VA Disability Compensation: Actions Needed to Address Hurdles Facing Program Modernization
Published: 2012-09-10T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: VA administers one of the nations largest federal disability compensation programs, providing veterans with a cash benefit based on average loss of earning capacity as a result of service-connected disabilities. However, concerns exist that VAs rating schedulethe criteria used to assign degree of work disabilityis not consistent with changes in medicine and the labor market. Due in part to these types of challenges, GAO designated federal disability programs as high risk. Consequently, GAO examined (1) VAs progress in revising its rating schedule with updated medical and economic information; and (2) the opportunities and challenges of various policy approaches proposed by commissions and others for updating VAs disability benefits structure. To do this, GAO reviewed literature and VA documents, and relevant federal laws and regulations, as well as interviewed VA officials, disability experts, and veteran groups.
section_title: What GAO Found
paragraphs: The Department of Veterans Affairs (VA) initiated a comprehensive effort in 2009 to revise its disability rating schedule with both updated medical and earnings information, but faces hurdles with several key aspects. The current revision effort takes a more comprehensive and empirical approach than VAs past efforts. VA has hired full-time staff to revise the rating schedules medical information and plans to conduct studies to evaluate veterans average loss of earnings in todays economy. As part of this effort, VA is considering modifying the rating schedulecurrently based largely on degree of medical severityto include a veterans ability to function in the workplace. Moving in this direction is more consistent with how experts conceive of disability. However, this change, in part, has resulted in VA falling behind schedule. As of July 2012, VA is over 12 months behind in revising criteria for the first categories of impairments. In addition, VA has not developed its capacity to produce timely research on the impact of impairments on earnings. Moreover, VA lacks a complete planwith specific activities and updated time framesfor conducting earnings loss and related studies. VA also does not have a written strategy to address the possible effects that revisions may have on agency operations, including impacts on an already strained claims workload. Finally, although VA intends to conduct medical and earnings updates beyond the current effort, VA lacks a formal mechanism to guide its commitment to do so. It is important that VA update and maintain its rating schedule to reflect current medical and labor market information to avoid overcompensating some veterans with service-connected disabilities while undercompensating others.
Three key approaches for modernizing VAs disability programs recommended by disability commissions and othersproviding quality of life payments, providing integrated vocational services with transitional cash assistance, and systematically factoring the effects of assistive technology and medical interventions into rating decisionshold opportunity and challenges. Experts and veteran groups GAO interviewed believe each approach holds at least some opportunity for serving veterans more fairly, equitably, and effectively. However, challenges exist. For example, they noted that it could be difficult to achieve consensus for specific design elements among the diverse set of stakeholders. Also, VAs capacity to administer these approacheswhich could increase the complexity and/or number of claimsis questionable. Importantly, costs of each approach were raised. Some interviewees also noted that two or more of the approaches could be combined into a comprehensive benefits package that may mitigate concerns raised by the implementation of any single approach. For example, if factoring assistive technology into disability ratings resulted in lower disability compensation payment levels for some, a quality of life payment could offset that loss. VA officials told GAO they are not considering these approaches because they fall outside of VAs legal responsibility to compensate for loss of earning capacity. However, a system that maximizes equity, balances fiscal pressures, and ultimately serves individual veterans effectively will benefit from deliberations informed by more modern views about disability.
section_title: What GAO Recommends
paragraphs: Congress may wish to direct VA to conduct focused studies on various approaches to modernize disability benefits and, if necessary, propose relevant legislation. GAO is also making several recommendations to improve VAs capacity to revise the rating schedule now and in the future. These include completing plans for conducting earnings loss studies and developing a written strategy for implementing revisions to the rating schedule. VA agreed with the recommendations and noted plans to address them.

section_title: Letter
paragraphs: The nation is committed to caring for veterans who incurred injuries  during their military service. To compensate for these sacrifices, the U.S.  Department of Veterans Affairs (VA) administers one of the largest  federal disability compensation programs in the nation. VA’s disability  compensation program provides veterans with a cash benefit based on  the average loss in earning capacity in civilian occupations that result  from injuries or conditions incurred or aggravated during military service.  In fiscal year 2011, VA’s program provided about $39.4 billion in disability  payments to nearly 3.4 million veterans with service-connected  disabilities. In the years ahead, enrollment and costs could increase given  the conflicts in Iraq and Afghanistan and as more Vietnam veterans—a  significant proportion of the total veteran population—further age into  disability-prone years. Given the large cash outlays and increasing  demand for VA services, VA must be well positioned to make accurate  disability decisions and ensure that veterans are appropriately and  equitably compensated.
In 2003, GAO designated federal disability programs, including VA’s  disability program, as high risk due in part to challenges agencies face in  keeping their criteria for evaluating disability and determining  compensation consistent with advances in medicine, technology, and  changes in the labor market and society. According to experts, VA’s  disability program infers the ability to work based on an individual’s  medical conditions and symptoms—a concept that originated with the  creation of the schedule for rating disabilities over 65 years ago.  However, experts believe that, in assessing disability, a modern practice  includes considering an individual’s ability to function in their work and  other environments along with their medical conditions.
These concerns, in light of more modern concepts of disability, present an  opportunity to reevaluate this federal program. Various reports and  studies conducted by GAO, congressional- and presidential-appointed  commissions (including the Veterans’ Disability Benefits Commission and  the Dole-Shalala Commission), and task forces have individually  suggested various approaches to address a sensitive, but critical, national  issue: how to update and strengthen VA’s disability benefits structure,  including the type, timing, and conditions of cash and other assistance to  ensure that veterans with service-connected disabilities receive the  compensation and services they deserve.
We have prepared this report under the Comptroller General’s authority to  evaluate government programs as part of our continued effort to assist  policymakers in determining how VA programs could more effectively  meet the needs of veterans with disabilities in the 21st Century. In this  report, we (1) identify the progress that VA has made in revising the  criteria used to determine eligibility for veterans’ disability benefits with  updated medical and economic information, and (2) discuss the  opportunities and challenges associated with various policy approaches  that disability commissions and others have raised for updating VA’s  disability benefits structure.
To conduct our work, we reviewed prior GAO, disability commission and  committee reports; relevant federal laws and regulations; program  documentation, including policies, procedures, strategic goals, and  supporting project plans; and testimonies from disability groups and  commissions. We interviewed VA officials, disability experts, and  representatives of veteran groups. We also evaluated VA’s project plans  for revising its disability criteria against generally accepted project  management practices. To identify the policy approaches for our second  objective, we conducted a literature search of relevant reports by  disability commissions, task forces, committees, as well as GAO reports.  We selected policy approaches that address VA’s disability benefits  structure and which reflect more modern concepts of disability. To identify  the opportunities and challenges associated with these policy  approaches, we conducted 16 interviews with a range of informed experts  and veteran groups on the political and administrative feasibility,  effectiveness, and fiscal sustainability they believe are associated with  each approach. Of those we interviewed, most said that the policy  approaches we selected were relevant approaches for our research  purposes. Our nongeneralizable sample of experts included individuals  who participated in disability commissions, research, or congressional  testimony on the topic, or who serve in an organization that represents  veterans with disabilities. Additional information about our scope and  methodology is provided in appendix I.
We conducted this performance audit from August 2011 to September  2012 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.
subsections: section_title: Background
subsections: section_title: VA’s Disability Compensation Program and Related Services
paragraphs: VA’s disability program compensates veterans with a service-connected  disability by providing a monthly cash benefit. As required by statute, the  benefit is based upon an average reduction in earning capacity across a  group of individuals with a similar physical or mental impairment. Thus,  the benefit is not based on the loss of individual earnings or noneconomic  losses. A veteran with a service-connected disability receives the benefit  whether or not employed and regardless of the amount of income he or  she is earning.
The level of cash benefit is determined in part through the Veterans  Affairs Schedule for Rating Disabilities (VASRD or rating schedule). The  rating schedule is based on the extent to which the veteran’s disability  limits average earning capacity. VA staff use the rating schedule to assign  disability ratings to veterans. The rating schedule contains medical  conditions or injuries categorized into 15 body systems, with a level of  severity ranging in 10 percent increments up to 100 percent. For  example, the removal of three ribs is rated as a 30 percent impairment in  earning capacity, or $389 per month, and cash benefits are increased for  veterans with spouses and dependents. A veteran must be rated at least  10 percent to receive cash benefits. For veterans with multiple  impairments, VA uses a table that applies a formula for combining ratings  into a single rating.
Besides cash assistance, VA provides health care, housing, vocational  rehabilitation, and other employment-related services to eligible  veterans. and programs within VA, such as the Veterans Health Administration and  Vocational Rehabilitation and Employment program. In many instances, a  veteran must first receive a disability rating from the Veterans Benefits  Administration (VBA) and then apply for these services at the discretion of  the veteran, as shown in figure 1.
Generally, veterans with a disability rating of 20 percent or higher (who have an  employment handicap) and veterans with a disability rating of 10 percent (who have a  serious employment handicap) are eligible to receive vocational rehabilitation services.
subsections: section_title: Concerns about VA’s Disability Program in Light of Modern Approaches
paragraphs: Various commissions, expert panels, and our prior work have raised a  variety of concerns about the soundness of the rating schedule and about  VA’s basic disability benefits structure. The following were among these  concerns:
VA’s modifications of the medical information in the disability criteria  have been slow and have not fully incorporated advances in  technology and medicine. Moreover, the rating schedule has not been  adjusted since its creation in 1945 to reflect ongoing changes in the  labor market. Past studies evaluated veterans’ with service-connected  disabilities average loss of earnings and found that not all veterans  were being equitably compensated.
VA faces continuing challenges in the area of disability claims  processing, contributing to a large backlog of initial compensation  claims and appeals.
VA focuses too singularly on compensation without adequate focus on  rehabilitation to maximize a veteran’s recovery and reintegration. This  issue was raised by the Bradley Commission and Dole-Shalala  Commission. Also, a small proportion of veterans participate in VA’s  vocational services.
VA’s various disability benefits and services need to be better  integrated to serve individual veterans.
To address these and other concerns, GAO, commissions, committees,  and expert panels made a range of recommendations that generally  reflect modern concepts of disability. These modern concepts are  reflected in the International Classification of Functioning, Disability, and  Health (ICF), which is the World Health Organization’s framework for  health and disability. This framework takes into account the interaction  between an individual’s medical condition or impairment and intervening  factors, such as their physical and social environment. That is, rather  than predominately viewing disability as a medical condition (e.g., loss of  an arm), modern concepts of disability focus on an individual’s functional  ability. Under these concepts, two people with the same impairment and  symptoms, for a variety of reasons, might have different degrees of  disability. For example, some individuals with post-traumatic stress  disorder (PTSD) may experience symptoms such as anxiety, depression,  and insomnia that make maintaining employment very difficult. However,  other individuals with PTSD may be able to mitigate these symptoms  through medication or other therapies and perform adequately in a work  environment. Some frameworks of disability also distinguish work  participation from other consequences of injuries or diseases that have a  broader impact on a person’s quality of life. Examples include difficulty  interacting with family and friends and managing personal finances.
section_title: VA Has Begun to Update Its Disability Criteria, but Faces Delays and Lacks Complete Planning in Key Areas
subsections: section_title: VA Has Begun a Comprehensive Update of Its Disability Criteria with Medical and Earnings Information
paragraphs: In response to a directive from the Secretary, VA initiated an effort in  2009 to comprehensively revise all 15 body systems in its disability rating  schedule. This comprehensive revision will update the two major  components of the rating schedule: (1) the medical criteria, and (2)  earnings loss information. In 1989, VA took steps to conduct a  comprehensive revision of the medical criteria, but it did not complete  revisions for all body systems. Since then, VA has updated portions of  its medical criteria primarily in response to congressional or stakeholder  requests. (See app. II for more information about previous updates to the  rating schedule.) According to VA, while the agency has conducted  economic earnings loss studies, it has never adjusted the rating schedule  based on the findings from these studies. According to VA, the purpose  of the current initiative to update the medical and earnings loss  information is to ensure the rating schedule is as accurate and  modernized as possible to meet the needs of veterans in the 21st  century.
VA is using a multiphase process to comprehensively revise the medical  and earnings information for each body system. This process is led by  VBA—which hired six full-time medical officers to lead the revisions—in  consultation with the Veterans Health Administration. Phase 1 involves a  2-day public forum to solicit updated medical information from various  stakeholders, and the process ends with the publication of revisions as  final rules in the Federal Register, as shown in figure 2.
To conduct the medical updates, the workgroups evaluate all impairments  in the current rating schedule and make recommendations to add or  remove impairments, update medical and diagnostic terminology, and  clarify impairments that cannot be easily identified. For example, as part  of the current updates, VA workgroups proposed adding a new body  system, “rheumatic diseases.” See table 1 for examples of changes being  considered to existing body systems. In addition to specific updates and  clarifications, the medical workgroups consider broader concepts such as  how VA measures pain for the purposes of evaluating claims.
In recognition of medical advances and current research on disability, VA  is considering revising its criteria to reflect a more modern view of  disability that gives greater consideration to a veteran’s ability to function  with a service-connected disability. According to VA officials, a common  theme emerging from the workgroups is the need to shift from the current  symptom-based rating criteria to one that incorporates a veteran’s ability  to function in the workplace. Subject-matter experts involved in the  workgroups have suggested that, while symptoms determine diagnosis,  the best indicator of impairment in earnings is the translation of symptoms  into functional impairment. To develop the indicators of functional  impairment, VA conducted research and determined that four functional  domains directly impact one’s ability to secure and maintain gainful  employment. These include interacting with others, developing and  maintaining a routine or schedule, managing workload demands, and  completing tasks that require mental skills.
While VA is considering a number of different elements to update its  medical criteria, it is giving only limited consideration to the role that  supports—such as assistive technology and medical interventions—can  play in enhancing a veteran’s earning capacity. In 2002, we reported that  VA’s program was not designed to factor in the potential benefits of  treatment, corrective devices, and assistive technology when evaluating a  veteran’s service-connected disability. supports can play a critical role in a veteran’s capacity for work, according  to the ICF framework. VA officials told us that, while they plan to consider  how medical advances have decreased the severity and duration of some  conditions, they do not plan to change the way assistive technology and  medical interventions are considered when making individual disability  determinations for a number of reasons. Specifically, according to VA  officials, including the effects of assistive technology in evaluations of  disabilities would overlook the severity of the disability itself and focus on  the individualized adaptation to an assistive device, and the statute for  VA’s disability compensation program is based on the average reduction  in earning capacity across a group of individuals with a similar physical or  mental impairment.
GAO-02-597. analyses are necessary to make knowledge-based adjustments to the  rating schedule, a practice consistent with recommendations from expert  panels and our prior work. An important aspect of the earnings updates  are validation studies to confirm the findings of the earnings loss analyses  and to verify the accuracy of proposed changes to the rating schedule.  The validation studies will be conducted through separate contracts.  Specifically, VA plans to update all 15 body systems as follows:
For the first three body systems—the mental health, hemic/lymphatic,  and endocrine systems—VA plans to use the results from a 2008  earnings loss report to inform any adjustments to the level of  compensation associated with these various impairments.
For the remaining 12 body systems, VA plans to contract with external  organizations to conduct earnings loss studies and validation studies.  However, VA’s first contracted earnings study with a university for the  musculoskeletal system is pending termination as of August 2012,  according to VA.
For each earnings loss study, the contractor will identify the average  lifetime earnings loss incurred by veterans with specific service- connected disabilities. To do this, the studies will compare the earnings  levels of veterans with various service-connected disabilities to veterans  without a disability as well as with the nonveteran population. Contractors  will identify differences between veterans’ average earnings losses and  VA disability compensation levels (i.e., the extent that veterans are being  over- and undercompensated) and suggest improvements to the current  system.
section_title: VA’s Revision Process Faces Delays and Additional Hurdles
paragraphs: VA has experienced delays in revising its disability rating schedule.  Specifically, VA planned to publish final rules in the Federal Register  (phase 5) for the first three body systems by June 2011. VA has not,  however, met this goal. As of July 2012, VA has completed public forums  for all 15 body systems (phase 1) and has working drafts of revisions for  nine body systems (phase 3). However, VA has not issued any proposed  or final rules (phases 4 and 5). Moreover, as of July 2012, VA was more  than a year behind in completing the first earnings loss study for the  musculoskeletal body system and has yet to complete studies for the  remaining eleven body systems. According to VA officials, they now  expect to issue proposed rules for all body systems by 2016, but they  have moved the original project completion date from 2016 to an  unspecified future date.
VA officials noted various reasons for the delays, including a lengthy  drafting and review process for the potential medical revisions. VA  officials told us that giving greater consideration to functional impairment  represents a significant change to VA’s current disability criteria. As a  result, VA workgroups and staff have taken longer to draft and review  revisions than originally planned. Furthermore, VA took additional steps to  solicit comments from stakeholders about these changes. For example,  VA held a rating schedule status summit in June 2012 to publically share  the draft revisions for nine body systems before the publication of  proposed rules in the Federal Register in an effort to promote  transparency and solicit comments.
VA also is experiencing delays because it has had difficulty obtaining the  data it needs to study earnings loss. Specifically, to conduct these  studies, VA needs earnings data from the Social Security Administration  (SSA) and the Internal Revenue Service (IRS), among other data  sources, as well as VA data on veterans with service-connected  disabilities. VA officials stated that the coordination between the various  federal agencies took much longer than expected, in part, because  federal law generally prohibits the release of certain individual  information. VA officials also stated that VBA contractors must work  very closely with SSA to process, analyze, and transmit earnings data. As  of July 2012, VA had not obtained the aggregate data from SSA or the  IRS needed to conduct the first earnings loss study. In addition, VA  officials described hurdles obtaining internal agency data in a timely way.  For example, VBA has experienced challenges coordinating with another  VA office to obtain data needed to evaluate veterans’ earnings losses.  VBA recently received this data 12 months after first requesting it. To  address this hurdle and streamline the process, VBA is implementing a  system that will allow VBA staff to more independently access and  analyze internal data. However, as of July 2012, VBA had not fully  implemented this new system.
In addition to delays in obtaining data, VA faces other hurdles related to  the earnings loss studies. For example, VA currently relies on external  organizations that produce studies one body system at a time. Experts we  interviewed, including members of VA’s Advisory Committee on Disability  Compensation, said this process is inefficient and may not best facilitate  the agency’s goal to measure earnings loss on an ongoing basis. As one  expert noted, to contract with an external organization, VA must complete  market research and evaluate and select a contractor, among other tasks.  Once a contractor is selected, they must then perform a number of start- up tasks, including applying for security clearances and authorization to  use VA data, reviewing the methodology of previous earnings studies,  and identifying and gathering needed data from various federal agencies  to create a study group of veterans with service-connected disabilities  and a comparison group. To avoid repeating these tasks for each  contract, several experts we interviewed suggested that VA should build  its internal research capacity to more seamlessly conduct these studies.  For example, VA could develop more in-house resources for conducting  these types of analyses or establish long-term partnerships with research  organizations. VA has explored methods to build their research capacity,  but it has yet to adopt an approach for doing so.
According to some experts we interviewed, even after the earnings loss  studies are completed, VA’s revision initiative may face an additional  hurdle: gaining acceptance from a diverse group of stakeholders. Various  experts and veteran groups have raised concerns about the changes  being considered. Some experts and veteran groups we interviewed  raised concerns about incorporating measures of functional impairment  into the rating schedule. They stated that assessing a veteran’s function  may result in a more prolonged disability claims process and questioned  VA’s ability to successfully implement new functional criteria. In addition,  one veteran group raised concerns that the earnings loss studies may not  adequately capture the complex nature of a veteran’s impaired earning  capacity. For example, measuring veterans’ average lifetime earnings  losses due to a service-connected injury or illness—the aim of the current  studies—may not capture lost opportunities to pursue a more lucrative or  fulfilling career. At the same time, several experts did not agree with the  methodology of the current earnings loss studies.that these studies are a good way to measure average earnings loss. In  addition, several veteran group representatives told us that the rating  schedule in its present form generally represents an equitable method for  determining disability compensation.
section_title: VA’s Project Planning Reflects a Number of Sound Practices but Lacks Key Information
paragraphs: To guide the revision initiative, VA developed a project management plan  and operating plan that contain many elements of sound planning but lack  complete and updated information in key areas. In our previous work,  we have identified elements of sound planning that facilitate effective  project management. Sound planning practices include identifying and  documenting specific activities needed to achieve project goals. They  also include documenting when work activities will occur, how long they  will take, and how they are related to one another. VA’s project plans  include key elements of sound planning, such as clearly stating the  purpose and strategy, including the goals and objectives, of the revision  project. However, VA has not taken several key steps that may be critical  to completing and maintaining an updated rating schedule, such as  planning for earnings loss and validation studies, developing a strategy  for implementing revisions, and adopting a formal policy for regular  updates in the future (see table 2). Regarding an implementation strategy,  for example, if revisions to the mental health rating criteria resulted in  upward adjustments of the ratings, VA would re-rate those veterans with  mental health disabilities, according to VA officials. As noted previously,  the earnings study being used by VA to update the mental health rating  criteria showed the veterans with those conditions are likely  undercompensated. As of the end of fiscal year 2011, 878,417 or 6.7  percent of those disabilities for which veterans received benefits were  mental health conditions. Any effort to re-rate those cases likely  represents a significant workload increase. Some experts we interviewed  recommended that VA immediately develop a written strategy for  implementing these revisions to help ensure that veterans do not  experience any negative service-delivery consequences, such as  increased wait times for disability benefits.
section_title: Selected Policy Approaches for Updating VA’s Benefit Structure Present Both Opportunities and Challenges
paragraphs: Three key approaches for modernizing VA’s disability programs—as  recommended by disability commissions and others—present  opportunities and challenges. These approaches are (1) providing quality  of life payments, (2) providing integrated vocational services with  transitional cash assistance, and (3) factoring the effects of assistive  technology and medical interventions systematically into rating decisions.  See figure 3 for an overview of what VA does now and what these  approaches would do. Those we interviewed said to varying degrees that  the approaches could provide more equitable compensation and that  approaches two and three could better help veterans integrate into the  workforce and society. At the same time, however, experts and veteran  groups identified administrative, political feasibility, and cost challenges,  among others. Nevertheless, some experts said that combining the  approaches could create a more integrated, comprehensive benefits  package and could also mitigate challenges associated with any one  approach. When considering such large-scale policy changes, we have  previously identified strategies for policymakers to use to develop specific  policy proposals. In translating broad policy approaches or concepts— including the three outlined below—into specific proposals, policymakers  will need to define key design features (e.g., eligibility requirements and  the type and timing of payments). For a summary of key questions raised  during our discussions with experts and veteran groups about the  possible design of the approaches, see appendix III.
When assessing these policy approaches, one must keep in mind that  VA’s disability compensation program is a statutory scheme with  parameters set forth in federal law. This statutory scheme restricts the  extent to which VA can reform its disability program, as there are many  actions VA cannot take without Congress amending the relevant laws.  For example, under 38 U.S.C. § 1155, VA is required, as far as is  practicable, to base its disability ratings on the average impairments of  earning capacity resulting from various types of injuries. This provision  essentially prohibits VA from basing disability ratings (or a portion of the  ratings) on a loss of quality of life, thus making the first policy approach  discussed below legally impossible without a statutory change.
According to several of the experts and veteran groups we interviewed,  quality of life payments could better align VA’s compensation program  with more current thinking about disability while simultaneously providing  greater equity to VA’s disability compensation program. In general,  experts and veteran groups we interviewed said that a payment for quality  of life held more opportunity than the other proposed approaches to  update the nation’s veteran benefits program. However, they also cited  challenges relating to its implementation and fiscal sustainability, as  shown in figure 4.
In terms of opportunities, a payment for veterans’ loss in quality of life  might help align the program with more current thinking about disability by  recognizing the impact of illness or injury beyond loss in earnings. Along  these lines, many experts and veteran groups said that loss in earnings  and quality of life should be explicitly integrated into the compensation  program to recognize the overall impact of disability on veterans. For  example, veterans who lose a hand may be able to work in today’s  economy, but the injury could prevent them from tossing a football with  their children or engaging in other life activities. Most of those we  interviewed agreed with commissions and experts who concluded that a  modern program should compensate veterans with disabilities for losses  beyond their earnings, even though the current program is designed to  compensate based on economic losses.
According to several experts, VA has an opportunity to develop a  systematic approach to more equitably award quality of life  compensation. According to these experts, VA currently provides implicit  quality of life benefits to some veterans with service-connected disabilities  but not others. For example, several experts argued that some veterans  may receive compensation for impairments in the rating schedule that  have little, if any, associated earnings loss. Several experts added that,  in considering a quality of life payment, VA needs to determine the  degree to which the rating schedule already includes consideration of the  effect of a disability on quality of life. Two experts we interviewed said that  benefits currently provided to veterans outside of the rating schedule,  such as enhanced monthly compensation payments, could be viewed as  compensation for loss in quality of life.
While this approach presents opportunities, it could prove challenging  because it would require a change in law and could create a more  complex system, according to several of those we interviewed. Congress,  they noted, would likely need to revise the statute to expand the purpose  of disability compensation to include quality of life. And if the program’s  purpose is expanded, VA would need to determine how to make fair,  timely, and accurate payments but not exacerbate the existing claims  backlog, according to several experts and veteran groups we interviewed.  Specifically, adding a quality of life assessment might require additional  time to assess claims and create another avenue for appeals. Further, VA  would need to address how to adjust compensation for any changes in a  veteran’s quality of life loss over time, according to VA.
Another implementation challenge is how to measure quality of life—a  subjective judgment—and assign a dollar value to different degrees of  these losses. Two veterans with the same service-connected illness or  injury may experience pain, social difficulties, and other intangible  impacts that, depending on their circumstances and characteristics, may  result in different degrees of losses in quality of life. According to several  experts and veteran groups, a number of tools exist to make the process  more objective. For example, CNA surveyed veterans with and without  service-connected disabilities to show differences in quality of life loss  between the two groups. While losses in quality of life can be measured,  a process to attach a dollar value will need to be developed and refined,  according to several experts and veteran groups, because none of the  existing tools are intended to determine levels of compensation. Also,  several experts suggested that VA could use benchmarks, such as the  compensation provided by other countries’ programs.
Finally, many experts added that quality of life payments would increase  program costs. In the short term, VA would likely need additional funds to  cover the costs of researching and developing assessment tools and for  training staff on new procedures. In the long term, according to experts  and veteran groups, veterans may receive increased levels of  compensation, which could also affect the program’s long-term cost. Any  increased costs would need to be considered in the context of our  nation’s current and future fiscal challenges. However, several experts  noted that quality of life payments could offset any reduced compensation  for service-connected conditions that have no associated earnings loss,  subsequently resulting in total compensation remaining level.
Several of the experts we interviewed stated that a key goal for VA should  be helping veterans with disabilities return to the workforce. Moreover,  they identified this approach as an opportunity to provide early assistance  to help veterans achieve their full work potential. However, experts and  veteran groups suggested that moving forward with this approach would  present challenges, such as gaining consensus for the approach and its  potential cost, as shown in figure 5.
According to several experts we interviewed, the goal of VA’s disability  program should be to build a veteran’s capacity to work rather than  mainly providing income support or cash benefits. These experts said  that participation in work leads to better integration into civilian life and  other intangible benefits like greater satisfaction and self-esteem. In  addition, several experts suggested that, if vocational assistance  increases a veteran’s earning capacity, VA should consider that when  determining losses in earnings. That is, veterans should be rated after  they reach maximum medical improvement. However, several cautioned  that VA should maintain protections for veterans with service-connected  disabilities who may not succeed at work even after extensive assistance.
According to many experts we interviewed, this policy approach could  enhance veterans’ capacity to work by providing earlier vocational  assistance after the onset of disability rather than after a veteran has  been rated for disability compensation. Experts we interviewed cited  several benefits of early vocational assistance. For example, they said  that it improves the likelihood that veterans with service-connected  disabilities will obtain and retain employment after injury.
At the same time, achieving consensus for this approach may be difficult.  Several of those we interviewed suggested that the approach does not  provide much additional incentive to participate in rehabilitation. For  example, veterans already have access to employment and training  services, and many veterans work with or without these services. While  veteran groups we spoke with said they support rehabilitation services,  they would not favor this policy shift if it means that a veteran’s disability  payment may be reduced because of increased vocational capacity. They  maintained, in fact, that a veteran whose work potential was increased or  who completed the program should receive the same level of  compensation he or she would have received had he or she not received  services. Officials from two veteran groups also said that these services  should not be mandatory. In addition, while this approach would target  veterans of working age, several of the experts’ and veteran groups’  views differed on whether the approach should target veterans at any  point after military discharge and/or veterans shortly after discharge,  particularly those with no or little civilian work history.
Several veteran groups and experts also expressed concerns about VA’s  capacity to administer this approach. For example, they said that VA does  not have sufficient numbers of staff capable of assessing a veteran’s  vocational capacity or providing work supports through its current  vocational program. Moreover, others noted that this reform could divert  resources from current VA management initiatives, such as efforts to  expedite the delivery of VA benefits to servicemembers and veterans.
This approach also would likely have cost implications. In the short term,  VA would need to estimate costs, pilot the approach while running VA’s  current programs, and then implement the program, according to several  of those we interviewed. Others said that there could also be long-term  cost implications if this approach required resources in addition to those  being expended under the current program. According to two of those we  interviewed, the ultimate costs would depend on who is eligible for the  services. For example, limiting eligibility to veterans shortly after  discharge would be less costly than making services available to veterans  at any point in time after discharge.
According to experts we interviewed, systematically incorporating the  effects of assistive technology and medical interventions into rating  decisions affords an opportunity to more accurately assess veterans’  impaired earning capacity, including the loss of functioning in the  workplace. Assistive technology and medical interventions include, for  example, a prosthetic device for walking, a device to assist with a vision  impairment, and medications for pain. However, they suggested that  implementing this approach would present challenges, such as its  acceptability among veterans and other stakeholders, as shown in figure  6.
According to several experts we interviewed, factoring in these advances  may result in more accurate assessments of veterans’ average earnings  losses. Advances in assistive technology and modern medicine can help  veterans with service-connected disabilities increase their earnings by  helping them more fully integrate into the workplace. While assistive  devices and medications can play a critical role in an individual’s ability to  function, VA does not always consider them in its assessment of  disability. According to several experts we talked with, accurately  measuring veterans’ ability to function with personal and environmental  supports may result in less compensation for certain veterans. However,  a couple of experts said that this may allow VA to target resources to  those with the greatest earnings losses.
While many of those we interviewed acknowledged the benefits of  assistive technology and medicine, many of those we interviewed and VA  officials expressed concerns with factoring assistive technology into  disability rating decisions, including the following:
The effectiveness of assistive technology and medication is difficult to  demonstrate, or research is incomplete.
The interventions affect individuals differently and may not work for  everyone. Also, the effectiveness of assistive technology varies over  the lifetime of an individual—for example, as a person ages and  experiences changes in musculature, their ability to compensate using  a prosthetic decreases. Others described assistive technology that did  not perform as expected.
The incorporation of assistive technology into rating decisions could  introduce a disincentive for veterans to use such tools and supports.
Many experts and veteran groups discussed challenges similar to those  raised with the other policy approaches, such as potentially needing to  administer new assessments and the associated upfront costs. In  particular, individually assessing veterans would add complexity to a  ratings process that already faces challenges with making timely and  accurate rating decisions. For example, VA may need to determine  whether veterans are making good faith efforts to use interventions when  making disability assessments, according to two of those we interviewed.  In addition, to assess a veteran’s ability to function while using these  interventions, VA would need to hire staff with necessary skills. To  address some of these challenges, several experts said that VA’s  planned studies to measure earnings loss would automatically factor in  the average economic benefits of assistive technology use without  needing a new assessment. However, one expert cautioned that this  approach might not be as precise as an individual assessment.
According to several of those we interviewed, policymakers could create  a comprehensive benefits package for individual veterans by integrating  compensation with vocational training and treatment. Several experts  outlined a sequence for implementing the approaches to improve the  timing of benefits and provide seamless support to veterans. Initially, VA  would provide financial support during a temporary medical and  vocational rehabilitation period to maximize a veteran’s recovery. This  temporary period would be followed by long-term compensation for any  reduced earnings loss. In conjunction with these payments, veterans  would receive an explicit quality of life payment.
Several of the experts we talked to described potential benefits of  combining approaches. Specifically, VA may be able to provide more equitable compensation and services to veterans by  examining the interactive effects of existing and new approaches,  clarify the distinction between compensation for earnings loss and the  other impacts of living with a disability, and/or mitigate potential adverse effects associated with any single  approach. For example, if payments for average earnings loss were  reduced because the impact of assistive devices was incorporated,  adding an offsetting quality of life payment could ensure that future  veterans get sufficient compensation.
Several experts and veteran groups, however, did not necessarily support  combining the three approaches. Finally, if a comprehensive program  was targeted to new enrollees, VA may need to administer dual  programs.
subsections: section_title: Key Strategies to Consider in Updating VA’s Disability Program for the 21st Century
paragraphs: Although we and others have identified a need to reexamine federal  disability programs to meet the challenges and expectations of the 21st  Century, VA officials said they are not currently considering the three  policy approaches discussed in this report. VA officials said they have,  however, kept abreast of all studies and recommendations arising from  the various commissions and reports. Further, they said they have taken  into consideration many of the recommendations made in these studies.  For example, VA is implementing recommendations to comprehensively  revise the rating schedule. Moreover, in 2008 VA contracted with a  private consultant to study disability compensation, loss in quality of life,  transition benefits for rehabilitation, assistive technology, and other areas  raised by the disability commissions and our work. While their report  proposed many specific policy options to address these issues, it stated  that the Congress and VA needed to decide on the key goals of the  approaches. Doing so would help further specify how to design and  implement a new approach. According to VA officials, they currently are  not acting on these approaches because they fall outside the VA’s  statutory requirement to compensate veterans for average earnings loss.  VA officials said they will further consider new policy approaches at the  request of the Congress.
As our high-risk series notes, however, continued attention by the Office  of Management and Budget (OMB) and concerted efforts by agencies, as  well as sustained congressional attention, are critical to fully resolve high- risk areas, which include federal disability programs. Should the  Congress choose to pursue fundamental changes to the disability  compensation program, with assistance from VA, we have identified key  reexamination strategies that should be considered, such as building support within the Congress, the Administration, the agency,  and the broader public to justify a reexamination of the program.  identifying the most important goals for the program and developing  specific policy proposals to meet those goals.  choosing reexamination methods to guide the process and help  evaluate potential changes.
section_title: Conclusions
paragraphs: The nation has a long-standing commitment to compensate veterans for  injuries or illnesses incurred during their military service. After decades of  recurring criticism that VA’s rating schedule is out of date, VA is now  demonstrating a commitment to comprehensive revision of its disability  criteria and consideration of a more modern approach to determining  disability. VA faces challenges, however, that may impede its ability to  complete and implement the revisions. Specifically, without sufficient  capacity to conduct research on earnings loss, VA may be unable to  make fact-based and timely revisions to its rating schedule. Moreover,  incomplete plans for conducting earnings loss and related studies could  jeopardize project outcomes and result in a rating schedule that remains,  in the end, outdated. In addition, without a written strategy for  implementing the revisions, VA might not be adequately positioned to  mitigate possible increases to the disability claims backlogs. This could  increase veterans’ wait times for disability benefits, which runs counter to  one of the desired outcomes of the revision goal of improving claims  efficiency. Finally, in the absence of sustained, ongoing revisions and  adjustments, VA’s rating schedule is increasingly at risk of not reflecting  advances in medicine and changes in the labor market. Without a formal  policy for conducting regular updates in the future, VA may experience  extended gaps in its efforts to revise the rating schedule. Consequently,  some future veterans may not receive the appropriate level of  compensation. We recognize that adjusting the rating schedule and  making changes to veterans’ disability benefits can be contentious.  Stakeholders have different views about how to define disability, measure  the loss of earning capacity, and even the purpose of veterans’ disability  compensation. Nevertheless, without a rating schedule that reflects  advances in medicine and changes in the labor market, VA may continue  to overcompensate some veterans while undercompensating others.
As underscored by the policy approaches recommended by previous  commissions and other experts, current thinking on disability has  outpaced consideration of updates to VA’s disability compensation  benefits structure. Changes in our understanding of disability and the  economy create a compelling case for the Congress, VA, and  stakeholders to reexamine the goals of VA’s disability compensation  programs and how to best serve veterans with service-connected  disabilities. This examination would raise important, but difficult,  questions: Should veterans with disabilities be compensated for more  than loss of earning capacity? Should the discussion of disability benefits  structure be intertwined with efforts to build a veteran’s capacity to work  and provide work supports? Should some compensation be considered  temporary? Should any proposed disability compensation changes apply  to existing and/or future veterans? VA officials are giving little attention to  these larger issues, and the trade-offs involved. However, a system that  maximizes equity, balances fiscal pressures, and ultimately serves  individual veterans effectively will benefit from deliberations informed by  more modern views about disability. VA has signaled that, absent further  direction from the Congress, it will focus its efforts within its current  framework. Without a broader perspective, VA may miss the opportunity  to be an agent in its own transformation to the benefit of those it serves.
section_title: Matter for Congressional Consideration
paragraphs: To the extent that Congress wishes to consider various options to  modernize VA’s disability benefits program, Congress could direct the VA  to conduct focused studies on these or other policy approaches and, if  necessary, propose relevant legislation for congressional consideration.  For example, providing explicit quality of life payments, or some other  combination of policy changes, to veterans with service-connected  disabilities may help to modernize VA’s program, but such changes need  further study to determine their feasibility and fiscal impact.
section_title: Recommendations for Executive Action
paragraphs: Based on our review, we are making three recommendations.  1.  To ensure that decisions about veteran disability compensation  benefits are informed by current earnings loss information, we  recommend that the Secretary of Veterans Affairs  take necessary steps to increase research capacity to determine the  impact of impairments on earnings in a timely manner and develop a more complete plan for conducting earnings loss and  validation studies for the entire rating schedule.  2.  To ensure that VA is positioned to seamlessly implement revisions to  the rating schedule, we recommend that the Secretary of Veterans  Affairs develop a written implementation strategy. This strategy could  include steps to mitigate the possible effects of rating schedule  revisions on agency operations, including an increase in the number  of claims received.  3.  To ensure the rating schedule revisions are sustained beyond the  current update project, we recommend that the Secretary of Veterans  Affairs establish a formal policy, procedure, or mechanism to revise  the rating schedule—with updated medical and earnings loss  information—at regular intervals.
section_title: Agency Comments and Our Evaluation
paragraphs: We provided a draft of this report to VA for review and comment. VA  concurred with our recommendations and indicated it will take steps to  address them by a target completion date of August 31, 2013. Its written  comments are reproduced in appendix IV. VA also provided technical  comments that we incorporated, as appropriate.
VA agreed with our recommendation to take necessary steps to increase  its research capacity to determine the impact of impairments on earnings  in a timely manner and develop a more complete plan for conducting  earnings loss and validation studies for the entire rating schedule. VA  stated that it is exploring the option of engaging in research partnerships  to conduct more than one earnings loss study at a time. After exploring  this and any other appropriate options, we encourage VA to take all  necessary actions to ensure it conducts earnings loss studies in a timely  manner, now and in the future. In addition, VA stated that it will expand its  current project management plan to include milestones, deliverables, and  the designation of a sub-program manager to manage the earnings loss  and validation studies.
VA also agreed with our recommendation to develop a written  implementation strategy that could include steps to mitigate the possible  effects of rating schedule revisions on agency operations, including an  increase in the number of claims received. VA stated that, going forward,  it will develop a formal plan that establishes cross-functional teams  representing all business processes and procedural functions involved in  the rating schedule changes. VA acknowledged that now is the time to  standardize a process for implementing the rating schedule revisions.
Finally, VA agreed with our recommendation to establish a formal policy,  procedure, or mechanism to revise the rating schedule with updated  medical and earnings loss information at regular intervals. According to  VA, it is currently formulating a plan that evaluates the rating schedule  revision process, which will allow VA’s Compensation Service to establish  a formal, continuous revision policy that is efficient, traceable, and  transparent to produce a rating schedule that reflects up-to-date medical  information.
We are sending copies of this report to the appropriate congressional  committees; the Secretary of Veterans Affairs; and other interested  parties. In addition, the report is available at no charge on the GAO  website at http://www.gao.gov.
If you or your staff have any questions about this report, please contact  me 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 report. GAO staff who made key contributions to this  report are listed in appendix V.
section_title: Appendix I: Scope and Methodology
paragraphs: In this report, we (1) identified the progress that the Department of  Veterans Affairs (VA) has made in revising the criteria used to determine  eligibility for veterans’ disability benefits with updated medical and  economic information, and (2) discussed the opportunities and challenges  associated with selected policy approaches that disability commissions  and others have raised for updating VA’s disability benefits structure.  Overall, we reviewed prior GAO, disability commission, and committee  reports; relevant federal laws and regulations; program documentation,  including policies, procedures, strategic goals, and supporting project  plans; and congressional testimonies from disability groups and  commissions. We also interviewed VA officials, key stakeholders,  disability experts, and representatives of veteran groups.
To address our first reporting objective, we reviewed VA’s strategic goals,  plans, policies, Federal Register notices, and other relevant program  documentation and interviewed VA officials. We also reviewed VA’s  Advisory Committee on Disability Compensation reports,  recommendations, and meeting minutes and presentations on the rating  schedule updates. In addition, we interviewed several Advisory  Committee on Disability Compensation members and reviewed reports  and interviewed experts from relevant organizations—such as the  Institute of Medicine—and veteran disability commissions—such as the  Veterans Disability Benefits Commission. We also evaluated VA’s project  planning documents using established elements for sound planning.
subsections: section_title: Elements of Sound Planning
paragraphs: To determine the extent to which VA’s project plans to revise its disability  criteria included elements of sound planning, we relied on project  management practices in A Guide to Project Management Body of  Knowledge, our guidance on internal controls, and the Government  Performance and Results Act of 1993 (GPRA). We also considered  recent GAO work that evaluated federal planning efforts. Through these  efforts, we identified six elements for sound planning. Although there is no  established set of requirements for all project plans, we determined that  these elements of sound planning help decision makers effectively shape  policies, programs, priorities, and resource allocations intended to help  achieve desired results and ensure accountability. While these elements  may be organized in a variety of ways and use different terms, for the  purposes of this report, we grouped them into six categories, from plan  conception through implementation, that represent sufficiently broad,  higher-level criteria that may apply to a wide variety of project plans and  priorities. (See table 3.)
To address our second reporting objective, we identified policy  approaches that could update VA’s disability benefits structure by  conducting a literature search for relevant reports by disability  commissions, task forces, committees, and GAO. We selected  approaches from the following reports:
Advisory Committee on Disability Compensation, Biennial Report  dated 27, July 2010; Interim Report dated 7 July, 2009;
CNA, Final Report for the Veterans’ Disability Benefits Commission:  Compensation, Survey Results, and Selected Topics (August 2007);
Economic Systems Inc., A Study of Compensation Payments for  Service-Connected Disabilities (September 2008);
GAO, SSA and VA Disability Programs: Re-Examination of Disability  Criteria Needed to Help Ensure Program Integrity, GAO-02-597  (August 2002);  Institute of Medicine, Committee on Medical Evaluation of Veterans  for Disability Compensation, A 21st Century System for Evaluating  Veterans for Disability Benefits and PTSD Compensation and Military  Service (2007);
President’s Commission on Care for America’s Returning Wounded  Warriors (Dole-Shalala Commission), Serve, Support, Simplify: Report  of the President’s Commission on Care for America’s Returning  Wounded Warriors (July 2007); and
Veterans’ Disability Benefits Commission, Honoring the Call to Duty:  Veterans’ Disability Benefits in the 21st Century (October 2007).
These sources offered numerous recommendations intended to improve  VA’s disability benefits structure. We assumed that these high-level  commissions and review groups had identified many of the major policy  approaches to update VA’s disability benefits structure. We limited  selection of policy approaches to those that address more broadly  focused updates to VA’s current disability benefits structure, such as  changes to the type, timing, or conditions of disability benefits (e.g., levels  of benefits and changes in legislative authorities) and those that align with  modern concepts of disability. For example, policy approaches of relevant  scope would be those that facilitate the participation of people with  disabilities in the workforce and society by evaluating and addressing  environmental factors that can hinder employment and other activities.  For this review, we excluded recommendations aimed at VA’s  organizational structure, administrative processes, and management  operations (e.g., developing and using performance metrics and  improving processes for communicating with veterans).
Applying these criteria, we identified three relevant policy approaches: (1)  providing quality of life payments, (2) providing integrated vocational  services with transitional cash assistance, and (3) systematically factoring  assistive technology and medical interventions into rating decisions. To  identify other policy approaches, we asked 16 experts and veteran groups  what other policy approaches, if any, might improve VA’s disability  benefits structure. Of those we interviewed, most said that the policy  approaches we selected were the relevant approaches for our research  purposes.
section_title: Selection of Experts
paragraphs: To obtain information from experts and veteran groups on the  opportunities and challenges associated with each approach, we  developed a list of semi-structured interview questions. We conducted  several pretests of the interview questions to validate its structure and  ensure the clarity and logical sequence of the questions asked. During  each semi-structured interview, we obtained information from experts and  veteran groups on several topics, including their general assessments of  the fiscal sustainability, political and administrative feasibility, and  effectiveness of each approach. In addition, we obtained experts’ and  veteran groups’ views on design features—such as eligibility criteria and  the type and duration of payments—that could be considered part of each  policy approach. We also obtained experts’ and veteran groups’  perspectives on the need, if any, to combine two or more policy  approaches. Finally, we analyzed the information obtained from experts  and veteran groups to identify underlying opportunities and challenges  associated with each policy approach.
We selected a nongeneralizable sample of experts who had participated  in disability commissions, research, or a congressional hearing on the  topic, or who serve in an organization that represents veterans with  disabilities. In addition, we selected a group of experts to help ensure a  range of viewpoints. Although many points of view were represented by  our experts, they may not represent the complete range of opinions on  the policy approaches. Table 4 identifies the experts and veteran groups  we interviewed, including their respective title and professional affiliation.
section_title: Appendix II: Comprehensive Revisions and Other Key Updates to the VA Schedule for Rating Disabilities (VASRD)
paragraphs: Appendix II: Comprehensive Revisions and  Other Key Updates to the VA Schedule for  Rating Disabilities (VASRD)
subsections: section_title: Most recent comprehensive body system update (Final rule source) 1945
paragraphs: Most recent  noncomprehensive revision to  diagnostic codes (since last  comprehensive update)   (Final rule source)   2005  (70 Fed. Reg. 75,399, Dec. 20,  2005)
Not applicable (n/a) (Major Revision - 62 Fed.  Reg. 30,235, June 3, 1997)
2001  (66 Fed. Reg. 29,486, May 31,  2001)
Revision of diagnostic codes for residuals  of injury and cirrhosis of the liver and  revision to weight loss regulation 2011  (76 Fed. Reg. 78,824, Dec. 20,  2011)
Revised rating criteria for amyotrophic  lateral sclerosis 1994  (59 Fed. Reg. 2530, Jan. 18,  1994)
1997  (62 Fed. Reg. 8201, Feb. 24,  1997)
Relocated portions pertaining to  noncompensable conditions to Part 3   1994  (59 Fed. Reg. 2523, Jan. 18,  1994)
1994  (59 Fed. Reg. 46,339, Sept. 8,  1994)
Note regarding entitlement to Special  Monthly Compensation (SMC) for  deformity of the penis with loss of erectile  power, testis atrophy and removal   1995  (60 Fed. Reg. 19,851, April  21, 1995)
2002  (67 Fed. Reg. 6874, Feb. 14,  2002; corrected by 67 Fed. Reg.  37,695, May 30, 2002)
Entitlement to SMC for loss of a breast   1995  (60 Fed. Reg. 49,227, Sept.  22, 1995)
2012  (77 Fed. Reg. 6467, Feb. 8,  2012)
Diagnostic code for AL amyloidosis  (primary amyloidosis) was added   1996  (71 Fed. Reg. 52,695, Oct. 8,  1996)
2009  (74 Fed. Reg. 18,467, Apr. 23,  2009)
Post-traumatic stress disorder  nomenclature change   1996  (61 Fed. Reg. 20,446, May  7, 1996)  1996  (61 Fed. Reg. 39,875, July  31, 1996)
section_title: Most recent comprehensive body system update (Final rule source) 1996 (61 Fed. Reg. 46,720, Sept. 5, 1996)
paragraphs: Most recent  noncomprehensive revision to  diagnostic codes (since last  comprehensive update)   (Final rule source)   2006  (71 Fed. Reg. 52,457, Sept. 6,  2006)  (71 Fed. Reg. 28,586, May 17,  2006)
Nature of noncomprehensive change   Substantive revisions to the evaluation  criteria for certain respiratory and  cardiovascular conditions, hypertension  with heart disease; amended provisions  pertaining to tuberculosis for those entitled  on August 19, 1968  1997  (62 Fed. Reg. 65,207, Dec.  11, 1997)
2006  (71 Fed. Reg. 52,460, Sept. 6,  2006)
Substantive revisions to the evaluation  criteria for respiratory and cardiovascular  conditions, hypertension with heart  disease  1999  (64 Fed. Reg. 25,210, May  11, 1999)
2003  (68 Fed. Reg. 25,822, May 14,  2003)
Amendment on the evaluation of tinnitus 2002  (67 Fed. Reg. 49,590, July  31, 2002; corrected by 67  Fed. Reg. 58,448, Sept. 16,  2002)
2008  (73 Fed. Reg. 54,708, Sept. 23,  2008; corrected by 77 Fed. Reg.  2910, Jan. 20, 2012)
2008  (73 Fed. Reg. 66,543, Nov.  10, 2008)
According to the Institute of Medicine report, the “Spine” section was comprehensively updated in  2003 (68 Fed. Reg. 51,454, Aug. 27, 2003).
section_title: Appendix III: Key Questions for Designing New Disability Compensation Programs
paragraphs: Transforming broad policy approaches into specific programs requires  that design features be defined. In reference to VA’s disability program for  veterans, the features relate to the form, amount, and eligibility for the  payments and services. The following summarizes key questions raised  during our discussions with experts and veteran groups about the  possible design of programs for providing quality of life payments,  providing integrated vocational services with transitional cash assistance,  and factoring the effects of assistive technology and medical interventions  systematically into rating decisions.
Should existing veterans be eligible for quality of life payments or just  new enrollees?
Should veterans have the opportunity to opt in or out of a new  program that provides quality of life payments?
Should quality of life payments supplement earnings loss payments  for veterans with low, high, or all disability ratings levels?
Should disability compensation be based primarily on quality of life,  with earnings loss payments being made only when actual earnings  loss occurs?
How frequently should quality of life payments be provided to veterans  (e.g., one-time lump sum, monthly annuity)?
What system should be used to determine payment levels (e.g.,  individual assessments or an average loss in quality of life across a  group of veterans)?
Should quality of life be inferred from impairment or measured  directly?
For veterans receiving quality of life payments and earnings loss  payments, should the earnings loss payments end at retirement age?
Integrating vocational rehabilitation services with disability compensation
Should all veterans be eligible for the program or just veterans shortly  after discharge?
Should the program be available for veterans at all disability rating  levels or for veterans with lower or higher degrees of disability?
Should the program focus on veterans with certain kinds of  impairments?
Should the payments be provided while the veteran participates in  vocational rehabilitation, education, or training programs (i.e., for a  longer rehabilitative period)? Or, should the payments also be  provided on a short-term basis to support a veteran’s return to the  community?
Should the loss of earnings be periodically reassessed following a  temporary rehabilitation period?
Assistive technology and medical interventions
Should VA assess the effects of assistive technology and medical  interventions during the disability examination process?
Should an assessment of the effects of assistive technology and  medical interventions only be considered for future  enrollees/veterans?
Should VA incorporate the anticipated effects of assistive technology  and medical interventions only when a veteran actually uses them?
Should VA incorporate the estimated effects of assistive technology  and medical interventions?
Should VA limit the incorporation of the effects of assistive technology  and medical interventions to those with empirically-based  demonstrations of their effectiveness?
section_title: Appendix IV: Comments from the Department of Veterans Affairs
section_title: Appendix V: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
paragraphs: Daniel Bertoni, (202) 512-7215 or bertonid@gao.gov.
section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, individuals making key  contributions to this report were Brett Fallavollita, Assistant Director;  Alison Grantham; Mark Ward; and James Whitcomb. In addition, key  support was provided by James Bennett, Tim Carr, David Chrisinger, Alex  Galuten, Kristen Jones, Jean McSween, Patricia Owens, and Almeta  Spencer.