Veterans' Disability Benefits:

VA Could Enhance Its Progress in Complying with Court Decision on Disability Criteria

GAO-06-46: Published: Oct 12, 2005. Publicly Released: Oct 17, 2005.

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Daniel Bertoni
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To properly decide veterans' disability claims, the regional offices of the Department of Veterans Affairs (VA) must obtain all medical evidence required by law and federal regulations. To do so, in fiscal year 2004, the regional offices asked VA's medical centers to examine about 500,000 claimants and provide examination reports containing the necessary medical information. Exams for joint and spine impairments are among the exams that regional offices most frequently request, and in 2002, VA found that 61 percent of the exam reports for such impairments did not provide sufficient information for regional offices to make decisions complying with disability criteria mandated by the U.S. Court of Appeals for Veterans Claims in DeLuca v. Brown, 8 Vet. App. 202 (1995). In DeLuca, the court held that when federal regulations define joint and spine impairment severity in terms of limits on range of motion, VA claims adjudicators must consider whether range of motion is further limited by factors such as pain and fatigue during "flare-ups" or following repetitive use of the impaired joint or spine. Whenever VA regional offices ask VA medical centers to conduct joint and spine disability exams, the medical centers should prepare exam reports containing the information mandated in DeLuca. Congress asked that we determine VA's progress since 2002 in ensuring that its medical centers consistently prepare joint and spine exam reports containing the information required by DeLuca.

In summary, since 2002, VA has made progress in ensuring that its medical centers' exam reports adequately address the DeLuca criteria, but more improvements are needed. As of May 2005, the percentage of joint and spine exam reports not meeting the DeLuca criteria had declined substantially from 61 percent to 22 percent. Much of this progress appears attributable to a performance measure for exam report quality that VHA established in fiscal year 2004. However, a 22 percent deficiency rate indicates that many joint and spine exam reports still did not comply with DeLuca, and moreover, the percentage of exam reports satisfying the DeLuca criteria varied widely--from a low of 57 percent to a high of 92 percent among VHA's 21 health care networks. Further, VA's Compensation and Pension Examination Project (CPEP) Office has found deficiencies in a substantial portion of the requests that VBA's regional offices send to VHA's medical centers, asking them to perform disability exams. For example, the CPEP Office found in early 2005 that nearly one-third of the regional office requests for spine exams contained errors such as not identifying the pertinent medical condition or not requesting the appropriate exam. However, VBA has not yet established a performance measure for the quality of the exam requests that regional offices submit to medical centers.

Recommendations for Executive Action

  1. Status: Closed - Implemented

    Comments: VA reported that it has VA deployed 58 computerized exam templates, one for each Compensation and Pension (C&P) exam type, to every VHA compensation and pension exam site. These templates guide examiners through a structured process for conducting exams and entering the results, which includes satisfying the Deluca criteria. According to VA, this approach promotes consistency and eliminates redundancy. VA also noted that it tracks exam quality, including performance in meeting the DeLuca criteria; reports monthly to VHA and VBA Central Offices and each VHA Veterans Integrated Service Network (VISN); and added compliance with DeLuca criteria to VISN Directors' performance standards for C&P exam quality.

    Recommendation: To help ensure continued progress in satisfying the DeLuca criteria, the Secretary of Veterans Affairs should direct the Under Secretary for Health to develop a strategy for improving consistency among the Veterans Health Administration (VHA) Veterans Integrated Service Networks (VISN) in meeting the DeLuca criteria. For example, if performance in satisfying the DeLuca criteria continues to vary widely among the VISNs during fiscal year 2006, VHA may want to consider establishing a new performance measure specifically for joint and spine exams. Also, if the CPEP Office's study of the costs and benefits of the automated exam templates supports their use, VHA could require that its medical centers use the automated templates for joint and spine exams.

    Agency Affected: Department of Veterans Affairs

  2. Status: Closed - Implemented

    Comments: VA reported that its Compensation and Pension Examination Project (CPEP) reviewers routinely score examination requests, and make case-specific review information available to Veterans Benefits Administration (VBA) regional offices. VA also noted several types of training provided to VBA disability claims processing staff on requesting medical examinations. This included, for example, examination request training as part of the standard curriculum for new VBA veterans service representatives. According to VA, examination request quality improved from 73 to 85 percent during fiscal year 2008.

    Recommendation: The Secretary of Veterans Affairs direct the Under Secretary for Benefits to develop a performance measure for the quality of exam requests that regional offices send to medical centers. This measure could be implemented as soon as the CPEP Office is able provide regional offices with case-specific exam request deficiency data via VA's intranet.

    Agency Affected: Department of Veterans Affairs


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