The witness will be able to discuss how the veteran interacts with others, which is a crucial part of PTSD. Second, veterans tend to forget important details about the exam.
If possible, the veteran should take the witness into the examination room with them. Unfortunately, the examiner frequently denies this request. Even if the witness cannot go with the veteran, it is important the veteran proceed with the exam. Remember, this exam is the chance to show how PTSD affects your life day-to-day.
What veterans sometimes feel are unimportant details could be the key to the claim. The examiner needs to know all the details. Nightmares are of the most intense symptoms of PTSD. Therefore, it is important to consider other symptoms like anger and difficulty dealing with authority. Loved ones usually are better at observing these, so written statements from those individuals may be helpful as well.
After the exam, the veteran will want to order a copy of the exam report. The veteran should check that the person doing the examination was the one who wrote the final report. This can lead to occupational and social impairment that prevents them from being unable to work.
It can also lead the veteran to be socially isolated. As important as it is to prove service connection, it is more important to make sure VA raters get the rating right.
This exam will include additional psychological testing. Too frequently, VA finds the veteran is malingering, instead of finding evidence for a rating increase. Malingering is not a mental illness. Clinicians are often able to offer an informed opinion on this question, but this is a professional judgment, not an empirically testable finding. The committee believes that it is possible to reduce the difficulties encountered in dealing with situations where PTSD co-exists with other mental disorders.
The committee recommends that a national standardized training program be developed for clinicians who conduct compensation and pension psychiatric evaluations.
This training program should emphasize diagnostic criteria for PTSD and comorbid conditions with overlapping symptoms, as set forth in the DSM. A model training program would consist of a set of video-recorded interviews—including both simple and complex cases—with standardized evaluations of the severity of criterion symptoms for PTSD and common comorbid conditions, identification of the appropriate diagnosis or diagnoses, delineation of how to prepare and present findings in a manner useful to the rating process, and justification for the decisions made.
Training on the uses and limitations of the GAF as discussed above should be a part of this initiative. The Committee was charged with addressing whether standardized psychometric testing would be valuable and appropriate in the conduct of PTSD examinations for compensation purposes.
The second includes PTSD scales that are derived from self-report tests developed for other purposes. These reviews concluded that all the tests for PTSD, including those derived from other scales see below , have good to excellent reliability and validity. The chapter by Keane and colleagues is most germane because it specifically addresses assessment of military-related PTSD.
However, because the prevalence of exposure to sexual assault and sexual harassment is high among. As noted in a number of sources Keane et al. All of these tests include items that measure each PTSD symptom, and all provide some scaling of the score based on the frequency or intensity of recently experienced PTSD symptoms.
It has been used frequently among veterans, but a version for civilians has also been developed Keane et al. The PK scale Keane et al. The PK scale has good reliability and validity, particularly when the diagnostic criterion of PTSD is measured using rigorous clinician-administered structured interviews for PTSD at the diagnostic level Keane et al.
The Symptom Checklist SCL; Derogatis, is a self-report test that has nine subscales measuring somatization, depression, anxiety, phobic anxiety, hostility, and four other characteristics using a 5-point rating scale for each of the 90 items. The SCL has been used extensively, has excellent reliability and validity, and has extensive norms. Ursano and colleagues Ursano et al.
This scale has good reliability as well as good sensitivity and specificity in samples of disaster and motor accident victims. The MMPI-2 and SCL are used widely in clinical assessment for posttraumatic stress reactions, and both these tests yield clinically useful information Elhai et al.
However, the same caveat exists about these scales as was true for the other tests measuring PTSD symptoms: they should not be used to make a PTSD diagnosis in a clinical assessment situation. Resnick notes that there are actually three types of malingering: 1 pure malingering , for example, complete fabrication of symptoms of traumatic events that are alleged to produce symptoms; 2 partial malingering , such as exaggeration of symptoms or embellishing traumatic events; and 3 false imputation , an intentionally inaccurate attribution of symptoms to a traumatic event.
Obviously, each of these three types of malingering could apply not just to symptoms but also to other areas of impaired functioning or disability. Rogers and Cruise highlight the high stakes involved in misclassification of malingering cases in forensic settings:. The devastation to defendants or plaintiffs of being falsely accused of malingering by forensic experts is unimaginable.
Conversely, undetected. In the context of assessment for service-connected disability status for PTSD, the consequences of falsely accusing a veteran of malingering are no less devastating. It is thus important to use the best methods possible to detect real cases of malingering. Notwithstanding the need for a reliable, valid way to detect malingering, experts agree that there is no magic bullet or gold standard for doing so Guriel and Fremouw, ; Resnick, ; Rogers, ; Wilson and Moran, In the type of clinical assessments used to determine service-connected compensation for PTSD, there is rarely clear, definitive evidence that pure malingering as defined by Resnick has occurred.
For that reason, in the research literature on malingering for PSTD there are no ecologically valid studies that have carefully ascertained pure malingering status criterion groups that is, malingering cases versus true cases using real-world assessment situations Guriel and Fremouw, Several investigators have used response set or validity scales from self-report measures such as the MMPI and MMPI-2 to indirectly infer the possibility of malingering Guriel and Fremouw, ; Taylor et al.
Test responses are then compared to responses from comparison groups or to responses from groups of people known to have the disorder in question. By comparing the response set or validity scale scores of the group simulating the disorder with those of the comparison group, researchers attempt to infer malingering.
But simulation designs fall short of real-life forensic-assessment situations in several ways that severely limit external validity or generalizability Guriel and Fremouw, ; Rogers and Cruise, Known-group-comparison designs involve comparing the test responses of individuals who are known to be malingering a specific disorder versus those who actually have the disorder, but studies using this design are plagued by the difficulty in identifying which individuals are actually responding dishonestly Guriel and Fremouw, A third basic type of study design has been called differential prevalence Rogers and Cruise, It compares test scores including validity scales measuring response sets of groups that are presumed to differ in response sets.
For example, such studies generally compare groups of veterans who are seeking service-connected compensation for PTSD versus those who are not, under the assumption that applying for disability increases the likelihood that malingering will occur. Some have argued that the MMPI and MMPI-2 are objective measures of psychopathology and that the validity scales provide objective evidence of whether respondents are likely to be malingering for example, Arbisi et al.
Clearly, their validity scales can be useful in providing some information about response set, but scores on these scales cannot provide definitive objective information on whether a respondent is malingering.
Reviewers who have examined the research literature on PTSD malingering conclude that there are major limitations with simulation designs, known-groups-comparison designs, and differential-prevalence designs Guriel and Fremouw, ; Rogers and Cruise, These limitations suggest that it is insufficient to use response-set validity scale scores from the MMPI, MMPI-2, or any other test as the sole basis for alleging that a veteran is malingering with respect to PTSD status.
The committee agrees but cautions that as reliable, valid, and sensitive measures of malingering, the MMPI-2 and other standardized tests have serious limitations that should be recognized. The VA charged the committee to address whether the scientific literature supports the existence of a form of PTSD where there is a long time interval between the stressor and the onset of symptoms.
This is a question that has received considerable research attention. However, the issues related to the duration between exposure to a stressor and.
Determining whether an apparent case of delayed-onset PTSD is actually delayed poses challenges in both clinical and research settings. The difficulty can be attributed to several factors. Foremost, it is rare that a careful longitudinal assessment has been conducted, with data collection beginning soon after exposure to a stressor and continuing long enough to establish 1 the developmental trajectory of PTSD symptoms, 2 the documentation of diagnostic criteria, and 3 the full diagnostic assessment itself.
Such information is needed to determine with some degree of confidence how long after exposure symptoms occurred, which and when individual diagnostic criteria manifested, and when and under which version of the DSM all diagnostic criteria for the PTSD diagnosis were met. Additionally, there exists a subpopulation of veterans with PTSD who do not seek mental health treatment services or compensation from the Department of Veterans Affairs at the time of the onset of the disease.
Some individuals exposed to potentially traumatic events, including war-zone stressors, develop subthreshold PTSD—that is, they meet some of the B, C, and D criteria for PTSD see Table but not all, or they fall one or two symptoms short of meeting full diagnostic criteria. Such individuals may not have a history of full PTSD, but with slight increases in symptomatology these cases can cross the diagnostic threshold to become full PTSD.
Thus, what appears to be a new, delayed-onset case may actually be someone who for years has experienced symptoms just short of the benchmark criteria required for PTSD diagnosis and who becomes a case due to a small increase in symptomatology. There are numerous risk and protective factors that influence how exposure to war-zone and other traumatic stressors leads to the development of PTSD and thus play a role in the timing of PTSD onset.
Protective factors, such as high IQ, intact cortical functioning, and strong social support networks, may originally act to suppress or mitigate PTSD symptoms but then later erode with advancing age, reducing their protective value against PTSD.
Or some people with chronic PTSD and related loss of function may. The often-seen consequences and comorbidities of PTSD, such as substance abuse, depression, panic, and somatic symptoms, may heighten PTSD-related loss of function as they manifest and make a person more likely to seek help as time goes on.
And substance abuse can represent attempts at self-medication, which may lead some to delay seeking care or compensation until much later than the actual trauma occurred.
However, it should be recognized that seeking care or compensation for PTSD years after an inciting event does not necessarily mean that the disorder was of delayed onset per se.
It is also the case that risk factors, such as exposure to a new traumatic stressor or vicarious exposure to stressors via extensive media coverage of new wars, can increase over time. Just as in the case of a decrease in protective factors, an increase in risk factors might be expected to produce cases of PTSD that were apparently of delayed onset but that would be more correctly viewed as subthreshold cases that were exacerbated by events that occurred long after exposure to war-zone stressors.
Approximately 40 percent of those diagnosed with PTSD in the first seven months after serious combat injury—having been screened at one, four, and seven months—did not have the diagnosis until seven months after combat injury Grieger et al.
There are also many documented cases of even longer delays in PTSD onset. Among Israeli veterans of the Lebanon War who were followed for 20 years after the war, approximately 5 percent of those who had a combat stress reaction but no PTSD in the first three years postcombat met PTSD criteria at the year follow-up. Even more striking, of those who had neither a combat stress reaction nor a diagnosis of PTSD at 1, 2, or 3 years postcombat, approximately 9 percent had PTSD 20 years postcombat Solomon and Mikulincer, Those with PTSD related to combat trauma were about 4.
In addition, of the five patients with delayed-onset PTSD, four of them had not been diagnosed with acute stress disorder in the first month after the accident although in general they did have higher symptom levels at one month than those who never had PTSD during the period of follow-up. Roughly half 47 percent of the PTSD cases seen in a cohort of injury admissions to the trauma service of a hospital were delayed-onset cases, where PTSD was observed at 12 months but not at 3 months Carty et al.
One study of delayed-onset PTSD after motor-vehicle accidents reported that 20 percent of the cases of the PTSD diagnosed during one year of follow-up after the accident were delayed-onset cases Ehlers et al. Other studies of motor-vehicle-accident cohorts have reported from 8 percent Koren et al. In a long-term follow-up study of a ship disaster Yule et al.
Delayed-onset PTSD is consistently observed, albeit in a fraction of the overall PTSD cases, and data indicate that delayed-onset PTSD is perhaps more common among those exposed to war-related trauma than among those exposed to other kinds of trauma.
A number of factors have been found to be associated with the delayed onset of PTSD in previously undiagnosed individuals, including the occurrence of negative life events, decline in self-esteem, ethnicity, and negative health changes.
Late life brings additional challenges to the assessment, diagnosis, and trajectory of war-related PTSD Davison et al. Cognitive decline, life losses, medical illness, increased feelings of powerlessness, and the psychological changes related to decreased autonomy and. However, little empirical research addresses these issues directly. Based on its review, the committee concludes that the scientific literature supports the existence of a form of PTSD that manifests long after the occurrence of the stressor upon which the diagnosis is based.
In addition, clinical experience indicates that some persons who are exposed to traumatic events may develop PTSD that is not recognized for an extended period of time and that others may develop some symptoms of PTSD that do not cross the diagnostic threshold to become incident cases of full PTSD until long after exposure to the stressor.
The scientific literature does not identify any differences material to the consideration of compensation between these delayed-onset or delayed-identification cases and those chronic PTSD cases where there is a shorter time interval between the stressor and the onset of symptoms. The committee did not address the issue of whether there may be differences relevant to treatment decisions. On the basis of the review of the papers, reports, and other information presented in this chapter, the committee has reached the following findings, conclusions, and recommendations, and identified the following research needs.
The scientific literature supports the existence of a form of PTSD that manifests long after the occurrence of the stressor upon which the. In the short term, VA should ensure that its mental-health professionals are well informed about the uses and limitations of the GAF, that it make certain—to the extent possible—that these professionals are trained to implement the GAF in a consistent and uniform manner, and that it provide periodic, mandatory retraining to minimize drift and variation in scoring over time and across facilities.
In the longer term, VA should identify and implement an appropriate replacement for the GAF: one or more measures that focus on the symptoms of PTSD used to define the disorder and on the other domains of disability assessment.
The research needed to accomplish this effort should be facilitated. A national standardized training program should be developed for VA and VA-contracted clinicians who conduct compensation and pension psychiatric evaluations.
Psychological testing may be a useful adjunct to the PTSD compensation and pension examination, but the committee recommends that the decision of whether to test and of which tests are appropriate should be left to the discretion of the clinician—the person who is best able to evaluate the individual circumstances of the case. Journal of Nervous and Mental Disorders — Violence and Victims 6 3 — Psychological Services 1 1 — Self-Selfreport and physician-rated health in combat veterans with posttraumatic stress disorder.
However, he is a Vietnam veteran and we have session where the first half is about me and the second half is about him. We understand each other and as is often the case, we feel better venting our frustrations with that war. Like him as a psychiatrist I am also required to have a mentor.
So I have the luxury of having one who is well known, well regarded, and is probably one of the worlds leading experts in PTSD. He got me to where I am today. Good book; a lot like the Bible, but few people follow it explicitly. Patrick, maybe I wasn't altogether clear with the intent I had for posting the OP.
I do agree with all you said, but my intent would probably be more clear to the VBN reader by restating the following parts of the OP: " That statement from Page 6 part of the Executive Summary : " So what I am saying is that I never indicated or suggested that the manual should be being followed by rote, just that knowing what it says may help veterans to better understand what their own exam accomplished or help them to obtain a better exam.
Hopefully this clarifies my intent with the original post. Your point is well taken, but a good examiner should be able to ask the right questions of the examinee to make an informed decision.
Even the form I posted does not cover it all because the circumstances the veteran faced may be different. For example, a person who suffered from MST will find the application of this manual and the examination requirements misleading.
Both instruments are geared for veterans who have been in combat. It is biased toward combat issues: There is mention of sexual assualt, but it is gleened over in favor of combat veterans. Military History dates and location of war zone duty and number of months stationed in war zone describe routine combat stressors veterans was exposed to refer to Combat Scale ombat wounds sustained describe I know during my time I may have run across the manual you spoke of once or twice.
But the average veteran would not have access to it as it is meant for clinical people much as is the case for DSM-IV. Not to belabor the point, and agree that "trying to interpret it is another thing" if strict interpretation alone is the intent of the reader, but just in case you did not rereview the Manual, there are 45 references to the word "sexual" in the Manual that cover both male and female sexual situations that may have bearing on a PTSD condition.
These include a larger share of claims with eight or more issues, more reopened claims submitted by veterans with chronic progressive conditions, additional claims submitted by the aging veteran population, and the claims submitted by veterans of Operation Iraqi Freedom OIF in Iraq and Operation Enduring Freedom OEF in and around Afghanistan.
In addition to the increasing number of disabilities claimed, VA reports that the nature of the disabilities has become more complex. Cases remanded by BVA also add to the workload and increase claim processing time. The inventory of remanded cases was 21, at the end of FY VA, b. Remands are discussed more fully below. As discussed earlier, veterans dissatisfied with the decision made by the regional office may file an appeal by submitting an NOD contesting the denial of service connection, rating level given, or effective date of the grant.
According to BVA, the appeal rate on disability determinations has historically been about 7 percent. More recently that rate has climbed from about. In FY , the appeal rate was about 13 percent—down from a high of 16 percent in FY , but still well above historical averages. During the same period, the rate of formal appeals based on number of VA Form 9s filed after the veteran receives the statement of the case from VBA was 6 percent in FY , down from 7 percent in FY , but more than double the rate in FY Figure As a result of this increasing workload, BVA has struggled to process appeals within a reasonable time period.
This increase was caused in part by the increased number of cases decided that could be appealed, but it is also caused by the greater propensity of veterans to appeal.
Many NODs are resolved by the regional office or when the veteran does not pursue the appeal, but the number of formal appeals was still higher in FY than in FY The annual number of BVA decisions, however, has not increased.
This does not include the substantial number of appeals being worked on by the appeals teams in regional offices and the Appeals Management Center, which was established by VBA in to consolidate expertise in processing remands from BVA Figure This continued a steady increase since FY , but was an improvement from the days it took in FY Figure Another 11, were resolved at the field office level after VA Form 9 was submitted.
That left 29, appeals, of which BVA resolved 25, and remanded 4, to the field offices for further development VA, b:6B BVA decided 39, cases involving disability compensation specifically in FY It upheld the field office denials 46 percent of the time,. The court received 3, appeals in FY During the same three years, the same court reversed the BVA decision or remanded the case for further development 50—60 percent of the time U. Court of Appeals for Veterans Claims, There were appeals to the federal circuit court in FY , the highest since FY , when appeals were filed Figure Remands are not considered to be final decisions in this measure.
Also not included are cases returned as a result of a remand by the CAVC. By law, BVA must decide on appeals in the order in which they were entered on the docket. If BVA remands a case to the regional office, and that case is subsequently returned to BVA for a decision, which happens about 75 percent of the time Terry, b , the returned case takes precedence over appeals currently before BVA.
If, as expected, 75 percent of the remands are returned to BVA after further development, they will constitute 30—40 percent of the 35,—40, cases decided by BVA each year in FY , for example, BVA received 14, remands returned by the Appeals Management Center and regional offices for decision, equal to 37 percent of BVA decisions that year VA, a:7C In , in response to a recommendation of the Claims Processing Task Force, BVA established an evidence development unit to develop evidence needed to make a final decision or correct a procedural error in cases that otherwise would have to be remanded.
The remand rate began to increase again, from 19 percent in FY to 43 percent the next year to 57 percent in FY In , the VA deputy secretary charged the under secretary for benefits and the chairman of BVA with developing a comprehensive plan to reduce the number of avoidable remands.
As part of that effort, a joint working group analyzed a representative sample of explanations for past remands and began to track them prospectively. The initial analysis of remand cases identified precertification reasons for the remands.
These steps include. NOTE: Other medical records include military service, VA, and private medical records that should have been requested but were not, or if requested but not forthcoming, were not followed up. Nonmedical reasons for remands have to do with duty to notify lack of, incorrect, or inadequate notices to appellants , duty to assist not obtaining nonmedical service and other records , and due process not following procedural rules.
VA has made accuracy of disability benefit decisions one of the key measures in its annual performance and accountability plans. STAR review of a rating-related case determines if the benefit. If the adjudication of the case fails any of these standards, it is classified as incorrect in the accuracy rate calculation.
STAR review also determines if there is adequate and correct decision documentation and proper notification of the decision, although these scores are not in the performance and accountability plan. During the year ending May 31, , VBA reviewed 6, rating cases and found the national benefit entitlement accuracy rate to be 88 percent and the decision documentation and notification rate to be 90 percent VA, a The entitlement accuracy rate was less than 60 percent in FY It improved steadily to 87 percent in FY , leveling off at approximately the same rate in FY 84 percent and FY 88 percent Figure The Claims Processing Task Force recommended that VBA measure them separately so that the benefit entitlement accuracy rate would only include items that, if inadequate, could result in remand from BVA.
The actual number of cases reviewed has been less—6, in FY VBA randomly samples rating cases per regional office each year, except it conducts annual rating reviews for the four largest regional offices and the six regional offices with the lowest overall accuracy VA, d.
Offices with low accuracy rates are required to implement corrective action plans. Trends in error types are used to design national training programs and to identify needed regional office-specific training, which is offered during site visits VA, a. Another indicator of accuracy problems is the percentage of initial decisions that are either reversed or remanded by BVA. In FY , BVA reversed the initial regional office denial decision on at least one issue claimed by the appellant in 19 percent of cases and remanded another 32 percent of the cases, suggesting problems with just over half the cases reviewed.
Although this is lower than the historical rate of about 60 percent, it still represents a substantial portion of the decisions BVA, BVA also has a quality assurance program that analyzes a sample of its own decisions to determine the percentage that have substantive or procedural deficiencies that would be expected to result in a reversal or a remand by the court.
Deficiencies are identified in five areas: issues, findings of fact, conclusions of law, reasons and bases, and due process. BVA also uses the results to determine areas of training emphasis. VA has only recently undertaken an effort to assess consistency of decision making across regional offices and adjudicators.
It is not a new issue. In a report on VA claims processing mentioned earlier , NAPA concluded that consistency would be difficult, at best, to achieve across 58 field offices. It also found that the quality assurance process did not address consistency:.
There is no current measure of decision consistency within the system, and on data collected to inform management regarding to what extent consistency may be a problem. Given the differing types of medical issues and cases within the system which in many cases require subjectivity such as psychiatric cases as compared with orthopedic cases , there is need to bound types of medical issues and the degree of subjectivity, set consistency standards, measure this as part of a QR process or through blind testing of a control case by several regions , and accumulate data NAPA, The task force noted the large disparities in average compensation payments across states, differences in appeal rates and results of appeals in terms of reversal and.
GAO identified lack of consistency as a problem in a series of reports:. Even though available evidence provides indications that variations in decision making may occur across all levels of VA adjudication, VA does not conduct systematic assessments to determine the degree of variation that occurs for specific impairments and to provide a basis for determining ways, if considered necessary, to reduce such variation GAO, a This makes it crucial that VA have a system for routinely identifying variations among its 57 regional offices so that such variations can be studied to determine if they are within the bounds of reasonableness and, if not, how to correct the problem.
Also … VA must deal with issues involving not only its regional offices but also its medical centers that conduct most of the disability examinations that regional offices rely on to provide the medical information they need to make disability decisions GAO, The report also looked at the differences in the percentages of veterans receiving compensation across states, which ranged from 6.
The inspector general could not analyze variations in grant rates, however, because VBA did not track them at that time. The report looked at correlations of explanatory factors with average payments one by one; a multivariate analysis was not done with average payment as the dependent variable or with other dependent variables of interest, such as percentage of veteran population receiving compensation or average combined rating degree.
The report concluded that. VBA should develop a comprehensive and systematic method for collecting data on factors impacting variance in payments that will enable VA to model the compensation claims process and predict outcomes.
In the course of the study, the inspector general collected information on state differences in the average number of service-connected disabilities per veteran, average combined degree of disability, average ratings for each of the 14 body systems, percentage of veterans service connected for PTSD, percentage of veterans with ratings of percent and with individual unemployability, and STAR error rates, each of which shows substantial state-to-state variability.
The average number of service-connected disabilities, for example, ranges from 2. The average combined rating degree ranged from 33 to 45 percent across the states. The rate of service connection for PTSD also varies by state, ranging from 4. The number of veterans service connected for IU ranged from 2. Overall STAR accuracy rates varied from 76 to 96 percent, while the median rate was 88 percent see Figure BVA data for FY also shows wide geographical variation in appeal reversal and remand rates.
Depending on the regional office from which cases originate, BVA remanded appeals between 22 and 65 percent of the time. Appeal allowance rates by region varied from 7 to 34 percent. BVA upheld the original denial in 63 percent of appeals from one office but in only 15 percent of appeals from another office BVA, Concerns with consistency are not limited to geographic variations. Regional office decisions on some conditions are much more likely to be reversed or remanded on appeal than are others.
Table lists the diagnostic codes present in cases that VLJs were most likely to reverse or remand, and those diagnostic codes present in cases that they were least likely to reverse or remand. Differences in judgment are inevitable in evaluating impairment and functional capacity, more for some conditions than others, depending on how subjective are the criteria; therefore, some degree of variation is inevitable.
However, wide variation may be an indicator of inconsistent decision making. In addition, high reversal or remand rates may also indicate that the evaluation criteria are not as clear or appropriate as they should be. In , NAPA pointed out that the large number of regional offices was a source of inconsistency and inefficiency.
The Claims Processing Task Force. In , a VBA task force on field office restructuring recommended some consolidations of compensation and pension functions, citing the following advantages:. During the s, VBA consolidated loan guaranty work in four regional centers, education benefits in four regional processing centers, and insurance in one national service center.
More recently, VBA consolidated the income and eligibility verification work of the pension program in three regional offices, and is planning to consolidate all pension work in these offices. To deal with the jump in pending claims, VBA established the tiger team unit at one regional office and established resource centers at nine regional offices to specialize in claims of older veterans. VBA centralized dependency and indemnity compensation claims by survivors of servicemembers who die on active duty in a casualty assistance unit in the Philadelphia regional office.
BDD claims are also handled in a few regional offices. Nevertheless, the VSOs do not favor consolidating regional offices because they do not want to lose access to adjudicators or make it more difficult for veterans to appear in person before DROs who are reconsidering initial denials of their claims.
The quality and completeness of the medical information needed to apply the criteria in the Rating Schedule are critical to the disability compensation claims process for veterans. Obtaining needed medical information affects the timeliness, accuracy, and consistency of adjudication decisions. It requires the predetermination team to request the correct information needed from the medical examiners, examiners to conduct thorough examinations and report the results completely and accurately, and raters to interpret the medical information in light of the criteria in the Rating Schedule.
It also requires VHA to ensure that the expertise of the examiner or examiners is appropriate for the condition or conditions being evaluated, especially for complex conditions such as PTSD, TBI, and polytrauma encountered in veterans of the current wars in Iraq and Afghanistan. VA has made a great deal of progress during the past 10 years in upgrading the medical evaluation process. Examination worksheets—two-to three-page outlines of the elements that must be addressed—for the most common conditions encountered in disability claims were developed.
They were made available to examiners online to view and download. Currently, VA is developing intelligent interactive examination templates that structure the input needed in each case, which increases completeness and timeliness. VA does not, however, have a regular process for updating the worksheets, most of which date from Committee members evaluated some of the worksheets in light of the criteria in the Rating Schedule and current medical knowledge and found problems with outdated tests and examinations.
Some of the problems stem from outdated criteria in the Rating Schedule. For example, rating of intervertebral disc syndrome relies on the duration of incapacitating episodes to assign 10 percent 1—2 weeks , 20 percent 2—4 weeks , 40 percent 4—6 weeks , or 60 percent 6 weeks or more.
Incapacitating episodes are defined as bed rest prescribed by a physician, although bed rest is not the standard treatment for back problems. Recommendation VA should develop a process for periodic updat ing of the disability examination worksheets. This process should be part of, or closely linked to, the process recommended above for updat ing and revising the Schedule for Rating Disabilities. There should be input from the disability advisory committee recommended above see Recommendation VA does not require examiners to use printed-out examination worksheets and, consequently, many examiners do not use them.
Although use of the online examination templates has increased rapidly presumably because of their ease of use , VA also does not require their use—although it is considering such a mandate. VBA rating personnel have seen only a limited number of examination reports submitted in the template format.
VSC personnel at five of the seven VAROs indicated that they either have not seen any examination reports completed in the template format or they have only seen a limited number completed by one medical center in their area. Use of the templates was more frequent at medical centers serving the other two VAROs.
According to VBA management, they are engaged in an effort to review and approve the report templates VA, b In the same report, the inspector general went on to recommend that the examination report templates be made mandatory, and that VA needed to ensure that medical and rating staff are familiar with the templates and that they are used consistently. The VA undersecretary for benefits concurred with this recommendation, and stated:. We will continue to work with the Veterans Health Administration to improve the quality of medical examinations performed to support disability compensation evaluations.
We will work with the CPEP Office to ensure that all automated examination report templates thoroughly and accurately solicit the medical evidence needed to consistently evaluate the disability. We will also work with VHA to establish a formal approval process for the templates and to obtain agreement on the mandatory use of approved templates VA, b By June , more than , examinations had been completed using the report templates, but they were still not mandatory, despite the fact that early results had shown template examination reports to have.
In addition, template reports were released from 7 to 17 days sooner than dictated reports. VA should mandate the use of the online tem plates that have been developed for conducting and reporting disability examinations. Improvement in meeting the quality indicators has been rapid since when the effort began.
The percentage of examinations meeting 90 percent of the quality indicators was 86 percent in January , much better than the 58 percent achieved three years earlier. However, this percentage is still too low. Another concern is that the quality indicators used in the QR process are more procedural rather than substantive.
They are measures of the presence or absence of a particular worksheet item in the report, not of whether the examination was good. Independent examinations of a sample of claimants to assess inter-rater reliability are not performed. Recently, CPEP began to assess the quality of the examination requests, which is critical.
Previously, if the examiner provided percent of the information requested, but the request was not correct, the QR system counted it as a quality examination. The next step would be for VA to make the quality of examination requests part of the performance program for predetermination teams and regional office directors.
In addition, the QR program currently does not directly assess consistency among examiners. It relies on improving accuracy to narrow the differences among examiners and VISNs. VA should establish a recurring assessment of the substantive quality and consistency, or inter-rater reliability, of examinations performed with the templates, and if the assessment finds problems, take steps to improve quality and consistency, for example, by revising the templates, changing the training, or adjusting the per formance standards for examiners.
This substantive assessment should be part of the QR audit and include a mechanism for random sampling. The training program should include examples of well-done and complete reports. The accuracy rate has improved from 64 percent in to 80 percent in FY , and to 88 percent in FY Although this represents substantial improvement, it still shows that one of every nine rating decisions is incorrect, and this leaves considerable room for further improvement.
In addition, the STAR accuracy rate is based on a relatively small sample—only large enough to determine the aggregate accuracy rate of regional offices.
It does not assess accuracy at the body system or diagnostic code level, and it does not measure consistency across regional offices. The results would be used to identify needs for additional training, better guidance, procedural changes, or regulatory changes U.
Ten subject-matter specialists were assigned to review 1, regional office decisions, followed by studies of additional conditions. These analyses were not made public. VA will analyze ratings and claims data to track any unusual patterns of variance for further consistency review.
Integrated systems and better data sharing will improve the quality of decision making by providing more accurate information to claims adjudicators. There are many sources of variability in decision making that, if not addressed and reduced to the extent possible, make it unlikely that veterans.
These studies are used to identify where additional guidance and training are needed to improve consistency and accuracy, as well as to drive procedural or regulatory changes.
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