Recovering Servicemembers: DOD and VA Have Jointly Developed the Majority of Required Policies but Challenges Remain
Released: 2009-07-08T00:00:00

Letter

Background

Over the past 8 years, DOD has designated over 34,000 servicemembers involved in OEF and OIF as wounded in action. The severity of injuries can result in a lengthy process for a patient to either return to duty or to transition to veteran status. The most seriously injured servicemembers from these conflicts usually receive care at 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 be treated as outpatients by the closest military or VA facility.

Recovering servicemembers potentially navigate two different disability evaluation systems that serve different purposes. DOD’s system serves a personnel management purpose by identifying servicemembers who are no longer medically fit for duty. If a servicemember is found unfit because of medical conditions incurred in the line of duty, the servicemember is assigned a disability rating and can be discharged from duty. This disability rating, along with years of service and other factors, determines subsequent disability and health care benefits from DOD. Under VA’s system, disability ratings help determine the level of disability compensation a veteran receives and priority status for enrollment for health care benefits. To determine eligibility for disability compensation, VA evaluates all claimed medical conditions, whether they were evaluated previously by the military service’s evaluation process or not. If VA finds that a veteran has one or more service-connected disabilities that together result in a final rating of at least 10 percent, VA will pay monthly compensation and the veteran will be eligible to receive a higher priority status for health care benefits enrollment.

Efforts to Address the Care and Benefits for Recovering Servicemembers

Efforts have been taken to address the deficiencies reported at Walter Reed related to the care provided and the transition of recovering servicemembers. After the press reports about Walter Reed, several high- level review groups were established to study the care and benefits provided to recovering servicemembers by DOD and VA. In addition, two previously-established review groups were already examining related issues. The studies produced from all of these groups, released from April 2007 through June 2008, contained over 400 recommendations covering a broad range of topics, including case management, disability evaluation systems, data sharing between the departments, and the need to better understand and diagnose TBI and PTSD.

In May 2007, DOD and VA established the SOC as a temporary, 1-year committee with the responsibility for addressing recommendations from these reports. To conduct its work, the SOC established eight work groups called lines of action (LOA). Each LOA is co-chaired by representatives from DOD and VA and has representation from each military service. LOAs are responsible for specific issues, such as disability evaluation systems and case management. (See table 1 for an overview of the LOAs.) The committee was originally intended to expire May 2008 but it was extended to January 2009. Then, the NDAA 2009 extended the SOC through December 2009.

In addition to addressing the published recommendations, the SOC assumed responsibility for addressing the policy development and reporting requirements contained in the NDAA 2008. Section 1611(a) of the NDAA 2008 directs DOD and VA, to the extent feasible, to develop and implement a comprehensive policy covering four areas—(1) care and management, (2) medical evaluation and disability evaluation, (3) the return of servicemembers to active duty, and (4) the transition of recovering servicemembers from DOD to VA. The specific requirements for each of these four areas are further enumerated in sections 1611 through 1614 of the law and include the development of multiple policies. Table 2 summarizes the requirements for the jointly developed policies.

Selected Initiatives of the SOC

Since its inception, the SOC has completed many initiatives, such as establishing the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury and creating a National Resource Directory, which is an online public resource for recovering servicemembers, veterans, and their families. In addition, the SOC supported the development of several programs to improve the care, management, and transition of recovering servicemembers, including the disability evaluation system pilot and the Federal Recovery Coordination Program. These programs are currently in pilot or beginning phases.

Disability evaluation system pilot: DOD and VA are piloting a joint disability evaluation system to improve the timeliness and resource use of their separate disability evaluation systems. Key features of the pilot include a single physical examination conducted to VA standards to be used by a medical evaluation board to document medical conditions that may limit a servicemember’s ability to serve in the military, a single source disability rating prepared by VA for use by both DOD and VA in determining disability benefits, and additional outreach and nonclinical case management provided by VA staff at the DOD pilot locations to explain VA results and processes to servicemembers. DOD and VA anticipate a final report on the pilot in August 2009.

Federal Recovery Coordination Program: In 2007, DOD and VA established the Federal Recovery Coordination Program in response to the report by the President’s Commission on Care for America’s Returning Wounded Warriors, commonly referred to as the Dole-Shalala Commission. The commission’s report highlighted the need for better coordination of care and additional support for families. The Federal Recovery Coordination Program serves the most severely injured or ill servicemembers. These servicemembers are highly unlikely to be able to return to duty and may have to adjust to permanent disabling conditions. The program was created to provide uniform and seamless care, management, and transition of recovering servicemembers and their families by assigning recovering servicemembers to coordinators who manage the development and implementation of a recovery plan. Each servicemember enrolled in the Federal Recovery Coordination Program has a Federal Individual Recovery Plan, which tracks care, management, and transition through recovery, rehabilitation, and reintegration. Although the Federal Recovery Coordination Program is operated as a joint DOD and VA program, VA is responsible for the administrative duties and program personnel are employees of the agency.

Beyond these specific initiatives, the SOC took responsibility for issues related to electronic health records through the work of LOA 4, the SOC’s work group focused on DOD and VA data sharing. This LOA also addressed issues more generally focused on joint DOD and VA data needs, including overseeing the development of components for the disability evaluation system pilot and the individual recovery plans for the Federal Recovery Coordination Program. LOA 4’s progress on these issues was monitored and overseen by the SOC. The NDAA 2008 established an interagency program office (IPO) to serve as a single point of accountability for both departments in the development and implementation of interoperable electronic health records. Subsequently, management oversight of many of LOA 4’s responsibilities were transferred to the IPO. Also, the IPO’s scope of responsibility was broadened to include personnel and benefits data sharing between DOD and VA.

DOD and VA Have Completed the Majority of the Requirements to Jointly Develop Policies on Care and Management, Medical and Disability Evaluation, Return to Active Duty, and the Transition from DOD to VA

As of April 2009, DOD and VA have completed 60 of the 76 requirements we identified for jointly developing policies for recovering servicemembers on (1) care and management, (2) medical and disability evaluation, (3) return to active duty, and (4) servicemember transition from DOD to VA. The two departments have completed all requirements for developing policy for two of the policy areas—medical and disability evaluation and return to active duty. Of the 16 requirements that are in progress, 10 are related to care and management and 6 are related to servicemembers transitioning from DOD to VA. (See table 3.)

DOD and VA Have Completed More Than Two-Thirds of the Requirements for the Care and Management of Recovering Servicemembers

We found that more than two-thirds of the requirements for DOD’s and VA’s joint policy development to improve the care and management of recovering servicemembers have been completed, while the remaining requirements are in progress. (See table 4.) We identified 38 requirements for this policy area and grouped them into five categories. Although 28 of the 38 requirements had been completed, one category—improving access to medical and other health care services—had most of its requirements in progress.

Most of the completed requirements were addressed in DOD’s January 2009 Directive-Type Memorandum (DTM), which was developed in consultation with VA. This DTM, entitled Recovery Coordination Program: Improvements to the Care, Management, and Transition of Recovering Service Members, establishes interim policy for the improvements to the care, management, and transition of recovering servicemembers in response to sections 1611 and 1614 of the NDAA 2008. In consultation with VA, DOD created the Recovery Coordination Program in response to the NDAA 2008 requirements. This program, which was launched in November 2008, extended the same comprehensive coordination and transition support provided under the Federal Recovery Coordination Program to servicemembers who were less severely injured or ill, yet who are unlikely to return to active duty in less than 180 days. This program follows the same structured process as the Federal Recovery Coordination Program. However, DOD oversees this program and the coordinators are DOD employees.

DOD’s January 2009 DTM includes information on the scope and program elements of the Recovery Coordination Program as well as on the roles and responsibilities of the recovery care coordinators, federal recovery coordinators, and medical care case managers and non-medical care managers. According to DOD officials, DOD took the lead in developing policy to address the requirements for care and management because it interpreted most of the requirements to refer to active duty servicemembers.

According to DOD and VA officials, the January 2009 DTM serves as the interim policy for care, management, and transition until the completion of DOD’s comprehensive policy instruction, which is estimated to be completed by August 2009. This policy instruction will contain more detailed information on the policies outlined in the DTM. A VA official told us that VA also plans to issue related policy guidance as part of a VA handbook during the fourth quarter of 2009. The VA official noted that the final form of the policy document would correspond with DOD’s instruction.

DOD and VA Have Completed All of the Requirements for Developing Policy on the Medical Evaluation and Disability Evaluation of Recovering Servicemembers

DOD and VA have completed all of the requirements for developing policy to improve the medical and physical disability evaluation of recovering servicemembers. (See table 5.) We identified 18 requirements for this policy area and grouped them into three categories: (1) policy for improved medical evaluations, (2) policy for improved physical disability evaluations, and (3) reporting on the feasibility and advisability of consolidating DOD and VA disability evaluation systems.

DOD issued a series of memoranda that addressed the first two categories starting in May 2007. These memoranda, some of which were developed in collaboration with VA, contained policies and implementing guidance to improve DOD’s existing disability evaluation system. To address the third category in this policy area, DOD and VA have issued a report to Congress that describes the organizing framework for consolidating the two departments’ disability evaluation systems and states that the departments are hopeful that consolidation would be feasible and advisable even though the evaluation of this approach through the disability evaluation system pilot is still ongoing. According to a DOD official, further assessment of the feasibility and advisability of consolidation will be conducted. DOD and VA anticipate issuing a final report on the pilot in August 2009. However, as we reported in September 2008, it was unclear what specific criteria DOD and VA will use to evaluate the success of the pilot, and when sufficient data will be available to complete such an evaluation.

DOD Has Completed Establishing Standards for Determining the Return of Recovering Servicemembers to Active Duty

DOD has completed the requirement for establishing standards for determining the return of recovering servicemembers to active duty. (See table 6.)

On March 13, 2008, DOD issued a DTM amending its existing policy on retirement or separation due to a physical disability. The revised policy states that the disability evaluation system will be the mechanism for determining both retirement or separation and return to active duty because of a physical disability. An additional revision to the existing DOD policy allows DOD to consider requests for permanent limited active duty or reserve status for servicemembers who have been determined to be unfit because of a physical disability. Previously, DOD could consider such cases only as exceptions to the general policy.

According to a DOD official, it is too early to tell whether the revisions will have an effect on retirement rates or return-to-duty rates. DOD annually assesses the disability evaluation system and tracks retirement and return to duty rates. However, because of the length of time a servicemember takes to move through the disability evaluation system—sometimes over a year—it will take a while before changes resulting from the policy revisions register in the annual assessment of the disability evaluation system.

Over Two-Thirds of the Requirements for Improving the Transition of Recovering Servicemembers from DOD to VA Have Been Completed

DOD and VA have completed more than two-thirds of the requirements for developing procedures, processes, or standards for improving the transition of recovering servicemembers. (See table 7.) We identified 19 requirements for this policy area, and we grouped them into five categories. We found that 13 of the 19 policy requirements have been completed, including all of the requirements for two of the categories—the development of a process for a joint separation and evaluation physical examination and development of procedures for surveys and other mechanisms to measure patient and family satisfaction with services for recovering servicemembers. The remaining three categories contain requirements that are still in progress.

Most of the requirements for improving the transition from DOD to VA were addressed in DOD’s January 2009 DTM—Recovery Coordination Program: Improvements to the Care, Management, and Transition of Recovering Service Members—which establishes interim policy for the care, management, and transition of recovering servicemembers through the Recovery Coordination Program. However, we found that DOD’s DTM includes limited detail related to the procedures, processes, and standards for transition of recovering servicemembers. As a result, we could not always directly link the interim policy in the DTM to the specific requirements contained in section 1614 of the NDAA 2008. DOD and VA officials noted that they will be further developing the procedures, processes, and standards for the transition of recovering servicemembers in a subsequent comprehensive policy instruction, which is estimated to be completed by June 2009. A VA official reported that VA plans to separately issue policy guidance addressing the requirements for transitioning servicemembers from DOD to VA in the fourth quarter of 2009.

DOD and VA Officials Experienced Challenges during Joint Development of Required Policies

DOD and VA officials told us that they experienced numerous challenges as they worked to jointly develop policies to improve the care, management, and transition of recovering servicemembers. According to officials, these challenges contributed to the length of time required to issue policy guidance, and in some cases the challenges have not yet been completely resolved. In addition, recent changes to the SOC staff, including DOD’s organizational changes for staff supporting the SOC, could pose challenges to the development of policy affecting recovering servicemembers.

Various Challenges Arose during Policy Development

DOD and VA officials encountered numerous challenges during the course of jointly developing policies to improve the care, management, and transition of recovering servicemembers, as required by sections 1611 through 1614 of the NDAA 2008, in addition to responding to other requirements of the law. Many of these challenges have been addressed, but some have yet to be completely resolved. DOD and VA officials cited the following examples of issues for which policy development was particularly challenging.

Increased support for family caregivers. The NDAA 2008 includes a number of provisions to strengthen support for families of recovering servicemembers, including those who become caregivers. However, DOD and VA officials on a SOC work group stated that before they could develop policy to increase support for such families, they had to obtain concrete evidence of their needs. Officials explained that while they did have anecdotal information about the impact on families who provide care to recovering servicemembers, they lacked the systematic data needed for sound policy decisions—such as frequency of job loss and the economic value of family-provided medical services. A work group official told us that their proposals for increasing support to family caregivers were rejected twice by the SOC, due in part to the lack of systematic data on what would be needed. The work group then contracted with researchers to obtain substantiating evidence, a study that required 18 months to complete. In January 2009, the SOC approved the work group’s third proposal. A provision for caregiver benefits based on the SOC’s proposal was included in the NDAA 2010 bill that was introduced in May 2009.

Establishing standard definitions for operational terms. One of the important tasks facing the SOC was the need to standardize key terminology relevant to policy issues affecting recovering servicemembers. DOD took the lead in working with its military services and VA officials to identify and define key terms. DOD and VA officials told us that many of the key terms found in existing DOD and VA policy, the reports from the review groups, and the NDAA 2008, as well as those used by the different military services were not uniformly defined. Consequently, standardized definitions were important to promote agreement on issues such as identifying the recovering servicemembers who are subject to NDAA 2008 requirements, identifying categories of servicemembers who would receive services from the different classes of case managers or be eligible for certain benefits, managing aspects of the disability evaluation process, and establishing criteria to guide research.

In some cases, standardized definitions were critical to policy development. The importance of agreement on key terms is illustrated by an issue encountered by the SOC’s work group responsible for family support policy. In this case, before policy could be developed for furnishing additional support to family members that provide medical care to recovering servicemembers, the definition of “family” had to be agreed upon. DOD and VA officials said that they considered two options: to define the term narrowly to include a servicemember’s spouse, parents, and children, or to use broader definitions that included distant relatives and unrelated individuals with a connection to the servicemember. These two definitions would result in significantly different numbers of family members eligible to receive additional support services. DOD and VA officials decided to use a broader definition to determine who would be eligible for support.

Of the 41 key definitions identified for reconciliation, DOD and VA had concurred on 33 as of April 2009 and these 33 standardized definitions are now being used. Disagreement remains over the remaining definitions, including the definition of “mental health.” A DOD official stated that given the uncertainty associated with the organizational and procedural changes recently introduced to the SOC (which are discussed below), obtaining concurrence on the remaining definitions has been given lower priority.

Improving TBI and PTSD screening and treatment. Requirements related to screening and treatment for TBI and PTSD were embedded in several sections of the NDAA 2008, including section 1611, and were also discussed extensively in a task force report on mental health. DOD and VA officials told us that policy development for these issues was difficult. For example, during development of improved TBI and PTSD treatment policy, policymakers often lacked sufficient scientific information needed to help achieve consensus on policy decisions. Also, members of the SOC work group told us that they disagreed on appropriate models for screening and treatment and struggled to reorient the military services to patient-focused treatment. A senior DOD official stated that the adoption of patient-focused models is particularly difficult for the military services because, historically, the needs of the military have been given precedence over the needs of individual servicemembers. To address these challenges, the SOC oversaw the creation of the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury—a partnership between DOD and VA. While policies continue to be developed on these issues, TBI and PTSD policy remains a challenge for DOD and VA. However, DOD officials told us that the centers of excellence have made progress with reducing knowledge gaps in psychological health and TBI treatment, identifying best practices, and establishing clinical standards of care.

Release of psychological health treatment records to DOD by VA health care providers who treat members of the National Guard and Reserves. Section 1614 of the NDAA 2008 requires the departments to improve medical and support services provided to members of the National Guard and Reserves. In pursuing these objectives, VA faced challenges related to the release of medical information to DOD on reservists and National Guard servicemembers who have received treatment for PTSD or other mental health conditions from VA. DOD requests medical information from VA to help make command decisions about the reactivation of servicemembers, but VA practitioners face an ethical dilemma if the disclosure of medical treatment could compromise servicemembers’ medical conditions, particularly for those at risk of suicide. The challenge of sharing and protecting sensitive medical information on servicemembers who obtain treatment at VA was reviewed by the Blue Ribbon Work Group on Suicide Prevention convened in 2008 at the behest of the Secretary of Veterans Affairs. DOD and VA are continuing their efforts to address the privacy rights of patients who receive medical services from VA while serving in the military, and to protect the confidential records of VA patients who may also be treated by the military’s health care system. The need to resolve this challenge assumes even greater importance in light of DOD’s and VA’s increasing capability to exchange medical records electronically, which will expand DOD’s ability to access records of servicemembers who have received medical treatment from VA.

Changes to the SOC’s Staff and Scope of Responsibilities Could Pose Future Challenges to Joint Policy Development

The SOC has experienced turnover in leadership, reconfiguration in its organizational structure at DOD, and changes affecting policy development responsibilities. These changes could pose future challenges to DOD’s and VA’s efforts to develop joint policy.

The SOC has experienced leadership changes caused by the turnover in presidential administrations as well as turnover in some of its key staff. For example, the outgoing deputy secretaries of DOD and VA, who previously chaired the SOC, left their positions in January 2009 with the change in administration, and new deputy secretaries were not confirmed until February and April 2009. In their absence, the Secretaries of VA and DOD co-chaired a SOC meeting as a short-term measure. DOD also introduced other staffing changes to replace personnel who had been temporarily detailed to the SOC and needed to return to their primary duties. DOD had relied on temporarily-assigned staff to meet SOC staffing needs because the SOC was originally envisioned as a short-term effort. In a December 2008 memorandum, DOD outlined the realignment of its SOC staff. This included the transition of responsibilities from detailed, temporary SOC staff and executives to permanent staff in existing DOD offices that managed similar issues. For example, the functions of LOA 7 (Legislation and Public Affairs) will now be overseen by the Assistant Secretary of Defense for Legislative Affairs, the Assistant Secretary of Defense for Public Affairs, and the DOD General Counsel. DOD also established two new organizational structures—the Office of Transition Policy and Care Coordination and an Executive Secretariat office. The Office of Transition Policy and Care Coordination oversees transition support for all servicemembers and serves as the permanent entity for issues being addressed by LOA 1 (Disability Evaluation System), LOA 3 (Case Management), and LOA 8 (Personnel, Pay, and Financial Support). The Executive Secretariat office is responsible for performance planning, performance management, and SOC support functions. According to DOD officials, the new offices were created to establish permanent organizations that address a specific set of issues and to enhance accountability for policy development and implementation as these offices report directly to the Office of the Under Secretary of Defense for Personnel and Readiness. Currently, many of the positions in these new offices, including the director positions, are staffed by officials in an acting capacity or are unfilled.

DOD’s changes to the SOC are important because of the potential effects these changes could have on the development of policy for recovering servicemembers. However, officials in both DOD and VA have mixed reactions about the consequences of these changes. Some DOD officials consider the organizational changes to the SOC to be positive developments that will enhance the SOC’s effectiveness. They point out that the SOC’s temporary staffing situation needed to be addressed, and also that the two new offices were created to support the SOC and provide focus on the implementation of key policy initiatives developed by the SOC—primarily the disability evaluation system pilot and the new case management programs. In contrast, others are concerned by DOD’s changes, stating that the new organizations disrupt the unity of command that once characterized the SOC’s management because personnel within the SOC organization now report to three different officials within DOD and VA. However, it is too soon to determine how well DOD’s new structure will work in conjunction with the SOC. DOD and VA officials we spoke with told us that the SOC’s work groups continue to carry out their roles and responsibilities.

Finally, according to DOD and VA officials, the scope of responsibilities of both the SOC and the DOD and VA Joint Executive Council appear to be in flux and may evolve further still. According to DOD and VA officials, changes to the oversight responsibilities of the SOC and the Joint Executive Council are causing confusion. While the SOC will remain responsible for policy matters directly related to recovering servicemembers, a number of policy issues may now be directed to the Joint Executive Council, including issues that the SOC had previously addressed. For example, management oversight of many of LOA 4’s responsibilities (DOD and VA Data Sharing) has transitioned from the SOC to the IPO, which reports primarily to the Joint Executive Council. It is not clear how the IPO will ensure effective coordination with the SOC’s LOAs for overseeing the development of information technology applications for the disability evaluation system pilot and the individual recovery plans for the Federal Recovery Coordination Program. Given that information technology support for two key SOC initiatives is identified in the joint DOD/VA Information Interoperability Plan, if the IPO and the SOC do not effectively coordinate with one another, the result may negatively affect the development of improved policies for recovering servicemembers.

Agency Comments and Our Evaluation

We provided a draft of this report to DOD and VA for comment. VA provided technical comments, which we incorporated as appropriate. DOD and VA did not provide other comments.

We are sending copies of this report to the Secretaries of the Departments of Defense and Veterans Affairs, congressional committees, and other interested parties. The report is also available at no charge on GAO’s Web site at http://www.gao.gov.

If you or your staff have questions about this report, please contact me at (202) 512-7114 or at williamsonr@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 major contributions to this report are listed in appendix II.

Appendix I: Summary of Selected Requirements from the National Defense Authorization Act for Fiscal Year 2008

To summarize the status of the Departments’ of Defense (DOD) and Veterans Affairs (VA) efforts to jointly develop policies for each of the four policy areas outlined in sections 1611 through 1614 of the National Defense Authorization Act for Fiscal Year 2008 (NDAA 2008), we identified 76 requirements in these sections and grouped related requirements into 14 logical categories. Tables 8 through 11 enumerate the requirements in each of GAO’s categories and provide the status of DOD’s and VA’s efforts to develop policy related to each requirement, as of April 2009.

Appendix II: GAO Contact and Staff Acknowledgments

Acknowledgments

In addition to the contact named above, Bonnie Anderson, Assistant Director; Susannah Bloch; Catina Bradley; April Brantley; Frederick Caison; Lisa Motley; and Elise Pressma made major contributions to this report.