DOD and VA: Preliminary Observations on Efforts to Improve Health Care and Disability Evaluations for Returning Servicemembers
Published: 2007-09-26T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: In February 2007, a series of Washington Post articles disclosed troublesome deficiencies in the provision of outpatient services at Walter Reed Army Medical Center, raising concerns about the care for returning servicemembers. These deficiencies included a confusing disability evaluation system and servicemembers in outpatient status for months and sometimes years without a clear understanding about their plan of care. The reported problems at Walter Reed prompted broader questions about whether the Department of Defense (DOD) as well as the Department of Veterans Affairs (VA) are fully prepared to meet the needs of returning servicemembers. In response to the deficiencies reported at Walter Reed, the Army took a number of actions and DOD formed a joint DOD-VA Senior Oversight Committee. This statement provides information on the near-term actions being taken by the Army and the broader efforts of the Senior Oversight Committee to address longer-term systemic problems that impact health care and disability evaluations for returning servicemembers. Preliminary observations in this testimony are based largely on documents obtained from and interviews with Army officials, and DOD and VA representatives of the Senior Oversight Committee, as well as on GAO's extensive past work. We discussed the facts contained in this statement with DOD and VA.
section_title: What GAO Found
paragraphs: While efforts are under way to respond to both Army-specific and systemic problems, challenges are emerging such as staffing new initiatives. The Army and the Senior Oversight Committee have efforts under way to improve case management--a process intended to assist returning servicemembers with management of their care from initial injury through recovery. Case management is especially important for returning servicemembers who must often visit numerous therapists, providers, and specialists, resulting in differing treatment plans. The Army's approach for improving case management for its servicemembers includes developing a new organizational structure--a Warrior Transition Unit, in which each servicemember would be assigned to a team of three key staff--a physician care manager, a nurse case manager, and a squad leader. As the Army has sought to staff its Warrior Transition Units, challenges to staffing critical positions are emerging. For example, as of mid-September 2007, over half the U.S. Warrior Transition Units had significant shortfalls in one or more of these critical positions. The Senior Oversight Committee's plan to provide a continuum of care focuses on establishing recovery coordinators, which would be the main contact for a returning servicemember and his or her family. This approach is intended to complement the military services' existing case management approaches and place the recovery coordinators at a level above case managers, with emphasis on ensuring a seamless transition between DOD and VA. At the time of GAO's review, the committee was still determining how many recovery coordinators would be necessary and the population of seriously injured servicemembers they would serve. As GAO and others have previously reported, providing timely and consistent disability decisions is a challenge for both DOD and VA. To address identified concerns, the Army has taken steps to streamline its disability evaluation process and reduce bottlenecks. The Army has also developed and conducted the first certification training for evaluation board liaisons who help servicemembers navigate the system. To address more systemic concerns, the Senior Oversight Committee is planning to pilot a joint disability evaluation system. Pilot options may incorporate variations of three key elements: (1) a single, comprehensive medical examination; (2) a single disability rating done by VA; and (3) a DOD-level evaluation board for adjudicating servicemembers' fitness for duty. DOD and VA officials hoped to begin the pilot in August 2007, but postponed implementation in order to further review options and address open questions, including those related to proposed legislation. Fixing these long-standing and complex problems as expeditiously as possible is critical to ensuring high-quality care for returning servicemembers, and success will ultimately depend on sustained attention, systematic oversight by DOD and VA, and sufficient resources.

section_title: Letter
paragraphs: We are pleased to be here today as you examine issues related to the  provision of care and services for our returning servicemembers. In  February 2007, a series of Washington Post articles disclosed troublesome  deficiencies in the provision of outpatient services at Walter Reed Army  Medical Center, raising concerns about the care for returning  servicemembers and conditions at Army facilities across the country.  Deficiencies at Walter Reed included poor living conditions, a confusing  disability evaluation system, and servicemembers in outpatient status for  months and sometimes years without a clear understanding about their  plan of care or the future of their military service.
The reported problems at Walter Reed prompted broader questions about  whether the Department of Defense (DOD) as well as the Department of  Veterans Affairs (VA) are fully prepared to meet the needs of the  increasing number of returning servicemembers as well as veterans.  Several review groups were tasked with investigating the reported  problems and identifying recommendations. In February 2007, the  Secretary of Defense established the Independent Review Group, which  reported its findings in April 2007. In March 2007, the President  established both the Task Force on Returning Global War on Terror  Heroes and the President’s Commission on Care for America’s Returning  Wounded Warriors, commonly referred to as the Dole-Shalala  Commission. The Task Force reported its findings in April 2007 and the  Dole-Shalala Commission reported its findings in July 2007. In August  2007, the President announced that he had directed the Secretaries of DOD  and VA to study and implement the recommendations made by the Dole- Shalala Commission. See appendix I for a summary of selected findings  from each of the review groups.
The three review groups identified common areas of concern, including  inadequate case management to ensure continuity of care; confusing  disability evaluation systems; the need to better understand and diagnose  traumatic brain injury (TBI) or post-traumatic stress disorder (PTSD),  sometimes referred to as “invisible injuries;” and insufficient data sharing  between DOD and VA of servicemembers’ medical records. Problems in  these areas have been long-standing and the subject of much past work by  GAO. For example, we have reported that major disability programs,  including the VA’s disability programs, are neither well aligned with the  21st century environment nor positioned to provide meaningful and timely  support. Specifically, challenges exist related to ensuring timely provision  of services and benefits as well as interpreting complex eligibility  requirements, among other things. In January 2003, we designated  modernizing federal disability programs as a high-risk area.
In response to Walter Reed deficiencies reported by the media, the Army  took several actions, 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 more than 150 tasks for  establishing a continuum of care and services, optimizing the Army  Physical Disability Evaluation System, and maximizing coordination of  efforts with VA. According to the Army, most of the tasks in the Medical  Action Plan are to be completed by January 2008.
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 services  for returning servicemembers, including the concerns that were being  raised by the various review groups. 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 has  established workgroups that have focused on specific areas including case  management, disability evaluation systems, TBI and psychological health,  including PTSD, and data sharing between DOD and VA. Each workgroup  includes representation from DOD, including each of the military services,  and VA. The workgroups report their efforts and recommendations to the  Senior Oversight Committee, which directs the appropriate components of  DOD and VA to act. The Senior Oversight Committee was established for a  12-month time frame, which will end in May 2008.
Today, our remarks are based on preliminary observations drawn from our  ongoing reviews as well as extensive past work. Our statement addresses  the near-term actions being taken by the Army, as well as the broader  efforts of the Senior Oversight Committee to address longer-term systemic  problems that affect care for returning servicemembers, in the following  four areas: case management, disability evaluation systems, TBI and  PTSD, and data sharing between DOD and VA. We focused on efforts of  the Army because it has the majority of servicemembers in Operation Iraqi  Freedom and Operation Enduring Freedom, and, as a result the majority of  returning servicemembers needing care and rehabilitation go to Army  facilities. We also focused on the efforts of the Senior Oversight  Committee because it was specifically established to address concerns  about the care and services provided to returning servicemembers. Our  testimony is based largely on documents obtained from and interviews  with Army officials, including the Army’s Office of the Surgeon General,  and DOD and VA representatives of the Senior Oversight Committee.  Specifically, we reviewed Army’s staffing data related to the 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 Walter  Reed Army Medical Center in August 2007 to talk with officials about how  they are implementing the Army’s Medical Action Plan and to obtain views  from servicemembers about how the efforts are affecting their care. Our  findings are preliminary and it was beyond the scope of our work for this  statement to review the efforts under way in other military services or  throughout DOD and VA. We discussed the facts contained in this  statement with DOD and VA, and we incorporated their comments where  appropriate. We are conducting the work we began in June in accordance  with generally accepted government auditing standards.
In summary, the Army took near-term actions to respond to reported  deficiencies about the care and services provided to its returning  servicemembers, and the Senior Oversight Committee is undertaking  efforts to address more systemic problems. However, challenges remain to  overcome long-standing problems and ensure sustainable progress in the  four areas we reviewed: (1) case management, (2) disability evaluation  systems, (3) TBI and PTSD, and (4) data sharing between DOD and VA.
Case management: The Army has developed a new organizational  structure—Warrior Transition Units—for providing an integrated  continuum of care for its returning servicemembers. Within each unit, a  servicemember is assigned to a team of three critical staff—physician,  nurse case manager, and squad leader—who manage the servicemember’s  care. As of mid-September, 17 of the 32 units had less than 50 percent of  staff in place in one or more of these critical positions. To facilitate  continuity of care across departments, the Senior Oversight Committee is  developing a plan to establish recovery coordinators to oversee the care of  severely injured servicemembers across federal agencies, including DOD  and VA. This action is being taken to address a recommendation by the  Dole-Shalala Commission. Although initial implementation is slated for  mid-October 2007, as of mid-September, the committee had not  determined how many federal recovery coordinators will be needed. This  is partly because it is still unclear exactly what portion of returning  servicemembers these recovery coordinators will serve.
Disability evaluation systems: The Army is pursuing several initiatives  to help streamline the disability evaluation process for its  servicemembers—for example, by reducing the caseloads of staff who  help servicemembers navigate the system—and has taken steps to help  mitigate servicemembers’ confusion, such as providing additional briefings  about the process and an online tool. To address more systemic concerns  about the timeliness and consistency of DOD’s and VA’s disability  evaluation systems, the Senior Oversight Committee is planning to pilot a  joint DOD/VA disability evaluation system that may include variations of  three elements: (1) a single, comprehensive medical examination; (2) a  single disability rating performed by VA; and (3) a DOD-level retention  board for adjudicating servicemembers’ fitness for duty. The departments  initially slated the pilot to begin on August 1, 2007, but the date has slipped  as DOD and VA continue to review pilot options and take steps to address  key questions including those related to emerging legislative proposals and  long-standing challenges.
TBI and PTSD: To improve the care provided to servicemembers with  TBI and PTSD, both the Army and the Senior Oversight Committee have  efforts under way to improve screening, diagnosis, and treatment of these  conditions. As part of the Army Medical Action Plan, the Army has  established policies to provide training on mild TBI and PTSD to all its  nurse case managers and psychiatric nurses, among others. As of  September 13, 2007, 6 of the Army’s 32 Warrior Transition Units had  completed training for all of these staff. The Senior Oversight Committee  has developed a policy for DOD and VA to establish a national Center of  Excellence for TBI and PTSD that will coordinate the efforts of the two  departments related to promoting research, awareness, and best practices  on these conditions.
Data sharing: DOD and VA have been working for almost 10 years to  facilitate the exchange of medical information. The Army has service- specific efforts under way to improve the sharing of data between its  military treatment facilities and VA. Also, the Senior Oversight Committee  has developed a workgroup to accelerate data-sharing efforts between the  two departments and to help provide for the data-sharing needs of other  efforts being overseen by the Senior Oversight Committee. The need for  DOD and VA to share patient data continues to be critical. For example,  data sharing is important to the proposed recovery coordinators who will  require timely and reliable patient information to ensure continuity of care  across the many organizational seams in DOD and VA.
Given the importance of all these issues for providing appropriate and  high-quality care to our returning servicemembers, it is critical for top  leaders at DOD and VA to continue to implement as well as to oversee  these efforts to ensure the goals of the efforts are achieved in a timely  manner, particularly since there is an increasing need to provide care to  servicemembers.
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 29,000 servicemembers  involved in Operation Iraqi Freedom and Operation Enduring Freedom as  wounded in action, and almost 70 percent of these servicemembers are  from the Army active, reserve, and national guard components.  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 veterans’ 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.
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 goes through a  medical evaluation board proceeding, where medical evidence is  evaluated, and potentially unfit conditions are identified. The member then  goes through a physical evaluation board process, where a determination  of fitness or unfitness for duty is made and, if found unfit for duty, a  combined percentage rating is assigned for all unfit conditions and the  servicemember is discharged from duty. The injured servicemember then  receives monthly disability retirement payments if he or she meets the  minimum rating and years of duty thresholds or, if not, a lump-sum  severance payment.
VA provides veterans compensation 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 by the military service or not. If  the veteran is found to have 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, for example, if a  service-connected disability worsens.
section_title: While Efforts Are Under Way to Respond to Both Army-Specific and Systemic Problems, Challenges Are Emerging
paragraphs: While the Army took near-term actions to respond to reported deficiencies  in care for its returning servicemembers, and the Senior Oversight  Committee is undertaking efforts to address more systemic problems,  challenges remain to overcome long-standing problems and ensure  sustainable progress. In particular, efforts were made to respond to  problems in four key areas: (1) case management, (2) disability evaluation  systems, (3) TBI and PTSD, and (4) data sharing between DOD and VA.  The three review groups identified several problems in these four areas  including: a need to develop more comprehensive and coordinated care  and services; a need to make the disability systems more efficient; more  collaboration of research and establishment of practice guidelines for TBI  and PTSD; and more data sharing between DOD and VA. While efforts  have been made in all four areas, challenges have emerged including  staffing for the case management initiatives and transforming the disability  evaluation system.
subsections: section_title: Efforts to Improve Case Management for Servicemembers Under Way, but Human Capital and Other Challenges Are Surfacing
paragraphs: The three review groups reporting earlier this year identified numerous  problems with DOD’s and VA’s case management of servicemembers,  including a lack of comprehensive and well-coordinated care, treatment,  and services. Case management—a process intended to assist returning  servicemembers with management of their clinical and nonclinical care  throughout recovery, rehabilitation, and community reintegration—is  important because servicemembers often receive services from numerous  therapists, providers, and specialists, resulting in differing treatment plans  as well as receiving prescriptions for multiple medications. One of the  review groups reported that the complexity of injuries in some patients  requires a coordinated method of case management to keep the care of the  returning servicemember focused and goal directed, and that this type of  care was not evident at Walter Reed. The Dole-Shalala Commission  recommended that recovery coordinators be appointed to craft and  manage individualized recovery plans that would be used to guide the  servicemembers’ care. The Dole-Shalala Commission further  recommended that these recovery coordinators come from outside DOD  or VA, possibly from the Public Health Service, and be highly skilled and  have considerable authority to be able to access resources necessary to  implement the recovery plans. The Army and the Senior Oversight  Committee’s workgroup on case management have initiated efforts to  develop case management approaches that are intended to improve the  management of servicemembers’ recovery process. See table 1 for selected  efforts by the Army and Senior Oversight Committee to improve case  management services.
The Army’s approach includes developing a new organizational structure  for providing care to returning active duty and reserve servicemembers  who are unable to perform their duties and are in need of health care—this  structure is referred to as a Warrior Transition Unit. 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,” and it 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. As part of the Army’s Medical Action Plan,  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; and 1:12 for squad leaders. This approach is a marked departure  for the Army. Prior to the creation of the Warrior Transition Units, the  Army separated active and reserve component soldiers into different  units. One review group reported that this approach contributed to  discontent about which group received better treatment. Moreover, the  Army did not have formalized staffing structures nor did it routinely track  patient-care ratios, which the Independent Review Group reported  contributed to the Army’s inability to adequately oversee its program or  identify gaps.
As the Army has sought to fill its Warrior Transition Units, challenges to  staffing key positions are emerging. For example, many locations have  significant shortfalls in registered nurse case managers and non- commissioned officer squad leaders. As shown in figure 1, about half of  the total required staffing needs of the Warrior Transition Units had been  met across the Army by mid-September 2007. However, the Army had  filled many of these slots thus far by temporarily borrowing staff from  other positions.
Permanently assigned (832)
Temporarily borrowed (451)
Unfilled (1,127)
The Warrior Transition Unit staffing shortages are significant at many  locations. As of mid-September, 17 of the 32 units had less than 50 percent  of staff in place in one or more critical positions. (See table 2.)  Consequently, 46 percent of the Army’s returning servicemembers who  were eligible to be assigned to a unit had not been assigned, due in part to  these staffing shortages. As a result, these servicemembers’ care was not  being coordinated through the triad. Army officials reported that their goal  is to have all Warrior Transition Units in place and fully staffed by January  2008.
The Senior Oversight Committee’s approach for providing a continuum of  care includes establishment of recovery coordinators and recovery plans,  as recommended by the Dole-Shalala Commission. This approach is  intended to complement the military services’ existing case management  approaches and place the recovery coordinators at a level above case  managers, with emphasis on ensuring a seamless transition between DOD  and VA. The recovery coordinator is expected to be the patient’s and  family’s single point of contact for making sure each servicemember  receives the care outlined in the servicemember’s recovery plan—a plan to  guide and support the servicemember through the phases of medical care,  rehabilitation, and disability evaluation to community reintegration.
The Senior Oversight Committee has indicated that DOD and VA will  establish a joint Recovery Coordinator Program no later than October 15,  2007. At the time of our review, the committee was determining the details  of the program. For example, the Dole-Shalala Commission recommended  this approach for every seriously injured servicemember, and the Senior  Oversight Committee workgroup on case management was developing  criteria for determining who is “seriously injured.” The workgroup was  also determining the role of the recovery coordinators—how they will be  assigned to servicemembers and how many are needed, which will  ultimately determine what the workload for each will be. The Senior  Oversight Committee has, however, indicated that the positions will be  filled with VA staff. A representative of the Senior Oversight Committee  told us that the recovery coordinators would not be staffed from the U.S.  Public Health Service Commissioned Corps, as recommended by the Dole- Shalala Commission. The official told us that it is appropriate for VA to  staff these positions because VA ultimately provides the most care for  servicemembers over their lifetime. Moreover, Senior Oversight  Committee officials told us that depending on how many recovery  coordinators are ultimately needed, VA may face significant human capital  challenges in identifying and training individuals for these positions, which  are anticipated to be complex and demanding.
section_title: Efforts Are Under Way to Improve Disability Evaluation Processes, but Challenges Remain in Transforming the Overall System
paragraphs: As we have previously reported, providing timely and consistent disability  decisions is a challenge for both DOD and VA. In a March 2006 report  about the military disability evaluation system, we found that the services  were not meeting DOD timeliness goals for processing disability cases;  used different policy, guidance and processes for aspects of the system;  and that neither DOD nor the services systematically evaluated the  consistency of disability decisions. On multiple occasions, we have also  identified long-standing challenges for VA in reducing its backlog of claims  and improving the accuracy and consistency of its decisions.
The controversy over conditions at Walter Reed and the release of  subsequent reports raised the visibility of problems in the military  services’ disability evaluation system. In a March 2007 report, the Army  Inspector General identified numerous issues with the Army Physical  Disability Evaluation System. These findings included a failure to meet  timeliness standards for determinations, inadequate training of staff  involved in the process, and servicemember confusion about the disability  rating system. Similarly, in recently-issued reports, the Task Force on  Returning Global War on Terror Heroes, the Independent Review Group,  and the Dole-Shalala Commission found that DOD’s disability evaluation  system often generates long delays in disability determinations and creates  confusion among servicemembers and their families. Also, they noted  significant disparities in the implementation of the disability evaluation  system among the services, and in the purpose and outcome of disability  evaluations between DOD and VA. Two reports also noted the adversarial  nature of DOD’s disability evaluation system, as servicemembers endeavor  to reach a rating threshold that entitles them to lifetime benefits. In  addition to these findings about current processes, the Dole-Shalala  Commission questioned DOD’s basic role in making disability payments to  veterans and recommended that VA assume sole responsibility for  disability compensation for veterans.
In response to the Army Inspector General’s findings, the Army made near- term operational improvements. For example, the Army developed several  initiatives to streamline its disability evaluation system and address  bottlenecks. These initiatives include reducing the caseloads of evaluation  board liaisons who help servicemembers navigate the disability evaluation  system. In addition, the Army developed and conducted the first  certification training for evaluation board liaisons. Furthermore, the Army  increased outreach to servicemembers to address confusion about the  process. For example, it initiated briefings conducted by evaluation board  liaisons and soldiers’ counsels to educate servicemembers about the  process and their rights. The Army also initiated an online tool that  enables servicemembers to check the status of their case during the  evaluation process. We were not able to fully assess the implementation  and effectiveness of these initiatives because some changes are still in  process and complete data are not available.
To address more systemic concerns about the timeliness and consistency  of DOD’s and VA’s disability evaluation systems, DOD and VA are planning  to pilot a joint disability evaluation system. DOD and VA are reviewing  multiple options that incorporate variations of the 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. For example, in  one option, the DOD-level evaluation board makes fitness for duty  determinations for all of the military services; whereas in another option,  the services make fitness for duty determinations, and the DOD-level  board adjudicates appeals of these determinations. Another open question  is whether DOD or VA would conduct the comprehensive medical  examination. Table 3 summarizes four pilot options under consideration  by DOD and VA.
As recent pilot planning exercises verified, in addition to agreeing on  which pilot option to implement, DOD and VA must address several key  design issues before the pilot can begin. For example, it has not been  decided how DOD will use VA’s disability rating to determine military  disability benefits for servicemembers in the pilot. In addition, DOD and  VA have not finalized a set of performance metrics to assess the effect of  the piloted changes. DOD and VA officials had hoped to begin the pilot on  August 1, 2007, but the intended start date slipped as agency officials took  steps to further consider alternatives and address other important  questions related to recent and expected events that may add further  complexity to the pilot development process. For example, the Senior  Oversight Committee may either choose or be directed by the Congress to  pilot the Dole-Shalala recommendation that only VA and not DOD provide  disability payments to veterans. Implementing this recommendation would  require a change to current law, and could affect whether or how the  agencies implement key pilot elements under consideration. In addition,  the Veterans’ Disability Benefits Commission, which is scheduled to report  in October 2007, may recommend changes that could also influence the  pilot’s structure. Further, the Congress is considering legislation that may  require DOD and VA to conduct multiple, alternative disability evaluation  pilots.
DOD and VA face other critical challenges in creating a new disability  evaluation system. For example, DOD is challenged to overcome  servicemembers’ distrust of a disability evaluation process perceived to be  adversarial. Implementing a pilot without adequately considering  alternatives or addressing critical policy and procedural details may feed  that distrust because DOD and VA plan to pilot the new system with actual  servicemembers. The agencies also face staffing and training challenges to  conduct timely and consistent medical examinations and disability  evaluations. Both the Independent Review Group and the Dole-Shalala  Commission recommended that only VA establish disability ratings.  However, as we noted above, VA is dealing with its own long-standing  challenges in providing veterans with timely and consistent decisions.  Similarly, if VA becomes responsible for servicemembers’ comprehensive  physical examinations, it would face additional staffing and training  challenges, at a time when it is already addressing concerns about the  timeliness and quality of its examinations. Further, while having a single  disability evaluation could ensure more consistent disability ratings, VA’s  Schedule for Rating Disabilities is outdated because it does not adequately  reflect changes in factors such as labor market conditions and assistive  technologies on disabled veterans’ ability to work. As we have reported,  the nature of work has changed in recent decades as the national economy  has moved away from manufacturing-based jobs to service- and  knowledge-based employment. Yet VA’s disability program remains mired  in concepts from the past, particularly the concept that impairment  equates to an inability to work.
section_title: Efforts Under Way to Improve Screening, Diagnosis, and Treatment for TBI and PTSD
paragraphs: The three independent review groups examining the deficiencies found at  Walter Reed identified a range of complex problems associated with DOD  and VA’s screening, diagnosis, and treatment of TBI and PTSD, signature  injuries of recent conflicts. Both conditions are sometimes referred to as  “invisible injuries” because outwardly the individual’s appearance is just as  it was before the injury or onset of symptoms. In terms of mild TBI, there  may be no observable head injury and symptoms may overlap with those  associated with PTSD. With respect to PTSD, there is no objective  diagnostic test and its symptoms can sometimes be associated with other  psychological conditions (e.g., depression). Recommendations from the  review groups examining these areas included better coordination of DOD  and VA research and practice guidelines and hiring and retaining qualified  health professionals. However, according to Army officials and the  Independent Review Group report, obtaining qualified health  professionals, such as clinical psychologists, is a challenge, which is due  to competition with private sector salaries and difficulty recruiting for  certain geographical locations. The Dole-Shalala Commission noted that  while VA is considered a leader in PTSD research and treatment,  knowledge generated through research and clinical experience is not  systematically disseminated to all DOD and VA providers of care. Both the  Army and the Senior Oversight Committee are working to address this  broad range of issues. (See table 4.)
The Army, through its Medical Action Plan, has policies in place requiring  all servicemembers sent overseas to a war zone to receive training on  recognizing the symptoms of mild TBI and PTSD. The Army is also  exploring ways to track events on the battlefield, such as blasts, that may  result in TBI or PTSD. In addition, the Army recently developed policies to  provide mild TBI and PTSD training to all social workers, nurse case  managers, psychiatric nurses, and psychiatric nurse practitioners to better  identify these conditions. As of September 13, 2007, 6 of the Army’s 32  Warrior Transition Units had completed training for all of these staff.
A Senior Oversight Committee workgroup on TBI and PTSD is working to  ensure health care providers have education and training on screening,  diagnosing, and treating both mild TBI and PTSD, mainly by developing a  national Center of Excellence as recommended by the three review  groups. This Center of Excellence is expected to combine experts and  resources from all military services and VA to promote research,  awareness, and best practices on mild TBI as well as PTSD and other  psychological health issues. A representative of the Senior Oversight  Committee workgroup on TBI and psychological health told us that the  Center of Excellence would include the existing Defense and Veterans  Brain Injury Center—a collaboration among DOD, VA, and two civilian  partners that focuses on TBI treatment, research, and education.
section_title: Efforts Under Way to Facilitate Data Sharing between DOD and VA
paragraphs: DOD and VA have been working for almost 10 years to facilitate the  exchange of medical information. However, the three independent review  groups identified the need for DOD and VA to further improve and  accelerate efforts to share data across the departments. Specifically, the  Dole-Shalala Commission indicated that DOD and VA must move quickly  to get clinical and benefit data to users, including making patient data  immediately viewable by any provider, allied health professional, or  program administrator who needs the data. Furthermore, in July 2007, we  reported that although DOD and VA have made progress in both their long- term and short-term initiatives to share health information, much work  remains to achieve the goal of a seamless transition between the two  departments. While pursuing their long-term initiative to develop a  common health information system that would allow the two-way  exchange of computable health data, the two departments have also been  working to share data in their existing systems. See table 5 for selected  efforts under way by the Army and Senior Oversight Committee to  improve data sharing between DOD and VA.
As part of the Army Medical Action Plan, the Army has taken steps to  facilitate the exchange of data between its military treatment facilities and  VA. For example, the Army Medical Department is developing a  memorandum of understanding between the Army and VA that would  allow VA access to data on severely injured servicemembers who are  being transferred to a VA polytrauma center. The memorandum of  understanding would also allow VA’s Veterans Health Administration and  Veterans Benefits Administration access to data in a servicemember’s  medical record that are related to a disability claim the servicemember has  filed with VA. Army officials told us that the Army’s medical records are  part paper (hard copy) and part electronic, and this effort would provide  the VA access to the paper data until the capability to share the data  electronically is available at all sites.
Given that DOD and VA already have a number of efforts under way to  improve data sharing between the two departments, the Senior Oversight  Committee, through its data sharing workgroup, has been looking for  opportunities to accelerate the departments’ sharing initiatives that are  already planned or in process and to identify additional data sharing  requirements that have not been clearly articulated. For example, the  Senior Oversight Committee has approved several policy changes in  response to the Dole-Shalala Commission, one of which requires DOD and  VA to ensure that all essential health and administrative data are made  available and viewable to both agencies, and that progress is reported by a  scorecard, by October 31, 2008. A representative of the data sharing  workgroup told us that the departments are achieving incremental  increases to data sharing capabilities and plan to have all essential health  data—such as outpatient pharmacy, allergy, laboratory results, radiology  reports, and provider notes—viewable by all DOD and VA facilities by the  end of December 2007. Although the agencies have recently experienced  delays in efforts to exchange data, the representative said that the  departments are on track to meet all the timelines established by the  Senior Oversight Committee.
A Senior Oversight Committee workgroup on data sharing has also been  coordinating with other committee workgroups on their information  technology needs. Although workgroup officials told us that they have met  numerous times with the case management and disability evaluation  systems workgroups to discuss their data sharing needs, they have not  begun implementing necessary systems because they are dependent on the  other workgroups to finalize their information technology needs. For  example, the Senior Oversight Committee has required DOD and VA to  establish a plan for information technology support of the recovery plan to  be used by recovery coordinators, which integrates essential clinical   (e.g., medical care) and nonclinical aspects (e.g., education, employment,  disability benefits) of recovery, no later than November 1, 2007. However,  this cannot be done until the case management workgroup has identified  the components and information technology needs of these clinical and  nonclinical aspects, and as of early September this had not been done.  Data sharing workgroup representatives indicated that the departments’  data sharing initiatives will be ongoing because medications, diagnoses,  procedures, standards, business practices, and technology are constantly  changing, but the departments expect to meet most of the data sharing  needs of patients and providers by end of fiscal year 2008.
section_title: Concluding Observations
paragraphs: Our preliminary observations are that fixing the long-standing and  complex problems spotlighted in the wake of Walter Reed media accounts  as expeditiously as possible is critical to ensuring high-quality care for our  returning servicemembers, and success will ultimately depend on  sustained attention, systematic oversight by DOD and VA, and sufficient  resources. Efforts thus far have been on separate but related tracks, with  the Army seeking to address service-specific issues while DOD and VA are  working together to address systemic problems. Many challenges remain,  and critical questions remain unanswered. Among the challenges is how  the efforts of the Army—which has the bulk of the returning  servicemembers needing medical care—will be coordinated with the  broader efforts being undertaken by DOD and VA.
The centerpiece of the Army’s effort is its Medical Action Plan, and the  success of the plan hinges on staffing the newly-created Warrior Transition  Units. Permanently filling these slots may prove difficult, and borrowing  personnel from other units has been a temporary fix but it is not a long- term solution. The Army can look to the private sector for some skills, but  it must compete for personnel in a civilian market that is vying for medical  professionals with similar skills and training.
Perhaps one of the most complex efforts under way is that of redesigning  DOD’s disability evaluation system. Delayed decisions, confusing policies,  and the perception that DOD and VA disability ratings result in inequitable  outcomes have eroded the credibility of the system. Thus, it is imperative  that DOD and VA take prompt steps to address fundamental system  weaknesses. However, as we have noted, key program design and  operational policy questions must be addressed to ensure that any  proposed system redesign has the best chance for success and that  servicemembers and veterans receive timely, accurate, and consistent  decisions. This will require careful study of potential options, a  comprehensive assessment of outcome data associated with the pilot,  proper metrics to gauge success, and an evaluation mechanism to ensure  needed adjustments are made to the process along the way. Failure to  properly consider alternatives or address critical policy and procedural  details could exacerbate delays and confusion for servicemembers, and  potentially jeopardize the system’s successful transformation.
Mr. Chairman, this completes my 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 John H.  Pendleton at (202) 512-7114 or pendletonj@gao.gov or Daniel Bertoni at  (202) 512-7215 or bertonid@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 report  are listed in appendix II.
section_title: Appendix I: Selected Issues Identified by Three Review Groups following the Reporting of Deficiencies at Walter Reed
paragraphs: In the aftermath of deficiencies identified at Walter Reed Medical Center,  three separate review groups—the President’s Commission on Care for  America’s Returning Wounded Warriors, commonly referred to as the  Dole-Shalala Commission; the Independent Review Group, established by  the Secretary of Defense; and the President’s Task Force on Returning  Global War on Terror Heroes—investigated the factors that may have led  to these problems. Selected findings of each report are summarized in  table 6.
section_title: Appendix II: GAO Contacts and Staff Acknowledgments
subsections: section_title: GAO Contacts
section_title: Acknowledgment
paragraphs: In addition to the contact named above, Bonnie Anderson, Assistant  Director; Michele Grgich, Assistant Director; Jennie Apter; Janina Austin;  Joel Green; Christopher Langford; Chan My Sondhelm; Barbara Steel- Lowney; and Greg Whitney, made key contributions to this statement.
section_title: Related GAO Products
paragraphs: DOD Civilian Personnel: Medical Policies for Deployed DOD Federal  Civilians and Associated Compensation for Those Deployed.   GAO-07-1235T. Washington, D.C.: September 18, 2007.
Global War on Terrorism: Reported Obligations for the Department of  Defense. GAO-07-1056R. Washington, D.C.: July 26, 2007.
Information Technology: VA and DOD Are Making Progress in Sharing  Medical Information, but Remain Far from Having Comprehensive  Electronic Medical Records. GAO-07-1108T. Washington, D.C.: July 18,  2007.
Defense Health Care: Comprehensive Oversight Framework Needed to  Help Ensure Effective Implementation of a Deployment Health Quality  Assurance Program. GAO-07-831. Washington, D.C.: June 22, 2007.
DOD’s 21st Century Health Care Spending Challenges, Presentation for  the Task Force on the Future of Military Health Care. Statement  delivered by David M. Walker, Comptroller General of the United States.  GAO-07-766-CG. Washington, D.C.: April 18, 2007.
Veterans’ Disability Benefits: Long-Standing Claims Processing  Challenges Persist. GAO-07-512T. Washington, D.C.: March 7, 2007.
DOD and VA Health Care: Challenges Encountered by Injured  Servicemembers during Their Recovery Process. GAO-07-589T.  Washington, D.C.: March 5, 2007.
VA Health Care: Spending for Mental Health Strategic Plan Initiatives  Was Substantially Less Than Planned. GAO-07-66. Washington, D.C.:  November 21, 2006.
VA and DOD Health Care: Efforts to Provide Seamless Transition of  Care for OEF and OIF Servicemembers and Veterans. GAO-06-794R.  Washington, D.C.: June 30, 2006.
Post-Traumatic Stress Disorder: DOD Needs to Identify the Factors Its  Providers Use to Make Mental Health Evaluation Referrals for  Servicemembers. GAO-06-397. Washington, D.C.: May 11, 2006.
Military Disability System: Improved Oversight Needed to Ensure  Consistent and Timely Outcomes for Reserve and Active Duty Service  Members. GAO-06-362. Washington, D.C.: March 31, 2006.
VA and DOD Health Care: Opportunities to Maximize Resource Sharing  Remain. GAO-06-315. Washington, D.C.: March 20, 2006.
VA and DOD Health Care: VA Has Policies and Outreach Efforts to  Smooth Transition from DOD Health Care, but Sharing of Health  Information Remains Limited. GAO-05-1052T. Washington, D.C.:  September 28, 2005.
Federal Disability Assistance: Wide Array of Programs Needs to be  Examined in Light of 21st Century Challenges. GAO-05-626. Washington,  D.C.: June 2, 2005.
Veterans’ Disability Benefits: Claims Processing Problems Persist and  Major Performance Improvements May Be Difficult. GAO-05-749T.  Washington, D.C.: May 26, 2005.
DOD and VA: Systematic Data Sharing Would Help Expedite  Servicemembers’ Transition to VA Services. GAO-05-722T. Washington,  D.C.: May 19, 2005.
VA Health Care: VA Should Expedite the Implementation of  Recommendations Needed to Improve Post-Traumatic Stress Disorder  Services. GAO-05-287. Washington, D.C.: February 14, 2005.
VA and Defense Health Care: More Information Needed to Determine If  VA Can Meet an Increase in Demand for Post-Traumatic Stress Disorder  Services. GAO-04-1069. Washington, D.C.: September 20, 2004.
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