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House Hearing, 109th Congress - OVERSIGHT HEARING ON THE VARIANCES IN DISABILITY COMPENSATION CLAIMS DECISIONS MADE BY VA REGIONAL OFFICES; THE POST-TRAUMATIC STRESS DISORDER CLAIMS REVIEW; AND UNITED STATES COURT OF APPEALS FOR THE FEDERAL CIRCUIT DECISION ALLEN V. PRINCIPI Thursday, October 20, 2005 U.S. HOUSE OF REPRESENTATIVES, SUBCOMMITTEE ON DISABILITY ASSISTANCE AND MEMORIAL AFFAIRS, COMMITTEE ON VETERANS' AFFAIRS, Washington, D.C. The Subcommittee met, pursuant to call, at 10:40 a.m., in Room 340, Cannon House Office Building, Hon. Jeb Bradley [Vice Chairman of the Subcommittee] presiding. Present: Representatives Miller, Bradley, Berkley, Udall, Evans, and Brown-Waite. MR. BRADLEY. [Presiding] Good morning. The hearing will come to order. Congressman Miller will be here shortly. He has asked for me to pitch in for him. I am going to read his opening statement. Today we are receiving testimony on several issues: number one, variances in claims decisions throughout the Veterans Benefits Administration's regional offices; two, the ongoing review of certain Post-Traumatic Stress Disorder claims; and, three, a 2001 U.S. Court of Federal Appeals decision, Allen v. Principi, which clarified that the VA may pay compensation for an alcohol or drug abuse condition when it is secondary to a primary service-connected condition such as, in Mr. Allen's case, PTSD. In late 2004, the Chicago Sun Times' ran a series of articles that focused on the compensation rates of Illinois veterans. As a result, then Secretary Principi asked the VA Inspector General to conduct a review of compensation payments. The IG reported its findings in May 2005. The IG cited several factors to account for variances in annual disability compensation payments, some of which VA has no control over and others in which VA has some control. During the IG's review of 2,100 PTSD claims, it was found that the total number of veterans receiving disability compensation between 1999 and 2004 grew by a little more than 12 percent. However, PTSD claims increased by more than 80 percent. Likewise, PTSD compensation payments increased almost 149 percent while compensation for all other disabilities increased by only 41.7 percent. It concerns me that the IG determined that Veterans Benefits Administration procedures were not always followed in processing PTSD claims, resulting in error rates ranging from 11 to 41 percent. Due to the nature of certain disabilities, the adjudication of a claim requires the use of judgment; therefore, inherently, there will be variations in outcomes. I would expect, however, that the VA can mitigate and control for variances in decisions by ensuring that regional offices follow standardized adjudication policies and by developing methods for ensuring consistency. I look forward to the testimony of Ms. Bascetta, the GAO witness, and Dr. Brown of the Compensation and Pension Exam Program in this regard. Following an IG recommendation, VBA is currently examining the 2,100 PTSD claims that the IG reviewed. I understand there is some concern within the veterans' community that this review may be adding to veterans' stresses. At a briefing for the House and Senate committee staff earlier this month, Admiral Cooper, Under Secretary for Benefits, gave every assurance that benefits will be fully paid until a final decision is rendered - a veteran will not lose appeal rights - and that if a grant is overturned, the veteran will not have to repay past benefits. To date, the majority of the original 2,100 cases under review have been successfully closed without a need for further action. The initial grant was correct. It is my hope that VBA in conjunction with the Veterans Health Administration will educate veterans on the process as necessary. It is important not to overlook the fact that this review will also help VBA identify weaknesses and improve the quality of the claims adjudication process. [The statement of Mr. Bradley appears on p. 44] MR. BRADLEY. At this time, I would like to recognize the Ranking Member for her opening remarks. MS. BERKLEY. Thank you, Mr. Bradley. And please thank Chairman Miller for holding this hearing. I think it is critically important that we explore this issue from the perspective of severely disabled veterans who are being put at risk by a possibly illegal review of post-traumatic stress disorder claims. This review and the Inspector General's claim that billions of dollars can be saved by terminating benefits to severely disabled veterans places the health and lives of untold veterans and their families at risk. The Bush Administration says it seeks only to improve compensation and pension claims processing. However, the VBA has embarked upon a course which may very well lead to increased suicides, homicides, and violent behavior by veterans whose PTSD symptoms are so severe that they are unable to work or function in society. This review is causing some veterans to revisit their traumatic experiences and increase their psychiatric symptoms. Mental health professionals, treating psychiatrists, as well as veterans' advocates say this is simply, dare I say, madness. As Secretary Garcia states in his written testimony, an attack on one veteran is an attack on all of them. Even those who are unlikely to have benefits terminated are feeling under attack by a report which appears to recommend cutting severely mentally ill veterans from VA compensation rolls. How many veterans' suicide will it take to reverse this course? While many of our nation's veterans with severe PTSD fear the loss of their disability benefits and their VA health care, I fear the loss of their lives. Many agree with PVA's testimony that will appear later, written testimony, that the review which is underway may well be illegal. A court may ultimately find this to be so. Such a finding would be little comfort, however, to families who have already lost a spouse, father, grandfather, or child to suicide as a result of the stress this proposed review is placing upon severely disabled veterans. Does VBA really believe that it can meet the stringent requirements for clear and unmistakable error in the decisions of veterans whose claims are being reviewed? How can they do that? Does the IG have any evidence to support the suggestion that all of the claims which reportedly lack adequate stressor verification could be terminated under existing statutes? How can any review which ignored and continues to ignore the thousands of veterans who have had PTSD claims denied with little or no attempt to adequately develop their claims be viewed with any credibility by the veterans' community? The GAO recently found that many veterans' claims were rated without adequate medical examinations which may have entitled them to a higher rating and benefit. Will VA be contacting those veterans that were denied benefits and scheduling a new medical examination? Are we jeopardizing the lives and health of America's severely disabled veterans so that the bureaucracy will have a complete paper file? Does the government have a moral and ethical responsibility to mitigate the danger to the lives and health of veterans occasioned by this review? I hope that the witnesses will be able to answer my questions. And before I concluded, Mr. Bradley, as many people know, and I say this often enough, in Las Vegas, Southern Nevada has the fastest-growing veterans' population in the United States. We have veterans from World War II, Korea, Vietnam, the Gulf War, and now we have many returning veterans from Iraq and Afghanistan. I have witnessed with my own eyes people in the Vietnam era, that was my era, that came back seriously mentally damaged. And this nation did not do what I think was our moral responsibility to help these kids that came back, while I was sitting in a college classroom, severely mentally disabled from the experiences they had in their theater of war. Now, I did not appreciate it when I was in college. I appreciate it now when I am sitting here next to you in Congress. And under my watch, I would never forgive myself if we were to implement actions that would create further mental harm to these people who have sacrificed so much in the prime of their lives, who have had their lives completely altered on behalf of this nation. And I think we have a great responsibility to these people. And I want to hear what is going on, but I cannot imagine systematically reviewing 100 percent PTSD victims when I believe there are so many more out there that need the additional help and need to be taken care of rather than taking away benefits, putting these people in harm's way, sacrificing their families, and ultimately this nation. And I thank you very much. MR. BRADLEY. Thank you, Ms. Berkley. [The Statement of Ms. Berkley appear on p. 46] MR. BRADLEY. Are there any other members who have opening statements? Mr. Udall. MR. UDALL. Thank you, Mr. Chairman. Mr. Chairman, I would like to recognize and thank New Mexico Veterans' Secretary John Garcia for testifying today. John is going to appear on Panel Number II. We in New Mexico know Secretary Garcia well. We know his dedication and loyalty to veterans. It is not uncommon for a veteran to walk into his office and to speak directly with him about concerns and issues of importance. And I know that the Secretary is as concerned and angry as I am with the manner in which the VA has proceeded on this PTSD matter. It seems that time and time again we hear the larger facts about PTSD: How it affects 11.5 percent of all veterans; how nearly nine out of ten veterans with PTSD demonstrate signs of other disorders, including depression, alcohol and substance abuse, or anxiety; how the number of veterans diagnosed with PTSD has risen while the number of services being offered by the VA has dropped; how the stigma of PTSD is still prevalent throughout the military and prevents many veterans from seeing care until it may be too late. However, even with all these facts and figures, the individual stories of struggle are sometimes lost, and PTSD has become simply another medical term, another column in the books. And, unfortunately, this became the perspective, I think, of the VA. In August, it was immediately clear that the VA's review of 72,000 PTSD cases meant something different to them than it did to the veterans suffering from PTSD. To the VA, it was a process for seeking out incomplete cases and finding voids in paperwork that needed to be filled. The IG report that catalyzed the review included charts and graphs and made suggestions for action. To veterans, though, the announcement that their case might be reviewed was not seen as simply another bureaucratic process. It was for many a jolting realization that the day-to-day struggle they endure was being questioned and that their quest for help to deal with this struggle needed external validation. For those who live with PTSD, the review did not mean a paperwork review as much as it meant a personal attack on what is already a sensitive issue. Last week, a veteran in my district took his life after dealing with PTSD for years and years. He can certainly be perceived as one statistic within the larger, tragic figure of those veterans who contemplate or act on suicidal thoughts. But he can also be seen as he should be, as a Vietnam vet decorated with the Purple Heart and other commendations. He was a soldier who fought bravely and honorably for his country. Involved in local veterans' organizations, he helped out at events and with other veterans and all the while he struggled to deal with PTSD. Even though his case was well-documented and he was in no danger of finding his compensation or medical assistance benefits revoked, he was greatly shaken by the announcement of the VA review and frequently inquired whether he would be losing the support he had received. He believed, as so many veterans do, that he was being forced to prove himself yet again. It is that belief that makes veterans so angry and so frustrated with this process. I believe the VA's intentions to bring clarity and accountability to PTSD cases were not in any way meant to harm our veterans. But I believe the manner in which they proceeded with the review, without any input from mental health professionals concerning the risk of harm to veterans with severe psychiatric symptoms, has done far more harm than good. It is important that we compile facts and figures and that we be concerned with the larger picture. It is more important that we not forget veterans who have borne the battle and now struggle with PTSD, and how our actions affect then. I have called and will continue to call for a halt to the review. The VA must reevaluate the process it is using in this review and must take into account how it is affecting veterans. It is better that we stop this review before more lives are lost rather than continue with troublesome and tragic consequences. Again, Secretary Garcia, thank you for your presence. We look forward to your testimony today on Panel II. And I thank you for your tireless work on behalf of New Mexico's veterans. Thank you, Mr. Chairman. Look forward to our witnesses today. MR. BRADLEY. Thank you, Mr. Udall. [The statement of Mr. Udall appears on p. 50] MR. BRADLEY. Mr. Evans. MR. EVANS. Thank you, Mr. Chairman. I would like to thank the Ranking Member, Ms. Berkley. I requested a review of VA practices which have resulted in low benefits for service-disabled veterans in Illinois and throughout the nation. We certainly did not expect the lop-sided IG review that we received. My staff reviewed PTSD claims in Chicago. These are some of the veterans whose claims were denied: a World War II veteran with a Combat Infantry Badge, a Vietnam veteran who participated in the 1969 Tet Counter-offensive, a peacetime veteran who witnessed the extremely traumatic death of a co-worker, and an Iraq veteran with PTSD noted on compensation and pension examination form. The VA IG review completely ignored such claims. I hope today's hearing will lead to the end of the VA's destructive action against veterans with severe PTSD. The veterans' advocates are right. We must stop this process before any more veterans take or lose their lives. Mr. Chairman, I ask that a letter that Ranking Member Akaka and I sent to Secretary Nicholson concerning this matter be included in the record. I want to thank you and your staff. And I have this statement for the record. Thank you. MR. BRADLEY. So ordered. [The statement of Mr. Evans appears on p. 57] [The attachment appears on p. 151] MR. BRADLEY. Will panel one please come to the table. Mr. Jon Wooditch is the Acting Inspector General, Department of Veterans Affairs. He is accompanied by Mr. Michael Staley, the Assistant Inspector General for Auditing. Next, Ms. Cindy Bascetta, the Director of Education, Workforce, and Income Security Issues represents the Government Accountability Office. Welcome to you all. Your full statements will be included in the printed record of the hearing and we will hold our questions until each of you has testified. Please proceed. STATEMENTS OF JON A. WOODITCH, ACTING INSPECTOR GENERAL, DEPARTMENT OF VETERANS AFFAIRS, OFFICE OF THE INSPECTOR GENERAL; ACCOMPANIED BY MICHAEL L. STALEY, ASSISTANT INSPECTOR GENERAL FOR AUDITING, DEPARTMENT OF VETERANS AFFAIRS, OFFICE OF THE INSPECTOR GENERAL; CYNTHIA BASCETTA, DIRECTOR, EDUCATION, WORKFORCE, AND INCOME SECURITY ISSUES, GOVERNMENT ACCOUNTABILITY OFFICE STATEMENT OF JON A. WOODITCH MR. WOODITCH. Thank you. Mr. Chairman and other distinguished members of the Subcommittee, I am pleased to be here today to address the Office of Inspector General report, Review of State Variances in VA Disability Compensation Payments. I am pleased to be joined by Mike Staley, Assistant Inspector General for Audit. Last December, the VA Secretary asked the IG to conduct this review in response to concerns raised by several Members of Congress over the wide variance in average annual disability compensation payments by state. For Fiscal Year 2004, veterans in New Mexico received over $5,000 more per year than veterans in Illinois. To determine the cause of the variance, we analyzed six years worth of benefit claims' data, surveyed over 1,900 rating specialists, examined 2,100 claims' folders, and reviewed medical examination reports. Our review identified a number of factors that influenced the variance. Two key reasons highlighted in the report are veteran demographic factors and benefit rating decisions. Demographic factors are variables beyond VA control. For example, Vietnam veterans receive over $2,300 more than the next highest period of service. Enlisted personnel receive more than officers and military retirees receive more than nonretirees. Our review demonstrated that there was a direct correlation between these factors and those states with the highest average annual payments. This supports the position that some part of the variance is predictable and nonproblematic. Conversely, factors such as benefit rating processes over which the VA has direct influence are problematic in that they are not always consistently applied nationwide. Our analysis of rating decisions shows that for disabilities that can be independently validated on physical measurements, such as amputations, ratings were consistent. However, for other disabilities, such as mental disorders, much of the information needed to make a rating decision is not physically apparent. As such, these cases are more difficult to develop and document and are inherently more susceptible to variations in interpretation and judgment. This subjectivity leads to inconsistency in rating determinations. We selected the mental disorder system for further analysis because it had the highest overall average disability rating nationwide and it included PTSD, which is the fastest-growing condition. To illustrate, from fiscal years 1999 to 2004, the number of PTSD cases grew by 80 percent and PTSD payments increased from $1.7 to $4.3 million. There was also a dramatic rise in the number of PTSD cases rated 100 percent. In fact, data shows that differences in the number of 100 percent PTSD cases by state accounted for 34 percent of the variance. To understand why this variance may be occurring, we reviewed 2,100 PTSD cases at seven VBA regional offices. We found that 25 percent of the 2,100 cases needed further development to support the claimed stressor in order to verify that the PTSD was caused by an event related to military service. The 25 percent error rate is not an indicator of fraud. It reflects noncompliance with VBA regulations concerning required documentation to develop and support rating decisions. These requirements are essentially internal controls designed to ensure veterans receive everything they are entitled to under the law and to serve as a basis for denying claims when the evidence does not exist. To address this issue, we recommended that VBA do a review of all PTSD cases rated 100 percent. The intent of this recommendation is to ensure the VBA rules and regulations are fully complied with, that the processes for case development are consistently applied nationwide, and to ensure that benefits are being paid properly. In closing, I would like to add that the variances by state have existed for decades and that the factors that influence these payments are complex and intertwined. Yet, there are opportunities to improve the consistency of rating decisions. The impact of underlying factors such as medical examination reports that do not consistently provide sufficient data for rating purposes, incomplete case development, and a rating schedule that is subject to different interpretations will have to be fully studied and understood if the VBA is to be successful in detecting, correcting, and preventing unacceptable payment patterns. That concludes my statement. Thank you again, Chairman Bradley, and those members of the Subcommittee for this opportunity. I welcome any questions you may have. [The statement of Mr. Wooditch appears on p. 58] MR. BRADLEY. Ms. Bascetta. STATEMENT OF CYNTHIA A. BASCETTA MS. BASCETTA. Good morning, Mr. Chairman, and other members of the Subcommittee. Thank you for inviting us to testify today on the consistency of decisions made by VA on veterans' claims for disability compensation. Ensuring that disability decisions are consistent across the nation is vital to the integrity of the VA Disability Programs which GAO designated as high risk in January 2003. As you requested, my comments today are based on our two most recent reports on decisional consistency. Our November 2004 report concluded that VA still does not systematically assess consistency across its regional offices and the report we issued last week shows one important way for VA to improve consistency involving joint and spine impairments. We made recommendations in both reports that underscore the need for VA to routinely monitor consistency to ensure that veterans get the benefits they deserve for disabilities connected to their military service. Building on previous work, we reported last November that the need for adjudicator judgment results in inherent variation in the decision-making process. Examples where judgment is required include claims with conflicting medical opinions and claims for which disability standards are not entirely objective, such as those involving mental impairments or pain. In these cases, different adjudicators could reach different decisions about the severity of a veteran's disability depending on how they weigh various pieces of evidence. But it is still reasonable to expect that the extent of variation would be confined within an acceptable range as agreed to by knowledgeable professionals. Yet, we have reported and you have just heard the IG comment on why the state-to-state variations and average compensation payments per disabled veteran raise questions about consistency. Because of the need to reduce the risk of decisional inconsistency, we recommended that the Secretary develop a systematic, data-driven approach to identifying potential inconsistencies among VA's 57 regional offices and then to study those inconsistencies in detail with regard not only to awards but denial of benefits for specific impairments. VA concurred with our recommendation, but has not yet implemented it. The report we issued last week assessed VA's progress in improving consistency of the quality of medical information provided by VA physicians to regional offices for their use in deciding joint and spine claims. As you know, in the DeLuca case, the court held that VA claims adjudicators must consider whether range of motion is further limited by factors such as pain and fatigue during flare-ups or following the repetitive use of the impaired joint or spine. VA itself reported in a baseline study conducted in 2002 that fully 61 percent of exam reports on joint and spine impairments did not provide sufficient information to comply with DeLuca. We found that VA has made substantial progress since its 2002 study, decreasing the number of deficient exams from 61 to 22 percent. Three factors contributed to this progress: Creating the Compensation and Pension Exam Project Office to improve the disability exam process; providing extensive training to both VHA and VBA personnel; and establishing a performance standard for the quality of medical center exam reports. Nevertheless, more than one in five joint and spine exam reports still do not comply with DeLuca. And more improvement is needed to reduce the wide variations among VA's health care networks where deficient DeLuca exams range from eight percent in the best networks to forty-three percent in the worst. As a result, VA cannot reasonably assure that these veterans, no matter where they live, receive fair and equitable decisions on their disability claims. To continue the progress made so far, we recommended that VA use a strategy focused on improvement efforts within its health care networks, an additional performance measurement. VA concurred in principle with this approach. In conclusion, it is incumbent on VA to implement all of our recommendations relating to consistency. Until assessments of consistency become a routine part of VA's oversight decisions made by its regional offices, veterans may not consistently get the benefits they deserve for disabilities connected to their service, and taxpayers may lack confidence in the effectiveness and fairness of VA's disability program. While it would be unreasonable to expect that no decision-making variations would occur, we continue to urge VA to measure and limit inconsistency through systematic study, targeted improvements, and concerted performance measurement. And I would be happy to answer any questions you might have. MR. BRADLEY. Thank you. [The statement of Ms. Bascetta appears on p. 66] MR. BRADLEY. Mr. Staley, do you have an opening statement? MR. STALEY. No, sir. MR. BRADLEY. In that case, we will go right to questions. Mr. Wooditch, you indicate that one of the factors in the variances of decisions is insufficient medical exam reports. What is your sense of the working relationship between VBA and VHA? Are there clear guidelines between the two on what is needed to adjudicate a claim? MR. WOODITCH. I believe that VHA and VBA have made a lot of progress in the last few years to standardize templates in order to do medical examinations for rating purposes. As our report points out, very few people have access to these templates, but I know they are working together to improve the omission of data that has existed in past examination reports that is needed for rating purposes. And I think that they are making progress. MR. MILLER. [Presiding] I apologize for being late. We have been at a hurricane briefing for the State of Florida. Ms. Berkley, would you like to go ahead and ask your questions. MS. BERKLEY. Thank you, Mr. Chairman. I spent a lot of time with my veterans in Las Vegas, one, because I want to and, two, because they trust me and because of my position here on this Committee. They have grown to know that they can trust me and that I have their best interest at heart at all times. I meet with my disabled veterans a lot and I have had occasion to meet with those that have really suffered severe mental illness because of their service to this country. I admit one of the first veteran's cases that we took when I first came to Congress was at a town hall meeting where a Vietnam vet came to me with a stack of correspondence he had had with my predecessors who kept kicking back to him the same letters that we were getting from the VA that he was only 50 percent disabled as opposed to 100 percent disabled. And when he came to see me, it was very apparent within the first five minutes that this guy really had a serious problem and that we were doing a tremendous disservice to him because we never reviewed his case. We never looked at his case. We just kicked back the same stuff that was initially put in his file and nobody took the time to look behind that and see what was going on with this person. And after a whole lot of effort, we ended up ensuring that he was 100 percent disabled and I think that should have been the appropriate diagnosis from the beginning. And that was the first of many veterans that I have tried to help when it came to their rating for disability, especially when it comes to their mental health. This is an area that people do not like to acknowledge. It is an area that is subjective in many ways. I mean, you do not see an open wound. You do not see blood. You do not see broke bones. But you have a broken person in front of you. So I think it is a little more difficult to adjudicate. I do not know how much time you have spent with veterans, especially those with PTSD, but I have spent a considerable time. Did the IG expect that the VA would terminate benefits of veterans whose claims were reviewed? I mean, walk me through this. When we do this review of the 72,000 veterans that are 100 percent disabled, how do we do this and what do we expect from the veterans? And did we expect to terminate their benefits that they were accustomed to receiving? What was the thinking? MR. WOODITCH. The review started with trying to understand why the variance existed. We determined that 100 percent PTSD ratings was a primary contributor to that. When we looked behind it, we found what we called a 25 percent error rate in 2,100 cases. As I mentioned in my opening statement, the error rate is not an indicator of fraud. It is just an indicator of VBA not complying with its rules and regulations. The basis in doing the 72,000 review is to find out what the magnitude of the total population is with respect to this error rate. MS. BERKLEY. Are you going back and looking at cases where they were denied or people that have been adjudged 50 percent and maybe they are entitled to 100 percent? MR. WOODITCH. We did not look at denials. Denials did not contribute to the average payments in the state, so denial was not an issue for us. We just looked at approved claims. We did not look at the rating level to see whether or not it was an accurate rating level. All we looked at was whether or not the documentation that was required by law was, in fact, in the claims' folder to support the rating. MS. BERKLEY. And under what legal authority did we do that? MR. WOODITCH. The IG, under the "IG Act'' authority, has the mandate to look at compliance with rules and regulations. So it was a compliance issue. MS. BERKLEY. Well, according to 38 USCS Section 511, it says that the Secretary shall decide all questions of law and fact and that the Secretary's decision shall be final and conclusive except with a few exceptions. But I do not see how this fits into any of the exceptions. So how are we going about it? After these cases are adjudged and they are final, how do we go back and add additional stress to these veterans who are barely getting by on a day-to-day basis and tell them that they may not be entitled to this? How do you do that? Why would we be doing that? MR. WOODITCH. To go back and answer one of your earlier questions, our intent was never to terminate benefits. Our intent was to work with the veterans and their representatives to review unit records and other sources of information in order to come up with the documentation that was required by law in order to justify their ratings. MS. BERKLEY. Now, people with PTSD have high rates of suicide. We just heard of a tragic case in New Mexico. In recommending the review of finally-decided claims, did the IG take into account the risk of potential suicide or other violent behavior by asking the veterans to revisit their stressors? MR. WOODITCH. First of all, I am sorry to hear about that. It is a tragic incident. I think the problem here is information control. Our recommendation to review 72,000 cases was not intended to go out to all veterans and say we are going to review 72,000 cases. A lot of the review work can be done by looking at data systems or records within VA. In doing so, many of those cases could be eliminated from review. It is unfortunate that that impression is out there, this misinformation needs to be dealt with. MS. BERKLEY. Rather than go back and have these veterans who have already suffered serious stress because of their service in the military, why not develop the appropriate indicators for future cases? It would seem to me that the VA has the issue, not the veterans who have already been adjudicated to have PTSD at a 100 percent level. I mean, does it matter that they would be 95 or 90 percent? Does it save this country that much money that we would create additional burdens on these people who have already suffered so much? MR. WOODITCH. I agree with what you are saying. I think maybe if you just reviewed the 2,100 cases that VBA is doing, it would help to identify parameters for how we look at future cases. I think that the issue is worthy of discussion. we need to make a decision what we are going to do. MS. BERKLEY. And I would join with my colleagues in New Mexico and call for a halt to this. I think you have enough information and we have caused enough anguish. Thank you very much. MR. WOODITCH. Thank you. MR. MILLER. Mr. Bradley. MR. BRADLEY. Thank you very much, Mr. Miller. Ms. Bascetta, how do your findings regarding inconsistencies with VBA's decisions compare to the Social Security Disability system? MS. BASCETTA. We have spent an equal amount of time looking at both systems and in both cases, we find that neither SSA nor VA has tackled the consistency problem adequately in our view. In the Social Security case, it is a little bit different because their focus has been on looking at inconsistency between their appellate and their initial level. But we find in earlier work that they also among their disability determination services experience considerable inconsistency at the initial award level. The bottom line is that both agencies tell us that they are doing things to improve consistency such as improving training or tightening guidance to their offices. But neither one of them has actually measured how consistent their decisions are. And until they do that, we believe that program integrity just is not where it should be. MR. BRADLEY. You indicate that in applying the DeLuca criteria there have been substantial improvements in the joint and spine medical examination reports. Do you have recommendations as to how similar improvements can occur in PTSD exams? MS. BASCETTA. We actually looked at the CPEP report because in the DeLuca case, what the CPEP report shows is that the quality of medical exams certainly is an input that could be contributing to inconsistency. Actually, in the PTSD case, the data from CPEP show that they are doing pretty well in that domain with a couple of exceptions. At the initial review level, 25 percent of exams had problems in assessing the DSM-IV criteria and at the subsequent review level, almost two-thirds were inadequate with regard to an assessment of remission or readjustment capacity. So there is certainly something to look at in the medical exam area. But overall in that area, they were at 89 and 92 percent adequacy. So we think that to the extent that there is inconsistency in the PTSD decisions, something else, some other root cause must be driving it. So we go back to our broader recommendation and suggest that VA take a look at both awards and denials to find out where adjudicators may be weighing information differently or using different factors in ways that would create inconsistent outcomes. And perhaps the use of performance measures or other impairment-specific strategies would be helpful in eliminating or reducing the inconsistency. MR. BRADLEY. Thank you very much. MR. MILLER. Mr. Udall. MR. UDALL. Thank you, Chairman Miller. I'm trying to understand, Mr. Wooditch, first of all, what was your motivation for looking at PTSD and stressors? Was there some indication that came to you that there was some problem here or was this just something that was dreamed up in your shop? I mean, did somebody come forward and say we have a serious problem with the way the VA is doing this and that's what initiated it or was it an internal issue with your operation? MR. WOODITCH. It was an internal issue with the IG. We reviewed data from the 15 major body systems that disability ratings occur in. And as I mentioned earlier, we determined that in the mental disorder system

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