfaction as well as service and  organization acceptance. They also provided their views on legislative and  regulatory changes and resource requirements to implement alternative  processes, and identified advantages and disadvantages of each  alternative.
This table top exercise enabled DOD and VA to obtain sufficient  information to support a near-term decision to implement the pilot, but it  also required some trade-offs. For example, the intensity of the exercise— simulating four pilot alternatives, involving more than 40 participants over  a 5-day period—resulted in an examination of only a manageable number  of cases. To ensure that the cases represented each military service and  different numbers and types of potential medical conditions, a total of 33  cases were judgmentally selected by service: 8 Army, 9 Navy, 8 Marine,  and 8 Air Force. However, the sample used in the simulation exercise was  not statistically representative of each military service’s workload; as such  it is possible that a larger and more representative sample could have  yielded different outcomes. Also, expected servicemember satisfaction  was based on the input of the DOD and VA officials participating in the  pilot rather than actual input from the servicemembers themselves.
Based on the data from this exercise, the Senior Oversight Committee gave  approval in October 2007 to proceed with piloting an alternative process  with features that scored the highest in terms of participants’ preferential  voting and projected servicemember satisfaction. These elements included  a single VA rating (as provided in all the alternatives tested) and a  comprehensive medical examination conducted by VA. The selected pilot  design did not include a DOD-wide disability evaluation board. Rather,  the services’ physical evaluation boards would continue to determine  fitness for duty, as called for under Alternative 2.
section_title: The Pilot Is Geared toward Quick Expansion, but Evaluation Plans Lack Key Elements
paragraphs: DOD and VA officials have described to us a plan for expanding the pilot  that is geared toward quick implementation, but may have limited pilot  results available to them at a key juncture. With respect to time frames,  the pilot, which began in November 2007, is scheduled to last 1 year,  through November 2008. However, prior to that date, planners have  expressed interest in expanding the pilot outside the Washington  metropolitan area. Pilot planners have told us that around July 2008— which is not long after the first report on the pilot is due to Congress— they may ask the Senior Oversight Committee to decide on expansion to  more locations based on data available at that time. They suggested that a  few additional locations would allow them to collect additional experience  and data outside the Washington, D.C. area before decisions on broader  expansion are made. According to DOD and VA officials, time frames for  national expansion have not yet been decided. However, DOD also faces  deadlines for providing Congress an interim report on the pilot’s status as  early as October 2008, and for issuing a final report.
While expanding the pilot outside the Washington, D.C. area will likely  yield useful information to pilot planners, due to the time needed to fully  process cases, planners may have limited pilot results available to guide  their decision making. As of February 17, 2008, 181 cases were currently in  the pilot process, but none had completed the process. After conducting  the simulation exercise, pilot planners set a goal of 275 days (about 9  months) for a case to go through the entire joint disability evaluation  process. If the goal is an accurate predictor of time frames, potentially  very few cases will have made it through the entire pilot process by the  time planners seek to expand the pilot beyond the Washington area. As a  result, DOD and VA are accepting some level of risk by expanding the pilot  solely on the basis of early pilot results.
In addition to having limited information at this key juncture, pilot  planners have yet to designate criteria for moving forward with pilot  expansion and have not yet selected a comparison group to identify  differences between pilot cases and cases processed under the current  system, to allow for assessment of pilot performance. DOD and VA are  collecting data on decision times and rating percentages, but have not  identified how much improvement in timeliness or consistency would  justify expanding the pilot process. Further, pilot planners have not laid  out an approach for measuring the pilot’s performance on key metrics— including timeliness and accuracy of decisions—against the current  process. Selection of the comparison group cases is a significant decision,  because it will help DOD and VA determine the pilot’s impact, compared  with the current process, and help planners identify needed corrections  and manage for success. An appropriate comparison group might include  servicemembers with a similar demographic and disability profile. Not  having an appropriate comparison group increases the risk that DOD and  VA will not identify problem areas or issues that could limit the  effectiveness of any redesigned disability process. Pilot officials stated  that they intend to identify a comparison group of non-pilot disability  evaluation cases, but have not yet done so.
Another key element lacking from current evaluation plans is an approach  for surveying and measuring satisfaction of servicemembers and veterans  with the pilot process. As noted previously, several high-level commissions  identified servicemember confusion over the current disability evaluation  system as a significant problem. Pilot planners told us that they intend to  develop a customer satisfaction survey and use customer satisfaction data  as part of their evaluation of pilot performance but, as of February 2008,  the survey was still under development. Even after the survey has been  developed, results will take some time to collect and may be limited at key  junctures because the survey needs to be administered after  servicemembers and veterans have completed the pilot process. Without  data on servicemember satisfaction, the agencies cannot know whether or  the extent to which the pilot they are implementing has been successful at  reducing servicemember confusion and distrust over the current process.
section_title: Concluding Observations
paragraphs: Over the past year, the Army has made substantial progress toward  improving care for its servicemembers. After problems were disclosed at  Walter Reed in early 2007, senior Army officials assessed the situation and  have since dedicated significant resources—including more than 2,000  personnel—and attention to improve this important mission. Today, the  Army has established Warrior Transition Units at its major medical  facilities and doctors, nurses, and fellow servicemembers at these units  are at work helping wounded, injured, and ill servicemembers through  what is often a difficult healing process. Some challenges remain, such as  filling all the Warrior Transition Unit personnel slots in a competitive  market for medical personnel, lessening reliance on borrowed personnel  to fill slots temporarily, and getting servicemembers eligible for Warrior  Transition Unit services into those units. Overall, the Army is to be  commended for its efforts thus far; however, sustained attention to  remaining challenges and reliable data to track progress will be important  to sustaining gains over time.
For those servicemembers whose military service was cut short due to  illness or injury, the disability evaluation is an extremely important issue  because it affects their service retention or discharge and whether they  receive DOD benefits such as retirement pay and health care coverage.  Once they become veterans, it affects the cash compensation and other  disability benefits they may receive from VA. Going through two complex  disability evaluation processes can be difficult and frustrating for  servicemembers and veterans. Delayed decisions, confusing policies, and  the perception that DOD and VA disability ratings result in inequitable  outcomes have eroded the credibility of the system. The Army has taken  steps to increase the number of staff that can help servicemembers  navigate its process, but is challenged to meet stated goals. Moreover,  even if the Army is able to overcome challenges and sufficiently ramp up  staff levels, these efforts will not address the systemic problem of having  two consecutive evaluation systems that can lead to different outcomes.
Considering the significance of the problems identified, DOD and VA are  moving forward quickly to implement a streamlined disability evaluation  that has potential for reducing the time it takes to receive a decision from  both agencies, improving consistency of evaluations for individual  conditions, and simplifying the overall process for servicemembers and  veterans. At the same time, DOD and VA are incurring some risk with this  approach because the cases used were not necessarily representative of  actual workloads. Incurring some level of risk is appropriate and perhaps  prudent in this current environment; however, planners should be  transparent about that risk. For example, to date, planners have not yet  articulated in their planning documents the extent of data that will be  available at key junctures, and the criteria they will use in deciding to  expand the pilot beyond the Washington, D.C. area. More importantly,  decisions to expand beyond the few sites currently contemplated should  occur in conjunction with an evaluation plan that includes, at minimum, a  sound approach for measuring the pilot’s performance against the current  process and for measuring servicemembers’ and veterans’ satisfaction  with the piloted process. Failure to properly assess the pilot before  significant expansion could potentially jeopardize the systems’ successful  transformation.
Mr. Chairman, this completes our prepared remarks. We would be happy  to respond to any questions you or other Members of the Subcommittee  may have at this time.
For further information about this testimony, please contact Daniel  Bertoni at (202) 512-7215 or bertonid@gao.gov, or John H. Pendleton at  (202) 512-7114 or pendletonj@gao.gov. Contact points for our Offices of  Congressional Relations and Public Affairs may be found on the last page  of this statement. GAO staff who made major contributions to this  testimony are listed in appendix I.
section_title: Appendix I: GAO Contacts and Staff Acknowledgments
subsections: section_title: GAO Contacts
section_title: Acknowledgments
paragraphs: In addition to the contacts named above, Bonnie Anderson, Assistant  Director; Michele Grgich, Assistant Director; Janina Austin; Susannah  Compton; Cindy Gilbert; Joel Green; Christopher Langford; Bryan  Rogowski; Chan My Sondhelm; Walter Vance; and Greg Whitney, made key  contributions to this statement.
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