VA pays monthly disability compensation to veterans with disabling conditions caused or aggravated by their military service. The benefit is based on an average reduction in earning capacity across a group of individuals with similar physical or mental impairments. Disability compensation is generally paid according to the severity of the service- connected condition and is awarded in 10 percent increments, based on criteria in the VA Schedule for Rating Disabilities (VASRD or rating schedule). Veterans may claim more than one medical condition, and VBA assigns a rating percentage for each condition determined to be connected to the veteran’s service. For veterans with multiple service-connected conditions, VA calculates a rating (combined disability rating) using a table that applies a formula for combining multiple ratings into a single rating. The rating affects the amount of monthly compensation received by a veteran. Unlike some private-sector disability programs, the employment status, earnings, and ability to work generally are not factored into the disability rating and subsequent base payment. Moreover, unlike typical workers’ compensation programs for permanent impairments, no limits are generally placed on the length of time veterans can receive payments. Obligations for disability compensation have increased by 45 percent in the last 5 years, from about $54 billion in fiscal year 2013 to about $78 billion in fiscal year 2018. According to VA, this increase is due to several factors, including more beneficiaries (for example, as veterans of more recent conflicts leave military service and seek compensation), as well as rising average disability ratings that lead to higher average payments. VA reported that growth in the number of veterans with a service-connected condition is concentrated among those rated 50 percent or higher. VBA’s Compensation Service sets policy and oversees the process for determining eligibility for disability compensation. VBA staff in the regional offices process disability compensation claims. These claims processors include Rating Veterans Service Representatives (RVSR or rater), who decide on benefit entitlement and the rating percentage, and Veterans Service Representatives (VSR), who gather evidence needed for the raters to make their decisions and later authorize payment, if any. Claims processors use the Veterans Benefits Management System (VBMS)—an electronic, paperless system—to maintain, review, and make rating decisions for veterans’ claims. VBA’s reevaluation process determines whether veterans’ service- connected conditions may have changed, due to treatment or other factors, in the years following an initial evaluation for disability compensation. This process helps ensure that veterans’ service- connected conditions are being rated and compensated correctly. A first step in the process is deciding whether a condition may need to be reevaluated at a future date. As part of an evaluation for disability compensation, claims processors review medical evidence and consider whether to schedule a future review date (see fig.1). When the scheduled review date arrives, VBA revisits the case to determine whether a reevaluation of the disabling condition is still appropriate. This pre-exam review involves reviewing the veteran’s records to determine if the veteran is still experiencing similar symptoms. After this review, VBA may conduct, postpone, or cancel a reevaluation. If the reevaluation is conducted, a medical exam may be ordered, after which the rater will rate the condition based on exam results and other medical evidence. VBA regulations specify certain conditions that require reevaluation. In other instances, VA has discretion in whether to conduct reevaluations, determined upon review of a veteran’s medical record. For example, the medical record may suggest that a veteran with limited range of motion will be continuing physical rehabilitation and is expected to improve. Whether the reevaluation is required or discretionary, VBA’s regulations outline several exclusions that place limits on when VBA conducts reevaluations, such as if the veteran’s combined disability rating would not change as a result of a reduced evaluation for one or more conditions. Veterans may generally obtain health care through (1) VA medical facilities, (2) non-VA health care providers in the community for which VA pays (called community care), or (3) providers paid through veterans’ own health insurance. For VA medical facilities, VHA determines eligibility and priority for VA health care, enrolls veterans, and oversees 172 VA medical centers and over 1,000 outpatient facilities. In response to the Veterans’ Health Care Eligibility Reform Act of 1996, VHA developed a priority system to balance demand for health care with available resources. The system has eight priority groups, and first priority is generally given to veterans with service-connected conditions rated 50 percent or more and to veterans deemed unemployable because of service-connected conditions. Priority groups 2 and 3 include veterans with service-connected conditions rated 30 or 40 percent, or 10 or 20 percent, respectively, according to VHA. Veterans may be eligible for community care if, for example, VA does not offer the care or service the veteran requires, or when a VA medical facility is unable to provide the care or services consistent with the agency’s access standards. Before receiving health care through VA community care programs, veterans must generally obtain authorization from VA. The total number of veterans enrolled in VA’s health care system rose from 7.9 million to over 9 million from fiscal years 2006 through 2017. During that period, VHA’s budget more than doubled, from $37.8 billion to $92.3 billion, as health care costs were rising and its community care programs were expanding. In fiscal year 2017, VA obligated $13.6 billion of its budget for community care, and in fiscal year 2018, this increased to $14.9 billion. For health care services delivered outside of VHA medical facilities that are not funded by VA, veterans may use private health insurance. A 2018 VA survey of veterans enrolled in VA’s health care system found that about 28 percent reported being covered by private insurance. VBA tracks its performance in providing timely and accurate disability compensation decisions to veterans. VBA considers a decision to be timely if a veteran’s claim is processed within 125 days. As part of its quality assurance efforts, VBA conducts national and individual reviews of the accuracy of claims decisions, and periodic consistency studies to assess claims processors’ knowledge of regulations and guidance on specific claims processing issues, such as when to conduct reevaluations. At the VBA central office level, procedures call for VA to assess the accuracy of a random sample of completed claims from each regional office using its Systematic Technical Accuracy Review (STAR) method. STAR reviewers use a standardized checklist to review all actions taken in processing a claim and record any errors they find. VA reports national and regional office performance data for claim- based accuracy (based on the entirety of the claim) and issue-based accuracy (based on each of the individual medical conditions rated). In fiscal year 2018, VBA reported claim-based rating accuracy of about 90 percent and issue-based accuracy of about 95 percent. At the VBA regional office level, quality review teams conduct Individual Quality Reviews of individual claims processors’ work. For example, VA’s procedures call for reviews to be performed on five claims for every rater per month. The reviews are used to help assess individual claims processors’ performance. In addition to accuracy reviews, VBA’s national quality assurance efforts include periodic consistency studies on specific claims processing issues. These studies are intended to assess how consistently claims processors are making decisions across all regional offices by testing select claims processors on their knowledge of VBA’s regulations and procedures. Improvements in a veteran’s service-connected conditions and improvements in a veteran’s health outcomes have important differences. Federal law requires disability compensation to be based upon an average reduction in earning capacity across a group of individuals with a similar physical or mental impairment. In addition, for certain service- connected conditions such as amputations, VA evaluates the condition based on loss or loss of function of a body part or system, without considering assistive devices or prosthetics. As such, some service- connected conditions, such as hearing loss, are generally not expected to improve for purposes of disability compensation. In contrast, according to VHA research, a veteran’s use of a hearing aid is an example of a successful health outcome because this assistive technology can treat the symptoms of hearing loss and increase the functioning of a person. For health care delivered at VA medical facilities, our analysis of fiscal year 2018 VA data shows that more than half of veterans receiving disability compensation used VA health care for a service-connected condition. Specifically, we determined that about 54 percent of veterans, or about 2.6 million, who received disability compensation had at least one VA outpatient visit related to a service-connected condition. Veterans with higher combined disability ratings had more outpatient visits related to their service-connected conditions, on average. (See fig. 2.) Veterans using VA health care for service-connected conditions had an average of four such conditions, and the median age was 63. For veterans with the most prevalent service-connected conditions, in fiscal year 2018 the average number of visits ranged from about 6 to 11 (see table 1). The highest average number of visits was for veterans with service-connected post traumatic stress disorder (PTSD) and diabetes. For the same year, veterans receiving disability compensation had an average of nearly eight outpatient health care visits for service-connected conditions. In fiscal year 2018, about 13 percent of VA inpatient hospital stays for veterans receiving disability compensation were to treat a service- connected condition; about 87 percent of the stays for this population were to treat non-service-connected conditions. Nearly 2.1 million, or about 44 percent of veterans receiving disability compensation, had no VA outpatient visits or inpatient stays for their service-connected conditions. These veterans may have received treatment paid for through private insurance, from community care, or received no treatment for their service-connected conditions in fiscal year 2018. Veterans who did not use VA health care had an average of about four service-connected conditions, and the median age was 57. For community care (VA-funded health care delivered by non-VA providers), we could not determine the extent to which veterans receiving VA disability compensation used these health providers for their service- connected conditions because this area is not a focus of analysis for the program, according to VHA Office of Community Care officials. These officials told us that, other than for emergency care claims, information on service-connected conditions is not used to process authorizations and payments for the program because program eligibility is based on other factors, such as the availability of needed services. Veterans also receive health care outside of VHA facilities that is not funded by VA, such as through their private health insurance, and the number and types of these services for service-connected conditions are largely unknown. According to a statutorily mandated study of the use of VA’s health care system, these data are limited. The authors of this study recommended that VA consider expanding data collection efforts. VA has since worked with the Department of Health and Human Services’ Agency for Healthcare Research and Quality to expand its data collection regarding veterans, including veterans receiving disability compensation, specifically regarding veterans’ use of non-VA care and coordinating such care with VA providers. Data from this effort will be available beginning in fiscal year 2020, according to Agency for Healthcare Research and Quality researchers conducting the study. Health outcomes of veterans with service-connected conditions who receive VA health care services are not well understood, as they have not been specifically studied outside of veterans receiving disability compensation for PTSD. Based on a review of peer-reviewed literature and interviews with VA health research officials, we identified two studies on the health outcomes of veterans, both of which specifically focused on health outcomes for veterans receiving disability compensation for PTSD. One study published in 2011 found that receiving disability compensation benefits for PTSD was associated with clinically meaningful reductions in PTSD symptoms and reductions in poverty and homelessness. Another study published in 2017 found that 10 percent of men and 20 percent of women who applied for disability compensation for PTSD had a persistent serious mental illness, and over time, consistently reported more severe PTSD symptoms and poorer functioning in comparison to other study participants without severe mental illness. The study authors noted that serious mental illness was more prevalent in this population than in the VA health care system overall. They concluded that more information is needed about the characteristics of those receiving disability compensation to better understand their challenges and long-term outcomes. VA’s Health Services Research and Development office sponsors research on health conditions common in the veteran population, such as traumatic brain injury and Gulf War Illness, among others. According to an official from this office, data used for these studies generally do not include veterans’ receipt of disability compensation or their specific service-connected conditions. Several health care researchers within VA and a VA official we spoke with cited various reasons for limited research on health outcomes for veterans with service-connected conditions. According to these officials, a key challenge is that VBA and VHA data do not use the same identifiers for medical conditions that are needed to link the two information sources. VA health care researchers acknowledged benefits to including veterans’ VBA disability codes in their studies to analyze health information for veterans with service-connected conditions. A 2007 report on the options for improving the disability program also noted that the use of common diagnostic categories would allow VA program managers and researchers to compare populations and trends that would help in program planning and in epidemiological and health services research. However, VBA’s diagnostic codes are unique and do not allow comparisons of trends in disabilities in populations served by VHA or the Department of Defense. According to a VA health care researcher and a VHA official, also contributing to these challenges are the lack of data use agreements, which could better facilitate linking VBA and VHA administrative data for VA to further study health outcomes for this population. For example, according to a VA researcher, linking these data sources could allow researchers to investigate causal relationships between disability compensation and veterans’ health outcomes. We previously reported that such agreements can specify which data can be accessed and for what purpose, the duration of access, and requirements for safeguarding the data and ensuring confidentiality. VBA officials said that while they routinely share data with VHA for operational purposes, obtaining access to VBA data for research purposes has special requirements and is more cumbersome. Agency health care data are stored in VHA’s Corporate Data Warehouse, while benefits data are stored in VBA’s data warehouse. Both VHA and VBA officials noted that their data contain sensitive information and that access is carefully monitored. VA’s fiscal year 2018-2024 Strategic Plan includes goals and objectives for data-driven decision making, which include having comprehensive data to identify and meet veterans’ needs, as well as to understand the outcomes VA provides veterans and focus VA’s improvement efforts. In addition, we have previously reported that agencies can enhance and sustain their collaborative efforts by defining common outcomes, leveraging resources, and establishing compatible policies, among others. These practices include articulating agreements in formal documents, which can strengthen the commitment to working collaboratively, as well as establishing compatible policies and other means (including compatible standards and data systems) to operate across agency boundaries. VA has begun to consider ways to analyze health care services received by veterans with service-connected conditions. VA’s Office of Enterprise Integration (OEI) is tasked with providing analysis to inform VA decision- making, as well as to align planning and implementation across VA programs and initiatives. According to an OEI official, it plans to convene subject matter experts from VBA and VHA to determine options and pilot strategies to link available data, but has not yet determined the scope, specific activities, or timeframes for this effort. Until VA develops and implements a plan to address challenges that have hindered analysis thus far and enhance collaboration between VBA and VHA with regard to such analysis, VA will not be positioned to understand the characteristics, needs, and health outcomes of veterans with service-connected conditions, which available research suggests may be different from other veterans. VBA uses some information on conditions identified as potentially needing reevaluations; however, it is not analyzing and using trend and outcome information from completed reevaluations to inform which service-connected conditions to reevaluate in the future. Reevaluations of veterans’ service-connected conditions can serve as a proxy to gauge change, including improvement, in health. VBA assesses changes in veterans’ disabling conditions from reevaluations it conducts for various reasons, including evidence of potential improvement or when required by the rating schedule. A reevaluation showing a change in a given condition may result in one of three possible outcomes: an increase, decrease, or no change in the veteran’s associated disability rating. VBA developed a report to help identify unnecessary reevaluations, which included information on veterans’ conditions that are initially flagged by raters for potentially needing reevaluations in the future. Developed in 2017, VBA’s report identified potential reevaluations deemed unnecessary per VA’s regulations. For example, regulations state that veterans older than 55 are generally exempt from reevaluation, according to the VA Office of Inspector General (OIG). As part of this process, potential reevaluations identified as unwarranted by VBA’s report would be cancelled before their scheduled review dates arrived. This report also includes information on specific conditions identified for potential reevaluation, including the subset of conditions required by regulation to be reevaluated. For example, according to the data generated by the report in June 2019, PTSD was the most common condition identified for potential reevaluation, and of the conditions requiring reevaluation, prostate cancer was most common. However, VBA officials explained that if the report were to find that any of the cases were for veterans older than 55, the reevaluation would be deemed unwarranted and the scheduled review date for considering reevaluation would be cancelled. According to VBA officials, using this report helped VBA identify and cancel about 70,000 potential reevaluations deemed unnecessary, saving about $29 million. VBA plans to run similar reports as needed to identify more reevaluations that could be cancelled, according to officials. Additionally, VBA officials said that they have data on the specific conditions for which medical exams are ordered as part of the reevaluation process. Ordering exams for reevaluations occurs after a condition identified for potential reevaluation has been reviewed and a decision has been made to proceed with a reevaluation. In particular, VBA’s Exam Management System tracks exams ordered, including exams for reevaluations, and provides information about the associated conditions. However, this system does not provide information on the outcome of a reevaluation decision based on the information from these exams. While VBA has some insight into conditions set to be reevaluated, management lacks information on completed reevaluations, including (1) trends and comparisons of certain reevaluated conditions and (2) rating outcomes of reevaluation decisions for individual service-connected conditions. Reevaluation trends. VBA officials told us that they analyze trends on the numbers of veterans who have had reevaluations. However, they said they do not analyze reevaluation data to identify trends on whether certain conditions are frequently or infrequently reevaluated, including for conditions requiring reevaluation under VBA regulation. Further, although VBA has a mechanism to identify potential reevaluations for veterans with conditions requiring them, it is not analyzing the broader universe of veterans with these conditions, according to VBA officials. Such information could determine the extent to which conditions are being identified for reevaluation as required as well as the outcomes or results of these reevaluations. This trend information could also help VBA determine whether claims processors are conducting reevaluations as needed or required. Reevaluation outcomes. VBA officials said that they do not analyze information on the outcomes of reevaluation decisions for individual conditions (i.e., whether a reevaluation resulted in an increase, decrease, or no change to the rating of a particular condition). According to our analysis of VBA data, reevaluations rarely result in changes to veterans’ combined ratings. Specifically, from fiscal years 2013 through 2018, about 95 percent of reevaluations resulted in no changes to combined ratings for veterans, with about 3 percent resulting in an increase and less than 1 percent resulting in a decrease. Combined ratings alone do not offer insight into what impact reevaluations may have on ratings for individual conditions, including which ones are improving as a result of treatment. Most veterans have multiple conditions that contribute to a combined disability rating. VA reported that in 2018 veterans receiving disability compensation had an average of about five service-connected conditions. For those receiving reevaluations, this circumstance means that although the rating of one condition may decrease as a result of a reevaluation, the rating of another condition may increase based on the claims processor’s review of the medical evidence. As a result, the combined rating may not decrease despite a decrease in the rating of an individual condition. A recent report examining reevaluations for veterans with PTSD had similar findings. In its review of a sample of veterans, the study found that these veterans rarely saw a reduction in their individual rating for PTSD. In cases where an individual rating was reduced, most saw no reduction in their overall combined rating due to the fact that they had other conditions whose ratings increased and thereby offset any reduction. According to VBA officials, the agency does not analyze data on trends in reevaluated conditions or the outcomes of reevaluation decisions for specific conditions because management has not expressed interest in doing so. Further, officials said that these data are not stored together in the database. Although analyzing these data and developing a report on types of conditions reevaluated and their outcomes is feasible, according to officials, doing so would require additional steps, including analyzing the text of rating decisions. According to VA regulation, reevaluations are intended to verify the continued existence or the current severity of a disability. Federal standards for internal control state that management should establish and operate monitoring activities to evaluate the results of activities and ensure that objectives are met with minimum wasted resources. Moreover, they state that management should design a process that uses the entity’s objectives and related risks to identify the information requirements needed to achieve the objectives and address risks. These standards also state that management should use quality information to achieve the entity’s objectives. Identifying the extent to which VBA is meeting these program objectives and effectively managing resources is difficult without analyzing information about the outcomes of reevaluations for specific conditions. Such analysis could also identify trends indicating conditions with little or no potential for a rating change or missed opportunities to target other conditions likely to change as a result of reevaluations. In recent years, VBA has focused its procedures on reducing the number of unnecessary reevaluations and generally limiting the number of reevaluations conducted overall. Using outcome information could allow the agency to better target the agency’s resources and avoid the risk of unnecessary reevaluations and burdening veterans. Analyzing reevaluation trends and outcomes could also inform existing VBA policy. For example, VA is updating the rating schedule with current medical and earnings loss information, including adding conditions requiring reevaluations. Analyzing information on which conditions are reevaluated and identifying any trends in conditions that improve could help inform future updates to the rating schedule or improve the policies or practices for how the reevaluation process is implemented. VBA uses information to help gauge the timeliness and quality of reevaluation decisions, but has not fully used information related to the consistency of raters’ decisions to address potential training needs, among other issues. VBA tracks its performance in providing veterans with timely and accurate decisions on their disability compensation benefits, and uses such information—including information on reevaluations—to manage the claims process. VBA holds its claims processing staff accountable for their timeliness and accuracy through performance standards for regional office managers and individual claims processors. Timeliness. VBA measures and reports to Congress and the public its total number of claims awaiting completion, including those that have been backlogged (awaiting completion for more than 125 days). According to VA, at of the end of fiscal year 2018 it had about 364,000 disability compensation rating claims awaiting completion. Of this total, about 19,000 were reevaluations, of which fewer than 5 percent were in the backlog. VBA uses additional timeliness measures to hold regional offices accountable by tracking the timeliness of their work in each of five steps or cycles in the claims process, as managed under the National Work Queue (VBA’s system for distributing the claims workload). For example, in fiscal year 2018, preparing a rating decision for a reevaluation took an average of 1.76 days. Quality. VA uses national, regional office, and individual-level data from its accuracy reviews to oversee the quality of rating claims decisions, including reevaluations. Each regional office is to meet the national STAR issue-based target of 96 percent accuracy for the year. For reevaluations, VBA reported both claim-based and issue-based accuracy of about 95 percent for fiscal year 2018. According to VBA officials, in response to a recommendation in the VA OIG’s report on unwarranted reevaluations, in October 2018 VBA updated the STAR national quality review checklist with additional questions on (1) the need for a reevaluation, and (2) the timeframe for future reevaluation. At the individual claims processor level, VA measures accuracy using the results of Individual Quality Reviews as part of claims processors’ performance evaluations. For example, a rater is considered fully successful by achieving 92 to 96 percent accuracy on Individual Quality Reviews for a month, depending on the rater’s experience. In fiscal year 2018, VBA reported that for Individual Quality Reviews, claims processors had a 98.4 percent accuracy rate for reevaluations. Overall, few reevaluations are reviewed because reevaluations are a small proportion of VA’s claims workload. Specifically, of about 102,000 reevaluations completed in fiscal year 2018, about 1,500 were reviewed under STAR and about 10,000 were reviewed in Individual Quality Reviews. In addition to using accuracy information to measure regional office and individual performance, VBA holds regional offices and individual claims processors responsible for correcting their errors. According to VBA officials, the agency uses information from its quality reviews to provide additional guidance and training to regional offices. VBA discusses quality review information, including trends in claims processing errors, through newsletters and periodic conference calls with regional office managers and quality review teams. For example, VBA officials noted that they discussed reevaluation policies and guidance with regional office staff on three occasions between May 2017 and May 2018. Officials at the four regional offices we visited indicated that they disseminated information on reevaluations to claims processors. For example, one office’s quality review team provided additional training on reevaluations to members of the claims processing teams. Quality review team officials in each of the regional offices we visited told us that they disseminate and reinforce guidance to claims processors through periodic meetings, newsletters, or other mechanisms. VBA, however, has not fully used available information about quality to oversee and improve the reevaluation process. Specifically, VBA did not use the results of a study it conducted to further identify and correct gaps in raters’ knowledge of reevaluation processing guidance. This May 2018 study—part of VBA’s quality assurance efforts that include periodic consistency reviews of specific claims processing issues—assessed how consistently raters across regional offices understood VBA’s policies on ordering reevaluations (see table 2). The study team recommended VBA take two actions: 1. Consider having experienced quality review team staff at regional offices provide additional training on reevaluation guidance to raters. 2. Consider reviewing reevaluation decisions at the seven lowest-scoring offices because they were at high risk of inaccuracies. While VBA provided regional offices with results of the May 2018 consistency study, the agency did not implement either recommendation. VBA officials told us that they did not direct regional offices to provide additional training because the agency expected the offices to use the results of the consistency study to plan training on reevaluations for their staff. However, VBA officials told us that not all regional offices provided additional training on reevaluations. Quality review officials at the four offices we visited—which included two of the seven offices the study team identified for further review—told us that they did not provide additional training. Officials at two offices said they had previously provided guidance and training to claims processors on reevaluations. VA’s goals are to ensure timely and accurate claims decisions for veterans. Federal standards for internal control state that management should establish monitoring activities, evaluate the results, and remediate any deficiencies on a timely basis. Consistent with these standards, GAO has previously reported that a key use of performance information is to identify problems and take corrective actions, for example, by changing agency guidance or by providing training. By not implementing the study’s recommendations, VBA is missing an opportunity to identify problems and their root causes as a guide to corrective actions, including training or the improvement of training. Many raters who are trained to make these decisions did not perform well on the consistency study’s initial test. Exploring deficiencies associated with this poor performance could position VA to better manage the reevaluation process. In addition, resources spent in developing the study and analyzing its results were not used as effectively as they could have been. VBA has recently updated its procedures manual to clarify who can determine whether a reevaluation is needed, but has not outlined guidance for the knowledge, skills, and abilities needed to perform these tasks. As part of the reevaluation process to assess veterans’ conditions, VBA procedures require claims processors in regional offices to conduct a pre-exam review to determine whether a reevaluation is still appropriate when its scheduled review date arrives (see fig. 3). For the reevaluation process to work effectively, proper procedures must be in place to ensure that claims processors can make informed decisions on whether to reevaluate these conditions. Until its recent update, VBA’s procedures manual stated that staff deemed part of “the rating activity” (defined in the manual as staff including raters who specialize in rating claims) were the only claims processors who were permitted to conduct a pre-exam review to determine whether a reevaluation is warranted. In February 2019, VBA updated its procedures manual to clarify that raters or “locally designated claims processors” may conduct this review. Officials said that Veterans Service Representatives (VSR) may fill this role in some offices. Although VBA’s procedures permit VSRs to conduct pre-exam reviews, VSRs may not be qualified to do so, according to the OIG’s July 2018 report and VBA regional staff we interviewed in 2019. The OIG found that VSRs were ordering exams without raters’ pre-exam reviews, resulting in an estimated 15,500 unwarranted exams (about 29 percent of the cases from the study’s review period). These exams were determined to be unwarranted based primarily on exclusions identified in VA’s procedures that exempt certain veterans from reevaluation (see text box). The report found that, rather than sending claims to raters for pre-exam review, VSRs were ordering exams despite not having the proper training and experience to decide on whether a reevaluation was warranted, such as the specialized knowledge needed to review medical evidence. Officials in regional offices we visited expressed concern about VSRs performing this role. Specifically, staff in three of the four regional offices we spoke with—including raters, supervisors, quality assurance staff, and managers—told us that raters do the pre-exam review in their respective offices because they are the only staff qualified to perform this duty. For example, raters have more experience and training than VSRs in reviewing medical evidence to determine the need for a reevaluation, according to officials from one office. In contrast, supervisors we spoke with at another regional office told us they have opted to have VSRs do the pre-exam review as a way to manage the claims workload and enable raters to focus exclusively on rating claims. However, these supervisors expressed concern that VSR reviews could have a negative impact on quality. VBA officials said they have not outlined guidance for the skills needed to perform the pre-exam review. Rather, VBA officials said that they believe it is most effective to allow the regional offices, which vary widely in size and scope, to have discretion to identify staff to fill this role. Further, VBA officials told us that the recent update to the agency’s procedures did not reflect a policy change broadening which staff can do pre-exam reviews, but rather clarified existing practice under which VSRs were already permitted to perform this task. However, given the OIG findings that VSRs performing this task resulted in many unwarranted exams, defining the knowledge, skills, and abilities needed for the pre-exam review could provide assurance that staff who do so are qualified. Federal standards for internal control call for management to clearly assign responsibilities and document internal controls, including who should carry out which roles. Identifying the knowledge, skills and abilities needed by qualified staff to carry out their responsibilities can also help management ensure the entity’s objectives are met. Providing flexibility for regional offices can ease implementation and management of workloads, especially for offices with varied situations. However, providing flexibility does not preclude VBA from outlining the basic knowledge, skills, and abilities required to perform the pre-exam review. Further, in our prior work we found that VBA has faced challenges in defining roles for its staff, which has led to inconsistencies in the way regional offices operate. We have also found that ambiguous policies provided by other VA programs can pose risks to the quality of the process. Without clarifying in VBA’s procedures manual which knowledge, skills, and abilities are needed to fill roles in the reevaluation process, VBA may be at risk of having unqualified staff continue to order unwarranted reevaluations. This risk, in turn, could result in wasted resources and an undue burden on veterans. Despite recent changes to its procedures manual, VBA has not ensured that its training program reflects the knowledge, skills, and abilities needed for relevant staff to conduct pre-exam reviews. VBA oversees national training requirements, including training related to reevaluations, but defers to regional offices to manage other training needs. As entry- level staff, claims processors receive national training from VBA related to their job duties. For raters, this initial training covers reevaluations, including instruction on when and when not to schedule reevaluations, and case studies exploring how to make reevaluation decisions based on medical and other evidence, among other topics. VSRs may also receive general training on reviewing and evaluating evidence and are introduced to reevaluations as they learn about general claim development and ordering exams. In addition to initial training, claims processors must complete 40 hours of training per year consisting of 15 hours of training mandated by VBA and 25 hours determined by each regional office. VBA officials told us that regional offices vary in what training and when delivered to their staff. In addition to this general training, VBA officials told us that VA added controls to the Veterans Benefits Management System (VBMS) system to restrict claims processors’ ability to schedule potential reevaluations, which could reduce the possibility of unqualified staff ordering unwarranted exams during the pre-exam review. Specifically, these controls prevent claims processors from scheduling review dates for potential reevaluations when certain exclusions apply (such as that outlined in VA regulation exempting from reevaluation veterans with the minimum rating for a given condition). Further, claims processors have the ability to request to override the restrictions when they believe a reevaluation is warranted based on the circumstances of the case. These override requests are reviewed by quality assurance staff, who may approve or deny the requests. Although these controls may impose some limits on ordering unwarranted exams, they may not affect the ability of claims processors to order reevaluations in circumstances where these exclusions do not apply and for which they must use their discretion. For example, for veterans who have migraine headaches and who do not fit any of the exclusion criteria, no VBMS controls would restrict claims processors from ordering a reevaluation even if it is not appropriate based on the medical evidence or other circumstances of the case. For these controls and VBA’s procedures to be effective, providing proper training to claims processors making these decisions remains important. VBA officials told us that they did not update training requirements as a result of the recent update to procedures because this update did not constitute a policy change. Rather, they said they revised the procedures to align with the existing practice before the update, in which VSRs were permitted to do pre-exam reviews. Further, officials said that each regional office can designate qualified claims processors to perform the pre-exam review and provide training as necessary. VBA officials also said that they do not believe additional training is necessary for VSRs who may be performing this role because the procedure for ordering exams—a skill for which they have been trained—is the same for all types of exams, including those for reevaluations. Although VSRs receive training on the process of ordering an exam, VBA officials confirmed that VSR coursework does not specifically cover the pre-exam review in the reevaluation process. In contrast, raters receive training on the process of deciding whether a reevaluation is warranted, including reviewing medical evidence and applying exclusions in VBA’s procedures. Further, staff in three of the four regional offices we spoke with, including supervisors, quality assurance staff, and managers, said that VSRs do not have the proper training for this task. For example, they are not trained to review medical evidence to make an informed decision about whether a reevaluation is still warranted, according to officials. Similarly, the OIG found in its 2018 report, which reviewed a sample of claims from March through August 2017, that VSRs were unfamiliar with criteria used to determine whether or not an exam is necessary. Federal standards for internal control highlight the importance of training to develop the relevant knowledge, skills, and abilities needed for key roles. We also have previously identified key practices for training and development that suggest that agencies should have a strategy that includes tracking and other control mechanisms to ensure that the relevant employees receive training in line with their responsibilities. Without ensuring that training reflects the relevant knowledge, skills, and abilities needed by claims processors in VBA regional offices, VBA may find these staff continue to make uninformed and incorrect reevaluation decisions that are not aligned with VBA policy, guidance, and procedures. VA spends substantial time, effort, and billions of dollars per year providing disability compensation, health care, and other forms of assistance that promote the wellness of veterans with service-connected conditions. However, VA does not know whether these efforts improve the health of these veterans on several fronts. While we are encouraged by VA’s interest in considering ways to analyze health outcomes, VA has not yet established a plan for addressing the identified research challenges. Without a plan, VA will not be positioned to understand the characteristics, needs, and health outcomes of veterans with service- connected conditions or how disability compensation and health care work together to help them. Disability reevaluations can shed light on whether veterans’ service- connected conditions have changed. However, the agency could take additional steps to analyze outcome and other data on completed reevaluations. Importantly, tracking and analyzing trends and outcomes could shed light on an apparent contradiction: why the majority of recent reevaluations resulted in no change in veterans’ combined ratings when the regulations state that reevaluations generally should not be conducted in these cases. Without these analyses, VA may be unaware of any reevaluation trends, possible explanations for them, or need to recalibrate guidance or resources to address these issues. Reevaluations represent an investment of resources for VA and the veterans who undergo them. Insights into the effectiveness of the reevaluation process are thus critical for managing VBA’s workload and informing agency policy. Specifically, while VBA tested raters’ knowledge of reevaluation policies in its May 2018 consistency study, it missed opportunities to review reevaluation decisions in the offices at greatest risk of making incorrect decisions, as recommended in the consistency study report. Following up on the report’s findings could also provide insights into root causes of errors in reevaluation decisions, which could inform decisions about additional targeted training or improved guidance. For veterans who show health improvements, VBA’s reevaluation process can ensure they have the correct disability rating and associated benefit payment. However, VBA could better mitigate the risks of making unwarranted reevaluation decisions by clarifying guidance in its procedures manual about the knowledge, skills, and abilities regional office staff need to determine whether a reevaluation should be conducted. Moreover, defining training requirements would help ensure that claims processors who conduct reevaluations have the needed skill sets and that their decisions are aligned with VBA policy and guidance. Ultimately, by enhancing and linking existing information about service- connected conditions and health care and from the results of reevaluations, VA could better understand the health outcomes of veterans who have incurred or aggravated disabling conditions during military service. We are making the following five recommendations to VA: The Secretary of Veterans Affairs should ensure that the Office of Enterprise Integration develops a plan—including milestones and roles and responsibilities for OEI, VBA, and VHA—to address identified challenges that have hindered research on the health care outcomes for service-connected conditions of veterans receiving disability compensation. To align VA’s efforts with the goals of its 2018-2024 Strategic Plan, VA’s development of this plan should be completed and ready for implementation by June 1, 2020. (Recommendation 1) The Under Secretary for Benefits should develop and implement a periodic analysis of program management data for trends in the individual service-connected conditions being reevaluated as well as data on the outcomes of reevaluations. (Recommendation 2) The Under Secretary for Benefits should implement the two recommendations in VBA’s May 2018 consistency study to provide training on how to determine when a reevaluation is needed and review reevaluation decisions for accuracy at the lowest-scoring offices and take corrective action as needed. (Recommendation 3) The Under Secretary for Benefits should clarify guidance in its procedures manual regarding the knowledge, skills, and abilities needed to make decisions on whether to reevaluate veterans for changes in their service- connected conditions. (Recommendation 4) The Under Secretary for Benefits should align training requirements with the knowledge, skills, and abilities needed for reviewing claims to decide whether to conduct a reevaluation. (Recommendation 5) We provided a draft of this report to the Department of Veterans Affairs (VA) for review and comment. VA provided written comments that are reproduced in appendix I. VA agreed with recommendations 1 and 2, and concurred in principle with our other three recommendations. The comment letter described steps the Veterans Benefits Administration (VBA) plans to take, or is in the process of taking, to address the recommendations. However, except for recommendations 1 and 2, VA’s proposed actions would not fully address the underlying issues we identified. With regard to recommendation 1 to develop a plan to address challenges to studying health outcomes, VA stated that the Office of Enterprise Integration (OEI) will coordinate with VBA and the Veterans Health Administration (VHA) to create an operational plan that addresses challenges that have hindered research on health care outcomes for service-connected conditions of veterans receiving disability compensation. VA anticipates completing this plan by June 2020. With regard to recommendation 2 to use information on reevaluations to improve program management, VA stated that VBA plans to expand its review of existing data and reports to analyze trends regarding which service-connected conditions are identified for reevaluation, and review the outcomes or results of these reevaluations. VBA plans to develop and implement this effort by the end of June 2020. With regard to recommendation 3 to implement the recommendations from the 2018 consistency study, VA stated that VBA provided a reminder to all regional offices about the availability of training resources on how to determine when a reevaluation is needed. VA also stated that VBA conducted another consistency study on this issue in August 2019 and plans to inspect claims at the two lowest-scoring regional offices identified in that study by January 15, 2020. We are encouraged by VBA’s plans to use the results of the 2019 study by inspecting claims at the lowest- scoring offices. However, using the results of both the 2018 and 2019 studies would allow VBA to more fully identify and correct root causes of any deficiencies, such as through additional training or the improvement of training. With regard to recommendation 4 to clarify guidance regarding the specific knowledge, skills, and abilities staff need to determine when to reevaluate disability claims, VA recognized the importance of having appropriately skilled and trained employees to process reevaluations and other claims. VA stated that each regional office identifies which employees complete these reviews based on their staff expertise. Further, VA stated that its Systematic Technical Accuracy Review (STAR) results of 95 percent for reevaluations indicate that further action is not needed. We continue to believe that flexibility for regional offices can be balanced with assurance that staff with the appropriate knowledge, skills, and abilities are conducting this work across regional offices. In addition, the STAR accuracy rate provides limited information about the accuracy of decisions to reevaluate claims, as discussed below. As noted in the report, identifying the knowledge, skills and abilities needed by qualified staff to carry out their responsibilities can help management ensure the program’s objectives are met. With regard to recommendation 5 to improve training for reevaluations, VA stated that additional training on reevaluations is not needed because its STAR accuracy rate for reevaluations is 95 percent. As noted in the report, VBA’s STAR reviews a small percentage of all completed reevaluations, and errors related to improperly ordered reevaluations are not reflected in STAR accuracy scores. We believe that additional action is needed to address our recommendation by ensuring staff are trained appropriately on these procedures to correctly determine whether reevaluations are needed. This additional training or guidance is particularly needed given the results of VBA’s May 2018 and August 2019 consistency studies, the views of regional staff we talked with, and the large volume of unwarranted exams. 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 curdae@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 II. In addition to the contact named above, James Whitcomb (Assistant Director), Dana Hopings (Analyst-in-Charge), Rachel Pittenger, and Greg Whitney made key contributions to this report. Also contributing to this report were Steven Campbell, Debra Draper, Alex Galuten, Sarah Gilliland, Alison Grantham, Amber Gray, Gina Hoover, Aaron Karty, Diona Martyn, Mimi Nguyen, Jessica Orr, Claudine Pauselli, Almeta Spencer, Srinidhi Vijaykumar, and Erin Wurtemberger.

Summary: VA receives billions of dollars per year to provide health care and disability compensation to promote the wellness of veterans with service-connected conditions. VA studies veterans' health through research and assesses changes in service-connected conditions through its reevaluation process. GAO was asked to review VA's efforts to study and gauge the health outcomes of veterans with service-connected conditions. This report examines the extent to which (1) veterans used VA health care services to treat service-connected conditions, and what is known about their health outcomes; (2) VA uses information on reevaluations to help manage the program; and (3) VA's procedures position it to determine when to conduct a reevaluation. GAO reviewed fiscal year 2018 VA health care data; selected studies; VA data on completed reevaluations from fiscal years 2013-2018; and relevant federal laws, regulations, and program guidance. GAO also interviewed staff at four VA regional offices (selected for variation in claims workload and location) and VA officials at the agency's central office. In fiscal year 2018, about 54 percent of veterans receiving Department of Veterans Affairs (VA) disability compensation had at least one VA outpatient visit to treat an injury or illness that VA deemed was incurred or aggravated during military service (i.e., a service-connected condition). However, the health outcomes of veterans with service-connected conditions, such as changes in the severity of symptoms or the incidence of mortality, are not well understood. Information about health outcomes is central to ensuring veterans' wellness and assessing improvement in their disability status. According to VA researchers GAO spoke with and academic studies GAO reviewed, various challenges have limited research on this population. For example, data reside in different VA systems and use different identifiers for medical conditions, hindering use of the data. While VA has begun to consider ways to analyze health outcomes, it has not yet established a plan for this effort, including the scope, specific activities, and timeframes for addressing the identified research challenges. VA does not glean information from the results of reevaluations to help manage its disability compensation program. Disability reevaluations help VA gauge whether veterans' service-connected conditions have changed, and whether disability compensation should be modified to reflect those changes (see figure). However, VA does not fully use key management information, such as: trends in how frequently certain conditions are reevaluated, including those required by VA regulations to be reevaluated; and outcomes of reevaluation decisions for individual conditions (i.e., whether conditions worsened or improved). Both trend and outcome information could help VA better target its resources toward reevaluating conditions more likely to change. VA recently updated its procedures manual to specify which staff may determine whether a veteran's condition should be reevaluated, but has not clearly defined skill sets and training needed to consistently implement these procedures. Specifically, the updated procedures do not indicate the knowledge, skills, and abilities staff need to determine when to conduct reevaluations. Further, VA has not ensured that training aligns with these needed skillsets. Without improving procedures and training, VA is at risk of conducting unnecessary reevaluations and burdening veterans. GAO is making five recommendations, including that VA develop a plan to address challenges to studying health outcomes, use information on reevaluations to improve program management, and improve procedures and training for reevaluations. VA agreed with two recommendations and agreed in principle with the other three, but its proposed actions do not fully address GAO's concerns.