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Suggested Citation:"Front Matter." Institute of Medicine. 2007. A 21st Century System for Evaluating Veterans for Disability Benefits. Washington, DC: The National Academies Press. doi: 10.17226/11885.
×

A 21st CENTURY SYSTEM FOR EVALUATING VETERANS FOR DISABILITY BENEFITS

Committee on Medical Evaluation of Veterans for Disability Compensation

Board on Military and Veterans Health

Michael McGeary, Morgan A. Ford, Susan R. McCutchen, and David K. Barnes, Editors

INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

Washington, D.C.
www.nap.edu

Suggested Citation:"Front Matter." Institute of Medicine. 2007. A 21st Century System for Evaluating Veterans for Disability Benefits. Washington, DC: The National Academies Press. doi: 10.17226/11885.
×

THE NATIONAL ACADEMIES PRESS

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NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance.

This study was supported by Contract No. V101 (93) P-2136 between the National Academy of Sciences and United States Department of Veterans Affairs. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project.

Library of Congress Cataloging-in-Publication Data

A 21st century system for evaluating veterans for disability benefits / Committee on Medical Evaluation of Veterans for Disability Compensation, Board on Military and Veterans Health ; Michael McGeary … [et al.], editors.

p. ; cm.

Includes bibliographical references.

ISBN-13: 978-0-309-10631-3 (pbk. : alk. paper)

ISBN-10: 0-309-10631-1 (pbk. : alk. paper) 1. Disabled veterans—United States. 2. Disability retirement—United States. 3. Military pensions—United States. I. McGeary, Michael G. H. II. Institute of Medicine (U.S.). Committee on Medical Evaluation of Veterans for Disability Compensation. III. Title: Twenty-first century system for evaluating veterans for disability benefits.

UB373.A113 2007

362.4086′97—dc22

2007027713

Additional copies of this report are available from the

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Copyright 2007 by the National Academy of Sciences. All rights reserved.

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The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.

Suggested citation: IOM (Institute of Medicine). 2007. A 21st Century System For Evaluating Veterans For Disability Benefits. Washington, DC: The National Academies Press.

Suggested Citation:"Front Matter." Institute of Medicine. 2007. A 21st Century System for Evaluating Veterans for Disability Benefits. Washington, DC: The National Academies Press. doi: 10.17226/11885.
×

“Knowing is not enough; we must apply.

Willing is not enough; we must do.”

—Goethe

INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES


Advising the Nation. Improving Health.

Suggested Citation:"Front Matter." Institute of Medicine. 2007. A 21st Century System for Evaluating Veterans for Disability Benefits. Washington, DC: The National Academies Press. doi: 10.17226/11885.
×

THE NATIONAL ACADEMIES

Advisers to the Nation on Science, Engineering, and Medicine


The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences.


The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering.


The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine.


The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council.


www.national-academies.org

Suggested Citation:"Front Matter." Institute of Medicine. 2007. A 21st Century System for Evaluating Veterans for Disability Benefits. Washington, DC: The National Academies Press. doi: 10.17226/11885.
×

COMMITTEE ON MEDICAL EVALUATION OF VETERANS FOR DISABILITY COMPENSATION

LONNIE R. BRISTOW (Chair), Former President,

American Medical Association, Walnut Creek, CA

GUNNAR B. J. ANDERSSON, Professor and Chair,

Department of Orthopedic Surgery, Rush University Medical Center

JOHN F. BURTON, JR., Professor Emeritus,

School of Management and Labor Relations, Rutgers University

LYNN H. GERBER, Director of the Center for Chronic Illness and Disability,

College of Nursing and Health Science, George Mason University

SID GILMAN, William J. Herdman Distinguished University Professor, Director,

Michigan Alzheimer’s Disease Research Center, Department of Neurology, University of Michigan

HOWARD H. GOLDMAN, Professor of Psychiatry,

School of Medicine, University of Maryland

SANDRA GORDON-SALANT, Professor,

Department of Hearing and Speech Sciences, University of Maryland

JAY S. HIMMELSTEIN, Assistant Chancellor for Health Policy, Director,

Center for Health Policy and Research, School of Medicine, University of Massachusetts

ANA E. NÚÑEZ, Associate Professor,

College of Medicine and Institute for Women’s Health and Leadership, Drexel University

JAMES W. REED, Chief of Endocrinology,

Grady Memorial Hospital,

Professor of Medicine and Associate Chair of Medicine for Clinical Research,

Morehouse School of Medicine

DENISE G. TATE, Professor, Director of Research,

Division of Rehabilitation Psychology and Neuropsychology, Department of Physical Medicine and Rehabilitation, University of Michigan

BRIAN M. THACKER, Regional Director,

Congressional Medal of Honor Society, Wheaton, MD

DENNIS TURK, Professor of Anesthesiology and Pain Research,

Department of Anesthesiology, School of Medicine, University of Washington

RAYMOND JOHN VOGEL, President,

RJ VOGEL and Associates, Mt. Pleasant, SC

REBECCA A. WASSEM, Professor of Nursing,

College of Nursing, University of Utah

EDWARD H. YELIN, Professor of Medicine,

Institute for Health Policy Studies, University of California, San Francisco

Suggested Citation:"Front Matter." Institute of Medicine. 2007. A 21st Century System for Evaluating Veterans for Disability Benefits. Washington, DC: The National Academies Press. doi: 10.17226/11885.
×

Project Staff

MICHAEL McGEARY, Study Director

MORGAN A. FORD, Program Officer

SUSAN R. McCUTCHEN, Research Associate

REINE Y. HOMAWOO, Senior Program Assistant

FREDERICK (RICK) ERDTMANN, Director,

Board on Military and Veterans Health and Medical Follow-up Agency

PAMELA RAMEY-McCRAY, Administrative Assistant

ANDREA COHEN, Financial Associate

WILLAM McLEOD, Senior Librarian

DAVID K. BARNES, Consultant

ROBERT J. EPLEY, Consultant

MARK GOODIN, Copy Editor

Suggested Citation:"Front Matter." Institute of Medicine. 2007. A 21st Century System for Evaluating Veterans for Disability Benefits. Washington, DC: The National Academies Press. doi: 10.17226/11885.
×

Reviewers

This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the NRC’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report:

Dan G. Blazer, Duke University Medical Center

Gerard N. Burrow, Dean Emeritus, Yale University School of Medicine

Molly Carnes, Departments of Medicine, Psychiatry, and Industrial & Systems Engineering and UW Center for Women’s Health Research, University of Wisconsin, Madison

Bruce M. Gans, Kessler Institute for Rehabilitation

Allen Heinemann, Department of Physical Medicine and Rehabilitation, Feinberg School of Medicine, Northwestern University

J. Gary Hickman, Former Director, Compensation and Pension Service, Department of Veterans Affairs

Richard T. Johnson, The Johns Hopkins University School of Medicine and Bloomberg School of Public Health and The Johns Hopkins Hospital

Arthur T. Meyerson, New York University School of Medicine

Page viii Cite
Suggested Citation:"Front Matter." Institute of Medicine. 2007. A 21st Century System for Evaluating Veterans for Disability Benefits. Washington, DC: The National Academies Press. doi: 10.17226/11885.
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Peter B. Polatin, Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center

Bonnie Rogers, Occupational Health Nursing Program, School of Public Health, University of North Carolina

Lewis P. Rowland, The Neurological Institute of New York, Columbia University Medical Center

Marc Swiontkowski, Department of Orthopaedic Surgery, University of Minnesota

Alvin J. Thompson, Emeritus Clinical Professor, University of Washington School of Medicine

John D. Worrall, College of Arts and Sciences, Rutgers University

Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Harold J. Fallon, Dean Emeritus, School of Medicine, University of Alabama at Birmingham, and Paul D. Stolley, Adjunct Professor, School of Medicine, University of Maryland. Appointed by the National Research Council and Institute of Medicine, respectively, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

Suggested Citation:"Front Matter." Institute of Medicine. 2007. A 21st Century System for Evaluating Veterans for Disability Benefits. Washington, DC: The National Academies Press. doi: 10.17226/11885.
×

Preface

As McCullough reports in his Pulitzer Prize winning book, 1776, Nathaniel Greene, one of George Washington’s most stalwart generals, wrote to John Adams on May 24, 1776, “that if Congress were to provide support for those soldiers maimed or killed, this in itself would increase enlistments and ‘inspire those engaged with as much courage as any measure that can be fixed upon.’” The scope of the concern for our servicemen and servicewomen has increased since then, of course, but there has been one unwavering constant: the desire of a nation to honor those who serve in our armed forces and to compensate for sacrifices incurred during military service.

Just prior to America’s entry into World War II, it was a common sight to see individuals with wooden “peg-legs” or eye patches covering an empty orbit. These were usually veterans of World War I. Our country’s entry into World War II had an enormous cost in life and treasure, but one of the more positive spin offs was a galvanizing of the field of bioengineering, leading to the development of improved prosthetics, along with a concern about the potential for rehabilitation. Over the subsequent years (and several wars) since then, we have progressed figuratively, and often literally, with the development of functioning prostheses and other assistive devices.

This IOM Committee on Medical Evaluation of Veterans for Disability Compensation notes in its report that our nation’s veterans benefits program has not kept a similar pace of progress in understanding disability. If one steps back in order to gain a multi-dimensional perspective, it could be argued that there is more emphasis being placed on the “dis” aspect of the word “disability” and less on the “ability” potential within the same

Suggested Citation:"Front Matter." Institute of Medicine. 2007. A 21st Century System for Evaluating Veterans for Disability Benefits. Washington, DC: The National Academies Press. doi: 10.17226/11885.
×

word. The original concern for the sacrifices made by those who serve our nation’s colors had it genesis in the Revolutionary War, when loss of limbs, eyes, or other body parts sharply reduced a person’s ability to support himself. This emphasis on anatomical loss persisted through the 19th century, was codified in the Rating Schedule developed to implement the War Risk Insurance Act of 1917, and retained with modifications in subsequent Rating Schedules, including the current one when it was developed in 1945. The architecture put in place at that time has been updated from time to time in a piecemeal manner, and some sections are largely the same as in 1945. There has been resistance to change the familiar and comfortable status quo, which is understandable, but this should not stand in the way of our ability to evaluate and compensate for disability based on up-to-date medical knowledge of impairment and function.

As the understanding of what constitutes disability has evolved, so has the ability to recognize and quantify the contributory components. The questions posed by the commission to this IOM committee reflect the uncertainties created by a lack of clear statement of purpose for the program, the use of an evaluation tool that has not kept pace with the changing dynamics of the likely losses incurred by our servicemen and servicewomen, and the changing economics of the workforce in America, as well as the changing social context into which our veterans return.

I deeply appreciate the willingness of the members of the committee that produced this report to serve in this timely effort to improve the system for compensating veterans for injuries and illnesses suffered while in military service. It was an important assignment. With members of the military being injured in combat nearly every day, the system of evaluating and rating disability should be as up to date as medical knowledge of impairment and its effects on a person’s functioning and quality of life permits. It also should have the capacity to keep pace with the constant advances in our understanding of the impacts of injuries and diseases that do not entail visible losses, for example, traumatic brain injury and posttraumatic stress disorder. The committee worked diligently to assess the current system and to develop the recommendations in this report. I thank the members for the time they spent in, and between, meetings to formulate the findings and recommendations. I also greatly appreciate the efforts of the staff and consultants who provided key assistance and support to the committee.

It is hoped this report will provide insight into how best to serve the needs of our men and women who left a civilian environment as individuals and entered into one in which they were trained to work and fight as a group, and who have experienced disability as a result. They have now returned to a society where the emphasis is again on them functioning as individuals, and our VA programs must facilitate that transition.

Suggested Citation:"Front Matter." Institute of Medicine. 2007. A 21st Century System for Evaluating Veterans for Disability Benefits. Washington, DC: The National Academies Press. doi: 10.17226/11885.
×

——

Since the preface (above) was drafted initially, the importance of ensuring an adequate system of veterans benefits has escalated sharply. Since the committee’s first meeting in May 2006, the U.S. military has continued to suffer steady casualties in Operation Enduring Freedom in Afghanistan and Operation Iraqi Freedom (OEF/OIF). Nearly 1.5 million servicemembers have been deployed to OEF/OIF. Of these, nearly 700,000 have separated from active duty and become veterans—some of them grievously wounded, physically or mentally, or both. This set of events has only heightened the need for a thorough review of the Schedule for Rating Disabilities, which contains the criteria used to evaluate the disabling effects of military service on servicemembers who are wounded, sickened, or otherwise injured. Additionally, the VA Rating Schedule is used by the military in their disability decision-making system, which has a slightly different primary focus, that of determining potential fitness for return to duty.

Recognition of the importance of ensuring an adequate system of veterans benefits also has escalated sharply. In February 2007, the Washington Post published a series of articles about problems facing injured service members being treated as outpatients at Walter Reed Army Hospital while on medical hold and awaiting a decision by the military on their disability status. The Post’s series resulted in a number of investigations, from a multitude of sponsors, of the adequacy of the military and VA systems of care and benefits.

While these inquiries are important and no doubt will result in needed changes, I do not think they will change the recommendations in this report, except perhaps to increase the impetus for implementing them. The VA claims process was largely shaped by the needs of veterans of World War II. It struggled to meet the needs of veterans of Vietnam and, more recently, of the first Gulf War. The current Rating Schedule is not as up to date as it should be in areas affecting many veterans. The musculoskeletal and neurological sections of the Rating Schedule have not been comprehensively updated since 1945, and other important sections, such as the one addressing mental disorders, have not been updated for more than 10 years. This is why the committee is recommending a complete overhaul of the Rating Schedule and establishment of a process for keeping it up to date. The committee is also recommending that the revisions be based in part on information about the effects of veterans’ impairments on their ability to function in society (including, but not limited to, employment) and their quality of life. This is in part because we now know that degree of impairment, on which most of the current Rating Schedule is based, does not always correlate with today’s understanding of degree of disability. Also, we have a better understanding of how to measure functional limitations.

Suggested Citation:"Front Matter." Institute of Medicine. 2007. A 21st Century System for Evaluating Veterans for Disability Benefits. Washington, DC: The National Academies Press. doi: 10.17226/11885.
×

Finally, some of the signature injuries incurred in OEF/OIF (e.g., closed head traumatic brain injury [TBI], posttraumatic stress disorder [PTSD]) are not visible or subject to a laboratory test and, instead, must be evaluated in terms of their functional consequences. Similarly, it is difficult to determine the disability resulting from multiple impairments (e.g., combinations of TBI, amputation, paralysis, loss of vision or hearing, PTSD, and depression) without referring to their net effect on a veteran’s functional capacity.

The committee respectfully hopes we have made the case for substantial change to be made and that our nation will respond to the challenge promptly and positively. Our veterans deserve no less.


Lonnie R. Bristow, M.D.

Chair

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Suggested Citation:"Front Matter." Institute of Medicine. 2007. A 21st Century System for Evaluating Veterans for Disability Benefits. Washington, DC: The National Academies Press. doi: 10.17226/11885.
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Acknowledgments

The committee and staff wish to thank many individuals for the information and views they provided during the course of the study. We particularly appreciate the support, guidance, and data we received from Rick Surratt, Ray Wilburn, Jim Wear, Steve Riddle, Jacqueline Garrick, and Kathleen Greve, Veterans’ Disability Benefits Commission. Marcelle Habibion, Department of Veterans Affairs’ (VA’s) contracting officer’s technical representative for the commission, was very helpful both by facilitating responses from the knowledgeable individuals to the many requests made by the committee, and in explaining VA operations and procedures and offering guidance as appropriate, particularly in facilitating the arrangement of site visits. George T. Fitzelle, VA Program Evaluation Service, was instrumental in arranging meetings with staff from the CNA Corporation, who are working with the commission on surveys and data analyses and who assisted the committee by coordinating their activities with ours.

VA staff (in alphabetical order) greatly assisted the committee by taking time out of their busy schedules to speak with and provide information about VA operations for the committee. These individuals included Mark Bologna, Daniel J. Cunningham, and Susan Perez from the Office of Performance Analysis and Integrity, Veterans Benefits Administration (VBA). Staff who helped further the committee’s understanding of VBA’s Compensation and Pension Service operations and the Veterans Health Administration’s compensation and pension examination process by making presentations to and answering questions from the committee, or by providing information, included Dr. Steven H. Brown, Ed Davenport, Catherine Dischner, Bradley B. Flohr, Kurt Hessling, Janice Jacobs, Dr. Patrick C. Joyce, Bradley

Suggested Citation:"Front Matter." Institute of Medicine. 2007. A 21st Century System for Evaluating Veterans for Disability Benefits. Washington, DC: The National Academies Press. doi: 10.17226/11885.
×

G. Mayes, Dr. Vicki Milton, Thomas J. Pamperin, Stephen C. Simmons, and Mike Wells. VBA’s Vocational Rehabilitation and Employment Service staff who provided information and spoke with the committee included Bill Borom and Fred Steier.

James P. Terry, chairman, and Steven L. Keller, senior deputy vice chairman, Board of Veterans’ Appeals, provided information and spoke with the committee about the board’s procedures. Betty Moseley Brown, associate director, Center for Women Veterans, offered valuable input about the center’s programs and procedures. The committee learned about the military disability program from Al Bruner, assistant director, Officer and Enlisted Personnel Management (Separation/Retirement), Office of the Under Secretary of Defense for Personnel and Readiness; Paul D. Williamson, president, Naval Physical Evaluation Board; and Lt. Col. Melissa J. Applegate, USAF, assistant director, Military Compensation, Office of the Under Secretary of Defense for Personnel and Readiness.

Dr. Elena M. Andresen, professor and chief, Epidemiology Division, Department of Health Services Research, Management and Policy, University of Florida Health Sciences Center, discussed defining and measuring quality of life. The committee also heard from Dr. Alan M. Jette, director, Health and Disability Research Institute, Boston University, about conceptualizing and measuring disability. Dr. William Narrow, American Psychiatric Institute for Research and Education and American Psychiatric Association (APA) Office of Research, gave an overview of DSM-V, the next edition of APA’s Diagnostic and Statistical Manual of Mental Disorders. Similarly, Dr. Robert D. Rondinelli gave an overview of the next edition of the American Medical Association’s Guides to the Evaluation of Permanent Impairment.

The committee wishes to thank individuals who were instrumental in arranging committee and staff site visits to several VBA regional offices and other facilities to enhance their understanding of actual operations. VA staff who worked with us in gaining approvals and making initial arrangements included Shana Brown, Central Office, and Beth McCoy, Office of Field Operations, Washington, DC. VA staff who hosted site visits included Joe Beaudoin and Earl Hutchinson, Veterans Service Center, Boston, MA; Judy Bilicki, Veterans Service Center, Detroit, MI; Paul Black, Veterans Service Center, San Antonio, TX; Mary L. Glenn and George C. Wolohojian, Veterans Service Center, Baltimore, MD; Larry Jordan, Veterans Service Center, Columbia, SC; Bill Kabel, Veterans Service Center, Atlanta, GA; Vickie Orlando and Pat Wicks, Veterans Service Center, Salt Lake City, UT; Jaime Ramirez and Frank M. Tejeda, [VA] Outpatient Clinic, San Antonio, TX; and Uli Willimon, Veterans Service Center, Oakland, CA.

Other individuals provided information about and represented the views of service and state organizations that work extensively with veterans.

Suggested Citation:"Front Matter." Institute of Medicine. 2007. A 21st Century System for Evaluating Veterans for Disability Benefits. Washington, DC: The National Academies Press. doi: 10.17226/11885.
×

These included Peter S. Gaytan, The American Legion; David Houppert, Vietnam Veterans of America; Sidney A. Lee, African American PTSD Association; Pat Rowe Kerr, Missouri Veterans Commission; Jerry Manar, National Veterans Service, Veterans of Foreign Wars; Leonard J. Selfon, United Spinal Association; and Rick Surratt, Disabled American Veterans.

We would like to thank Dr. Eric Christensen, Dr. Joyce McMahon, Dr. Laurie May, and Elizabeth Schaefer of the CNA Corporation; and Cynthia A. Bascetta, Dr. Carol D. Petersen, and Robert E. Robertson of the Government Accountability Office for their contributions as well.

We also received thoughtful comments from members of the public, including Dr. Craig Bash and John King.

Throughout the course of the study, the committee received several public comments that shed light on issues of concern. Committee and staff wish to thank those who followed our study’s progress and took the time to make comments that served to heighten our awareness of important issues to consider during the deliberations.

Finally, the committee wants to acknowledge the expert support of the IOM staff and consultants: Michael McGeary, study director; David K. Barnes and Robert Epley, consultants; Rick Erdtmann, board director; Morgan A. Ford, program officer; Susan R. McCutchen, research associate; Reine Y. Homawoo, senior program assistant; William McLeod, senior librarian (The National Academies); Andrea Cohen, financial associate; Pamela Ramey-McCray, administrative assistant; and Mark Goodin, copy editor.

Suggested Citation:"Front Matter." Institute of Medicine. 2007. A 21st Century System for Evaluating Veterans for Disability Benefits. Washington, DC: The National Academies Press. doi: 10.17226/11885.
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4

 

THE RATING SCHEDULE

 

92

   

 History,

 

93

   

 The Current Rating Schedule,

 

102

   

 Findings and Recommendations,

 

113

   

 Implementation and Cost Issues,

 

127

   

 References,

 

130

   

 Chapter 4 Appendix Table,

 

132

5

 

THE MEDICAL EXAMINATION AND DISABILITY RATING PROCESS

 

139

   

 Organization of the Veterans Benefits Administration,

 

140

   

 Medical Evaluation Process,

 

146

   

 The Disability Rating Process,

 

154

   

 Appeal Process,

 

157

   

 Disability Claims Process Issues: Timeliness, Accuracy, and Consistency,

 

166

   

 Findings and Recommendations,

 

189

   

 References,

 

196

6

 

MEDICAL CRITERIA FOR ANCILLARY BENEFITS

 

201

   

 Introduction,

 

201

   

 Ancillary Benefits,

 

206

   

 Task Force on Returning Global War on Terror Heroes,

 

224

   

 Issues,

 

226

   

 Findings and Recommendations,

 

228

   

 References,

 

231

7

 

INDIVIDUAL UNEMPLOYABILITY

 

232

   

 Background,

 

232

   

 Definition of Individual Unemployability,

 

233

   

 Origin and History of Individual Unemployability,

 

235

   

 Procedures for Determining Individual Unemployability,

 

235

   

 VA’s Proposal to Revise and Codify the Individual Unemployability Regulations,

 

238

   

 Current Status of Individual Unemployability: Growth and Controversy,

 

240

   

 Consistency in Individual Unemployability Decision Making,

 

242

   

 VA Responses,

 

244

   

 Findings and Recommendations,

 

246

   

 References,

 

250

Suggested Citation:"Front Matter." Institute of Medicine. 2007. A 21st Century System for Evaluating Veterans for Disability Benefits. Washington, DC: The National Academies Press. doi: 10.17226/11885.
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Suggested Citation:"Front Matter." Institute of Medicine. 2007. A 21st Century System for Evaluating Veterans for Disability Benefits. Washington, DC: The National Academies Press. doi: 10.17226/11885.
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Suggested Citation:"Front Matter." Institute of Medicine. 2007. A 21st Century System for Evaluating Veterans for Disability Benefits. Washington, DC: The National Academies Press. doi: 10.17226/11885.
×

Tables, Figures, and Boxes

TABLES

2-1

 

Number of Veterans and Number of Rated Conditions, by Diagnostic Code, End of FY 2005,

 

46

2-2

 

Disability Compensation Decisions on and Grants of Service Connection and Higher Ratings, CY 2004–CY 2006,

 

51

2-3

 

10 Conditions with the Highest Number of Decisions and 10 Most Common Conditions for Which Veterans Were Granted Disability Compensation, CY 2004–CY 2006,

 

53

2-4

 

10 Most Common Diagnoses for Which Veterans Were Granted Service Connection and Rated 100 Percent, CY 2004–CY 2006,

 

54

2-5

 

Most Common Conditions of Veterans of the Afghanistan and Iraq Wars, 2001–2006,

 

58

Appendix 2-1

 

Individual Service-Connected Conditions by Rating, FY 1995 and FY 2005,

 

64

Appendix 2-2

 

Five Most Common Service-Connected Conditions by Period of Service, All Veterans Receiving Disability Compensation as of FY 2005,

 

65

Appendix 2-3

 

20 Most Frequent Service-Connected Conditions Among Women and Men, 2004–2006,

 

67

Page xxii Cite
Suggested Citation:"Front Matter." Institute of Medicine. 2007. A 21st Century System for Evaluating Veterans for Disability Benefits. Washington, DC: The National Academies Press. doi: 10.17226/11885.
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Appendix 2-4

 

Frequency of Diagnoses Among Recent Veterans of Iraq and Afghanistan,

 

68

Appendix 2-5

 

Frequency of Mental Diagnoses Among Recent Veterans of Iraq and Afghanistan,

 

68

4-1

 

Revisions of Diagnostic Codes, by Body System, Since 1945,

 

107

4-2

 

Dates of Rating Schedule Changes in the 14 Body Systems,

 

108

Appendix 4-1

 

Summary of Key Revisions to Diagnostic Codes Since 1945,

 

132

5-1

 

The 10 Most Requested Medical Examinations,

 

150

5-2

 

Rates of A-Level Compensation and Pensions Examinations, by Type of Examination, January 2007,

 

168

5-3

 

Medical Conditions Most and Least Likely to Be Allowed or Remanded on Appeal by BVA (Minimum of 100 Appeals), October 1, 2005–May 31, 2006,

 

187

6-1

 

Veterans Benefits by Service-Connected Disability Rating Percentages,

 

204

6-2

 

Priority Groups for Health-Care Benefits,

 

207

8-1

 

Examples of ICD Classifications,

 

254

8-2

 

Comparative Impairment Ratings for Upper Limb Amputation,

 

269

9-1

 

10 Most Common Conditions Service Connected on the Basis of Aggravation, FY 2005–FY 2006,

 

274

9-2

 

10 Most Common Diagnoses Service Connected as a Secondary Condition, FY 2005–FY 2006,

 

279

C-1

 

Wisconsin Uncontested Permanent Partial Disability Cases for Men with 1968 Injuries,

 

312

C-2

 

California Permanent Partial Disability Cases,

 

330

C-3

 

Veterans with Disabilities in 1967,

 

344

D-1

 

Summary of the Role of Medical Personnel in Selected Disability Benefit Programs,

 

372

FIGURES

1-1

 

VA claims application and development process,

 

29

1-2

 

VA appeal process, 30 for caption, 31 for figure

 

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2-1

 

Estimated and projected cumulative number of veterans by period of service, FY 2000–FY 2032,

 

39

2-2

 

Projected percentages of veterans by age group, FY 2007–FY 2032,

 

40

2-3

 

Number of veterans with service-connected disabilities, by period of service, FY 2000–FY 2008,

 

42

2-4

 

Veterans receiving disability benefits by age range, FY 2005 (percentages),

 

43

2-5

 

Veterans by combined rating level, FY 2005 (percentages),

 

44

2-6

 

Disabling conditions by rating level, FY 2005 (percentages),

 

45

2-7

 

Service-connected veterans with 100 percent combined rating, by major diagnosis, end of FY 2005 (percentages),

 

48

2-8

 

Percent of conditions granted service connection or higher rating, by age group, CY 2004–CY 2005,

 

49

2-9

 

Percent of conditions granted service connection or higher rating, by period of service, CY 2004–CY 2006,

 

52

2-10

 

Distribution of service-connected OEF/OIF veterans and all service-connected veterans by combined rating degree,

 

57

3-1

 

The four domains of disablement (IOM, 1991: Figure 4),

 

70

4-1

 

The consequences of an injury or disease,

 

117

5-1

 

Number of original compensation claims from veterans and number of original compensation claims from veterans containing eight or more issues, end of fiscal years 2000–2006,

 

170

5-2

 

Number of rating-related claims filed and decided, FY 2000–FY 2006,

 

171

5-3

 

Number of rating-related claims pending and number pending more than six months, end of FY 2000–FY 2006,

 

172

5-4

 

Rate of appeals (NODs), FY 2000–FY 2006,

 

175

5-5

 

Number of appeals (NODs), FY 2000–FY 2006,

 

175

5-6

 

Number of appeals pending at BVA and at regional offices and the Appeals Management Center, FY 2000–FY 2006,

 

176

5-7

 

Average number of days to resolve appeals (i.e., appeals resolution time), FY 2000–FY 2006,

 

177

5-8

 

Annual number of appeals of BVA disability decisions to the courts, FY 2000–FY 2006,

 

178

5-9

 

Numbers of remands by reason, FY 2004–FY 2006,

 

180

5-10

 

Accuracy of compensation and pension entitlement decisions, FY 2000–FY 2006,

 

181

5-11

 

BVA accuracy rate, FY 2000–FY 2006,

 

183

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Suggested Citation:"Front Matter." Institute of Medicine. 2007. A 21st Century System for Evaluating Veterans for Disability Benefits. Washington, DC: The National Academies Press. doi: 10.17226/11885.
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5-12

 

STAR program accuracy rates, 5 highest and 5 lowest states, FY 2004,

 

186

5-13

 

Percentages of spine and joint examinations adequately addressing DeLuca criteria, by VISN, FY 2004,

 

187

7-1

 

IU beneficiaries by period of service, FY 2006,

 

234

7-2

 

Number of IU beneficiaries as percentage of veterans receiving disability compensation, by state, FY 2004,

 

243

7-3

 

Number of IU beneficiaries per 1,000 resident veterans, by state, FY 2004,

 

245

7-4

 

Number of IU claims processed by age group, CY 2004–CY 2006,

 

246

7-5

 

Percentage of IU grants by age group, CY 2004–CY 2006,

 

247

8-1

 

Rate of use of analogous codes by body system, FY 2005,

 

265

9-1

 

Distribution of grants for aggravation of preservice disability by rating degree from 0 to 100, FY 2005–FY 2006,

 

274

9-2

 

Distribution of grants for secondary service connection by rating degree from 0 to 100, FY 2005–FY 2006,

 

279

C-1

 

Three time periods in a workers’ compensation case where the injury has permanent consequences,

 

305

C-2

 

The consequences of an injury or disease resulting in work disability,

 

306

C-3

 

Actual losses of earnings for a worker with a permanent disability,

 

307

C-4

 

Percentage earnings losses for Wisconsin workers with upper extremity injuries,

 

320

C-5

 

Earnings losses for Wisconsin workers with upper extremity injuries: means and ranges of losses,

 

320

C-6

 

Percentage earnings losses for Wisconsin workers with four types of injuries,

 

321

C-7

 

Percentage earnings losses for all Wisconsin workers,

 

323

C-8

 

Replacement rates (benefits as a percentage of earnings losses) for Wisconsin workers with upper extremity injuries,

 

324

C-9

 

Replacement rates (benefits as a percentage of earnings losses) for Wisconsin workers with four types of injuries,

 

325

C-10

 

Replacement rates (benefits as a percentage of earnings losses) for all Wisconsin workers,

 

325

C-11

 

Percentage earnings losses for California workers with four types of injuries,

 

337

Suggested Citation:"Front Matter." Institute of Medicine. 2007. A 21st Century System for Evaluating Veterans for Disability Benefits. Washington, DC: The National Academies Press. doi: 10.17226/11885.
×
   

C-12

 

Percentage earnings losses for California workers with four types of injuries,

 

337

C-13

 

Percentage earnings losses for all California workers,

 

338

C-14

 

Percentage earnings losses for veterans with five types of injuries,

 

348

C-15

 

Percentage earnings losses for veterans with five types of injuries,

 

348

C-16

 

Percentage earnings losses for veterans: averages for ten types of injuries,

 

349

C-17

 

Replacement rates (benefits as a percentage of earnings losses) for veterans with five types of injuries,

 

350

C-18

 

Replacement rates (benefits as a percentage of earnings losses) for veterans with five types of injuries,

 

351

C-19

 

Replacement rates (benefits as a percentage of earnings losses) for veterans: averages for 10 types of injuries,

 

351

E-1

 

Diagram: Assessing impairment and functional disability,

 

375

BOXES

S-1

 

Summary of Tasks and Associated Recommendations,

 

16

3-1

 

Basic Concepts and Definitions of Terms Used,

 

72

3-2

 

ADLs and IADLs,

 

74

5-1

 

Excerpt from VA Publication: Understanding the Disability Claim Process,

 

148

6-1

 

Medical Eligibility Criteria to Qualify for Selected Benefits,

 

202

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×

Abbreviations and Acronyms

ADLs Activities of daily living

ALS Amyotrophic lateral sclerosis

AMA American Medical Association

AMIE Automated Medical Information Exchange

APA American Psychiatric Association

ASIA American Spinal Injury Association

BDD Benefits Delivery at Discharge

BDN Benefits Delivery Network

BVA Board of Veterans’ Appeals

C&P Compensation and Pension

CAPRI Compensation and Pension Record Interchange

CAVC (U.S.) Court of Appeals for Veterans Claims

CDC Centers for Disease Control and Prevention

CFR Code of Federal Regulations

CHAMPVA Civilian Health & Medical Program of the Department of Veterans Affairs

CHPR Center for Health Policy and Research of the University of Massachusetts

CHTW Coming Home to Work program

CM Clinical Modification

CPEP Compensation and Pension Examination Program

CPI Claims Process Improvement

CT Computerized tomography

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Suggested Citation:"Front Matter." Institute of Medicine. 2007. A 21st Century System for Evaluating Veterans for Disability Benefits. Washington, DC: The National Academies Press. doi: 10.17226/11885.
×

CY Calendar year

DIC Dependency and Indemnity Compensation

DoD Department of Defense

DOL Department of Labor

DOL-VETS Department of Labor Veteran’s Employment and Training Services

DRO Decision review officer

DSM-IV Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (1994)

DSM-IV-TR Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision 2000)

DTAP Disabled Transition Assistance Program

DVOP Disabled Veterans Outreach Program

ECAB Employee’s Compensation Appeals Board of the Department of Labor

ECVARS EConomic VAlidation of the Rating Schedule

EP End product

FECA Federal Employee Compensation Act

FERS Federal Employee Retirement System

FEV1 Forced expiratory volume in one second

FTE Full-time equivalent

FY Fiscal year

GAF Global Assessment of Functioning

GAO Government Accountability Office (formerly the General Accounting Office)

GWOT Global War on Terrorism

HIV Human immunodeficiency virus

HRQOL Health-related quality of life

IADLs Instrumental activities of daily living (see ADLs)

ICD-9 International Classification of Diseases, 9th Revision

ICD-9-CM International Classification of Diseases, 9th Revision, Clinical Modification

ICD-10 International Statistical Classification of Diseases and Related Health Problems, 10th Revision

ICD-10-CM International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Clinical Modification

Page xxix Cite
Suggested Citation:"Front Matter." Institute of Medicine. 2007. A 21st Century System for Evaluating Veterans for Disability Benefits. Washington, DC: The National Academies Press. doi: 10.17226/11885.
×

ICD-11 International Statistical Classification of Diseases and Related Health Problems, 11th Revision

ICF International Classification of Functioning, Disability and Health

IEEP Individualized extended evaluation plans

IU Individual unemployability

LVER Local veterans’ employment representative

MEB Medical Evaluation Board

METS Metabolic equivalents of task

mg/dL Milligrams per deciliter

M.P.H. Master of public health

MRI Magnetic resonance imaging

NAPA National Academy of Public Administration

NASI National Academy of Social Insurance

NCHS National Center for Health Statistics

NIH National Institutes of Health

NIMH National Institute of Mental Health

NOD Notice of disagreement

NOS Not otherwise specified

OEF Operation Enduring Freedom

OIF Operation Iraqi Freedom

OIG [VA] Office of Inspector General

OPM Office of Personnel Management

PA Physician’s assistant

PA&I Office of Performance Analysis and Integrity

PEB Physical Evaluation Board

Ph.D. Doctor of philosophy

P.L. Public law

POW Prisoner of war

PRTF Psychiatric Review Technique Form

PTSD Posttraumatic stress disorder

QOL Quality of life

QR Quality rating; quality review

QTC QTC Medical Group, Inc.

QUERI Quality Enhancement Research Initiative

RBA 2000 Rating Board Automation 2000

Suggested Citation:"Front Matter." Institute of Medicine. 2007. A 21st Century System for Evaluating Veterans for Disability Benefits. Washington, DC: The National Academies Press. doi: 10.17226/11885.
×

RO Regional office

RVSR Rating veterans service representative

SCI Spinal cord injury

SF-36 Short Form 36

SMR Service medical record

SOC/SSOC Statement of case/Supplemental statement of case

SOFAS Social and Occupational Assessment Scale

SSA Social Security Administration

SSDI Social Security Disability Insurance

SSI Supplemental Security Income

STAR Statistical Technical Accuracy Review

TAP Transition Assistance Program

TBI Traumatic brain injury

U.S.C. United States Code

VA Department of Veterans Affairs

VACO VA central office

VARO VA regional office

VBA Veterans Benefits Administration

VCAA Veterans Claim Assistance Act (of 2000)

VERIS Veterans Examination Request Information System

VHA Veterans Health Administration (VA)

VISN Veterans Integrated Service Network

VLJ Veterans law judge

VR Vocational rehabilitation

VRC Vocational rehabilitation counselor

VR&E Vocational Rehabilitation and Employment (Service)

VRECC Vocational rehabilitation and employment case coordinators

VSC Veterans service center

VSO Veterans service organization

VSR Veterans service representative

WHO World Health Organization

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21st Century System for Evaluating Veterans' Disability Benefits recommends improvements in the medical evaluation and rating of veterans for the benefits provided by the Department of Veterans Affairs (VA) to compensate for illnesses or injuries incurred in or aggravated by military service. Compensation is a monthly cash benefit based on a rating schedule that determines the degree of disability on a scale of 0 to 100. Although a disability rating may also entitle a veteran to ancillary services, such as vocational rehabilitation and employment services, the rating schedule is out of date medically and contains ambiguous criteria and obsolete conditions and language. The current rating schedule emphasizes impairment and limitations or loss of specific body structures and functions which may not predict disability well. 21st Century System for Evaluating Veterans' Disability Benefits recommends that this schedule could be revised to include modern concepts of disability including work disability, nonwork disability, and quality of life.

In addition to the need for an updated rating schedule, this book highlights the need for the Department of Veterans' Affairs to devote additional resources to systematic analysis of how well it is providing services or how much the lives of veterans are being improved, as well as the need for a program of research oriented toward understanding and improving the effectiveness of its benefits programs.

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