<DOC> [109th Congress House Hearings] [From the U.S. Government Printing Office via GPO Access] [DOCID: f:24078.wais] OVERSIGHT HEARING ON THE VARIANCES IN DISABILITY COMPENSATION CLAIMS DECISIONS MADE BY VA REGIONAL OFFICES; THE POST-TRAUMATIC STRESS DISORDER CLAIMS REVIEW; AND UNITED STATES COURT OF APPEALS FOR THE FEDERAL CIRCUIT DECISION ALLEN V. PRINCIPI Thursday, October 20, 2005 U.S. HOUSE OF REPRESENTATIVES, SUBCOMMITTEE ON DISABILITY ASSISTANCE AND MEMORIAL AFFAIRS, COMMITTEE ON VETERANS' AFFAIRS, Washington, D.C. The Subcommittee met, pursuant to call, at 10:40 a.m., in Room 340, Cannon House Office Building, Hon. Jeb Bradley [Vice Chairman of the Subcommittee] presiding. Present: Representatives Miller, Bradley, Berkley, Udall, Evans, and Brown-Waite. MR. BRADLEY. [Presiding] Good morning. The hearing will come to order. Congressman Miller will be here shortly. He has asked for me to pitch in for him. I am going to read his opening statement. Today we are receiving testimony on several issues: number one, variances in claims decisions throughout the Veterans Benefits Administration's regional offices; two, the ongoing review of certain Post-Traumatic Stress Disorder claims; and, three, a 2001 U.S. Court of Federal Appeals decision, Allen v. Principi, which clarified that the VA may pay compensation for an alcohol or drug abuse condition when it is secondary to a primary service-connected condition such as, in Mr. Allen's case, PTSD. In late 2004, the Chicago Sun Times' ran a series of articles that focused on the compensation rates of Illinois veterans. As a result, then Secretary Principi asked the VA Inspector General to conduct a review of compensation payments. The IG reported its findings in May 2005. The IG cited several factors to account for variances in annual disability compensation payments, some of which VA has no control over and others in which VA has some control. During the IG's review of 2,100 PTSD claims, it was found that the total number of veterans receiving disability compensation between 1999 and 2004 grew by a little more than 12 percent. However, PTSD claims increased by more than 80 percent. Likewise, PTSD compensation payments increased almost 149 percent while compensation for all other disabilities increased by only 41.7 percent. It concerns me that the IG determined that Veterans Benefits Administration procedures were not always followed in processing PTSD claims, resulting in error rates ranging from 11 to 41 percent. Due to the nature of certain disabilities, the adjudication of a claim requires the use of judgment; therefore, inherently, there will be variations in outcomes. I would expect, however, that the VA can mitigate and control for variances in decisions by ensuring that regional offices follow standardized adjudication policies and by developing methods for ensuring consistency. I look forward to the testimony of Ms. Bascetta, the GAO witness, and Dr. Brown of the Compensation and Pension Exam Program in this regard. Following an IG recommendation, VBA is currently examining the 2,100 PTSD claims that the IG reviewed. I understand there is some concern within the veterans' community that this review may be adding to veterans' stresses. At a briefing for the House and Senate committee staff earlier this month, Admiral Cooper, Under Secretary for Benefits, gave every assurance that benefits will be fully paid until a final decision is rendered - a veteran will not lose appeal rights - and that if a grant is overturned, the veteran will not have to repay past benefits. To date, the majority of the original 2,100 cases under review have been successfully closed without a need for further action. The initial grant was correct. It is my hope that VBA in conjunction with the Veterans Health Administration will educate veterans on the process as necessary. It is important not to overlook the fact that this review will also help VBA identify weaknesses and improve the quality of the claims adjudication process. [The statement of Mr. Bradley appears on p. 44] MR. BRADLEY. At this time, I would like to recognize the Ranking Member for her opening remarks. MS. BERKLEY. Thank you, Mr. Bradley. And please thank Chairman Miller for holding this hearing. I think it is critically important that we explore this issue from the perspective of severely disabled veterans who are being put at risk by a possibly illegal review of post-traumatic stress disorder claims. This review and the Inspector General's claim that billions of dollars can be saved by terminating benefits to severely disabled veterans places the health and lives of untold veterans and their families at risk. The Bush Administration says it seeks only to improve compensation and pension claims processing. However, the VBA has embarked upon a course which may very well lead to increased suicides, homicides, and violent behavior by veterans whose PTSD symptoms are so severe that they are unable to work or function in society. This review is causing some veterans to revisit their traumatic experiences and increase their psychiatric symptoms. Mental health professionals, treating psychiatrists, as well as veterans' advocates say this is simply, dare I say, madness. As Secretary Garcia states in his written testimony, an attack on one veteran is an attack on all of them. Even those who are unlikely to have benefits terminated are feeling under attack by a report which appears to recommend cutting severely mentally ill veterans from VA compensation rolls. How many veterans' suicide will it take to reverse this course? While many of our nation's veterans with severe PTSD fear the loss of their disability benefits and their VA health care, I fear the loss of their lives. Many agree with PVA's testimony that will appear later, written testimony, that the review which is underway may well be illegal. A court may ultimately find this to be so. Such a finding would be little comfort, however, to families who have already lost a spouse, father, grandfather, or child to suicide as a result of the stress this proposed review is placing upon severely disabled veterans. Does VBA really believe that it can meet the stringent requirements for clear and unmistakable error in the decisions of veterans whose claims are being reviewed? How can they do that? Does the IG have any evidence to support the suggestion that all of the claims which reportedly lack adequate stressor verification could be terminated under existing statutes? How can any review which ignored and continues to ignore the thousands of veterans who have had PTSD claims denied with little or no attempt to adequately develop their claims be viewed with any credibility by the veterans' community? The GAO recently found that many veterans' claims were rated without adequate medical examinations which may have entitled them to a higher rating and benefit. Will VA be contacting those veterans that were denied benefits and scheduling a new medical examination? Are we jeopardizing the lives and health of America's severely disabled veterans so that the bureaucracy will have a complete paper file? Does the government have a moral and ethical responsibility to mitigate the danger to the lives and health of veterans occasioned by this review? I hope that the witnesses will be able to answer my questions. And before I concluded, Mr. Bradley, as many people know, and I say this often enough, in Las Vegas, Southern Nevada has the fastest-growing veterans' population in the United States. We have veterans from World War II, Korea, Vietnam, the Gulf War, and now we have many returning veterans from Iraq and Afghanistan. I have witnessed with my own eyes people in the Vietnam era, that was my era, that came back seriously mentally damaged. And this nation did not do what I think was our moral responsibility to help these kids that came back, while I was sitting in a college classroom, severely mentally disabled from the experiences they had in their theater of war. Now, I did not appreciate it when I was in college. I appreciate it now when I am sitting here next to you in Congress. And under my watch, I would never forgive myself if we were to implement actions that would create further mental harm to these people who have sacrificed so much in the prime of their lives, who have had their lives completely altered on behalf of this nation. And I think we have a great responsibility to these people. And I want to hear what is going on, but I cannot imagine systematically reviewing 100 percent PTSD victims when I believe there are so many more out there that need the additional help and need to be taken care of rather than taking away benefits, putting these people in harm's way, sacrificing their families, and ultimately this nation. And I thank you very much. MR. BRADLEY. Thank you, Ms. Berkley. [The Statement of Ms. Berkley appear on p. 46] MR. BRADLEY. Are there any other members who have opening statements? Mr. Udall. MR. UDALL. Thank you, Mr. Chairman. Mr. Chairman, I would like to recognize and thank New Mexico Veterans' Secretary John Garcia for testifying today. John is going to appear on Panel Number II. We in New Mexico know Secretary Garcia well. We know his dedication and loyalty to veterans. It is not uncommon for a veteran to walk into his office and to speak directly with him about concerns and issues of importance. And I know that the Secretary is as concerned and angry as I am with the manner in which the VA has proceeded on this PTSD matter. It seems that time and time again we hear the larger facts about PTSD: How it affects 11.5 percent of all veterans; how nearly nine out of ten veterans with PTSD demonstrate signs of other disorders, including depression, alcohol and substance abuse, or anxiety; how the number of veterans diagnosed with PTSD has risen while the number of services being offered by the VA has dropped; how the stigma of PTSD is still prevalent throughout the military and prevents many veterans from seeing care until it may be too late. However, even with all these facts and figures, the individual stories of struggle are sometimes lost, and PTSD has become simply another medical term, another column in the books. And, unfortunately, this became the perspective, I think, of the VA. In August, it was immediately clear that the VA's review of 72,000 PTSD cases meant something different to them than it did to the veterans suffering from PTSD. To the VA, it was a process for seeking out incomplete cases and finding voids in paperwork that needed to be filled. The IG report that catalyzed the review included charts and graphs and made suggestions for action. To veterans, though, the announcement that their case might be reviewed was not seen as simply another bureaucratic process. It was for many a jolting realization that the day-to-day struggle they endure was being questioned and that their quest for help to deal with this struggle needed external validation. For those who live with PTSD, the review did not mean a paperwork review as much as it meant a personal attack on what is already a sensitive issue. Last week, a veteran in my district took his life after dealing with PTSD for years and years. He can certainly be perceived as one statistic within the larger, tragic figure of those veterans who contemplate or act on suicidal thoughts. But he can also be seen as he should be, as a Vietnam vet decorated with the Purple Heart and other commendations. He was a soldier who fought bravely and honorably for his country. Involved in local veterans' organizations, he helped out at events and with other veterans and all the while he struggled to deal with PTSD. Even though his case was well-documented and he was in no danger of finding his compensation or medical assistance benefits revoked, he was greatly shaken by the announcement of the VA review and frequently inquired whether he would be losing the support he had received. He believed, as so many veterans do, that he was being forced to prove himself yet again. It is that belief that makes veterans so angry and so frustrated with this process. I believe the VA's intentions to bring clarity and accountability to PTSD cases were not in any way meant to harm our veterans. But I believe the manner in which they proceeded with the review, without any input from mental health professionals concerning the risk of harm to veterans with severe psychiatric symptoms, has done far more harm than good. It is important that we compile facts and figures and that we be concerned with the larger picture. It is more important that we not forget veterans who have borne the battle and now struggle with PTSD, and how our actions affect then. I have called and will continue to call for a halt to the review. The VA must reevaluate the process it is using in this review and must take into account how it is affecting veterans. It is better that we stop this review before more lives are lost rather than continue with troublesome and tragic consequences. Again, Secretary Garcia, thank you for your presence. We look forward to your testimony today on Panel II. And I thank you for your tireless work on behalf of New Mexico's veterans. Thank you, Mr. Chairman. Look forward to our witnesses today. MR. BRADLEY. Thank you, Mr. Udall. [The statement of Mr. Udall appears on p. 50] MR. BRADLEY. Mr. Evans. MR. EVANS. Thank you, Mr. Chairman. I would like to thank the Ranking Member, Ms. Berkley. I requested a review of VA practices which have resulted in low benefits for service-disabled veterans in Illinois and throughout the nation. We certainly did not expect the lop-sided IG review that we received. My staff reviewed PTSD claims in Chicago. These are some of the veterans whose claims were denied: a World War II veteran with a Combat Infantry Badge, a Vietnam veteran who participated in the 1969 Tet Counter-offensive, a peacetime veteran who witnessed the extremely traumatic death of a co-worker, and an Iraq veteran with PTSD noted on compensation and pension examination form. The VA IG review completely ignored such claims. I hope today's hearing will lead to the end of the VA's destructive action against veterans with severe PTSD. The veterans' advocates are right. We must stop this process before any more veterans take or lose their lives. Mr. Chairman, I ask that a letter that Ranking Member Akaka and I sent to Secretary Nicholson concerning this matter be included in the record. I want to thank you and your staff. And I have this statement for the record. Thank you. MR. BRADLEY. So ordered. [The statement of Mr. Evans appears on p. 57] [The attachment appears on p. 151] MR. BRADLEY. Will panel one please come to the table. Mr. Jon Wooditch is the Acting Inspector General, Department of Veterans Affairs. He is accompanied by Mr. Michael Staley, the Assistant Inspector General for Auditing. Next, Ms. Cindy Bascetta, the Director of Education, Workforce, and Income Security Issues represents the Government Accountability Office. Welcome to you all. Your full statements will be included in the printed record of the hearing and we will hold our questions until each of you has testified. Please proceed. STATEMENTS OF JON A. WOODITCH, ACTING INSPECTOR GENERAL, DEPARTMENT OF VETERANS AFFAIRS, OFFICE OF THE INSPECTOR GENERAL; ACCOMPANIED BY MICHAEL L. STALEY, ASSISTANT INSPECTOR GENERAL FOR AUDITING, DEPARTMENT OF VETERANS AFFAIRS, OFFICE OF THE INSPECTOR GENERAL; CYNTHIA BASCETTA, DIRECTOR, EDUCATION, WORKFORCE, AND INCOME SECURITY ISSUES, GOVERNMENT ACCOUNTABILITY OFFICE STATEMENT OF JON A. WOODITCH MR. WOODITCH. Thank you. Mr. Chairman and other distinguished members of the Subcommittee, I am pleased to be here today to address the Office of Inspector General report, Review of State Variances in VA Disability Compensation Payments. I am pleased to be joined by Mike Staley, Assistant Inspector General for Audit. Last December, the VA Secretary asked the IG to conduct this review in response to concerns raised by several Members of Congress over the wide variance in average annual disability compensation payments by state. For Fiscal Year 2004, veterans in New Mexico received over $5,000 more per year than veterans in Illinois. To determine the cause of the variance, we analyzed six years worth of benefit claims' data, surveyed over 1,900 rating specialists, examined 2,100 claims' folders, and reviewed medical examination reports. Our review identified a number of factors that influenced the variance. Two key reasons highlighted in the report are veteran demographic factors and benefit rating decisions. Demographic factors are variables beyond VA control. For example, Vietnam veterans receive over $2,300 more than the next highest period of service. Enlisted personnel receive more than officers and military retirees receive more than nonretirees. Our review demonstrated that there was a direct correlation between these factors and those states with the highest average annual payments. This supports the position that some part of the variance is predictable and nonproblematic. Conversely, factors such as benefit rating processes over which the VA has direct influence are problematic in that they are not always consistently applied nationwide. Our analysis of rating decisions shows that for disabilities that can be independently validated on physical measurements, such as amputations, ratings were consistent. However, for other disabilities, such as mental disorders, much of the information needed to make a rating decision is not physically apparent. As such, these cases are more difficult to develop and document and are inherently more susceptible to variations in interpretation and judgment. This subjectivity leads to inconsistency in rating determinations. We selected the mental disorder system for further analysis because it had the highest overall average disability rating nationwide and it included PTSD, which is the fastest-growing condition. To illustrate, from fiscal years 1999 to 2004, the number of PTSD cases grew by 80 percent and PTSD payments increased from $1.7 to $4.3 million. There was also a dramatic rise in the number of PTSD cases rated 100 percent. In fact, data shows that differences in the number of 100 percent PTSD cases by state accounted for 34 percent of the variance. To understand why this variance may be occurring, we reviewed 2,100 PTSD cases at seven VBA regional offices. We found that 25 percent of the 2,100 cases needed further development to support the claimed stressor in order to verify that the PTSD was caused by an event related to military service. The 25 percent error rate is not an indicator of fraud. It reflects noncompliance with VBA regulations concerning required documentation to develop and support rating decisions. These requirements are essentially internal controls designed to ensure veterans receive everything they are entitled to under the law and to serve as a basis for denying claims when the evidence does not exist. To address this issue, we recommended that VBA do a review of all PTSD cases rated 100 percent. The intent of this recommendation is to ensure the VBA rules and regulations are fully complied with, that the processes for case development are consistently applied nationwide, and to ensure that benefits are being paid properly. In closing, I would like to add that the variances by state have existed for decades and that the factors that influence these payments are complex and intertwined. Yet, there are opportunities to improve the consistency of rating decisions. The impact of underlying factors such as medical examination reports that do not consistently provide sufficient data for rating purposes, incomplete case development, and a rating schedule that is subject to different interpretations will have to be fully studied and understood if the VBA is to be successful in detecting, correcting, and preventing unacceptable payment patterns. That concludes my statement. Thank you again, Chairman Bradley, and those members of the Subcommittee for this opportunity. I welcome any questions you may have. [The statement of Mr. Wooditch appears on p. 58] MR. BRADLEY. Ms. Bascetta. STATEMENT OF CYNTHIA A. BASCETTA MS. BASCETTA. Good morning, Mr. Chairman, and other members of the Subcommittee. Thank you for inviting us to testify today on the consistency of decisions made by VA on veterans' claims for disability compensation. Ensuring that disability decisions are consistent across the nation is vital to the integrity of the VA Disability Programs which GAO designated as high risk in January 2003. As you requested, my comments today are based on our two most recent reports on decisional consistency. Our November 2004 report concluded that VA still does not systematically assess consistency across its regional offices and the report we issued last week shows one important way for VA to improve consistency involving joint and spine impairments. We made recommendations in both reports that underscore the need for VA to routinely monitor consistency to ensure that veterans get the benefits they deserve for disabilities connected to their military service. Building on previous work, we reported last November that the need for adjudicator judgment results in inherent variation in the decision-making process. Examples where judgment is required include claims with conflicting medical opinions and claims for which disability standards are not entirely objective, such as those involving mental impairments or pain. In these cases, different adjudicators could reach different decisions about the severity of a veteran's disability depending on how they weigh various pieces of evidence. But it is still reasonable to expect that the extent of variation would be confined within an acceptable range as agreed to by knowledgeable professionals. Yet, we have reported and you have just heard the IG comment on why the state-to-state variations and average compensation payments per disabled veteran raise questions about consistency. Because of the need to reduce the risk of decisional inconsistency, we recommended that the Secretary develop a systematic, data-driven approach to identifying potential inconsistencies among VA's 57 regional offices and then to study those inconsistencies in detail with regard not only to awards but denial of benefits for specific impairments. VA concurred with our recommendation, but has not yet implemented it. The report we issued last week assessed VA's progress in improving consistency of the quality of medical information provided by VA physicians to regional offices for their use in deciding joint and spine claims. As you know, in the DeLuca case, the court held that VA claims adjudicators must consider whether range of motion is further limited by factors such as pain and fatigue during flare-ups or following the repetitive use of the impaired joint or spine. VA itself reported in a baseline study conducted in 2002 that fully 61 percent of exam reports on joint and spine impairments did not provide sufficient information to comply with DeLuca. We found that VA has made substantial progress since its 2002 study, decreasing the number of deficient exams from 61 to 22 percent. Three factors contributed to this progress: Creating the Compensation and Pension Exam Project Office to improve the disability exam process; providing extensive training to both VHA and VBA personnel; and establishing a performance standard for the quality of medical center exam reports. Nevertheless, more than one in five joint and spine exam reports still do not comply with DeLuca. And more improvement is needed to reduce the wide variations among VA's health care networks where deficient DeLuca exams range from eight percent in the best networks to forty-three percent in the worst. As a result, VA cannot reasonably assure that these veterans, no matter where they live, receive fair and equitable decisions on their disability claims. To continue the progress made so far, we recommended that VA use a strategy focused on improvement efforts within its health care networks, an additional performance measurement. VA concurred in principle with this approach. In conclusion, it is incumbent on VA to implement all of our recommendations relating to consistency. Until assessments of consistency become a routine part of VA's oversight decisions made by its regional offices, veterans may not consistently get the benefits they deserve for disabilities connected to their service, and taxpayers may lack confidence in the effectiveness and fairness of VA's disability program. While it would be unreasonable to expect that no decision-making variations would occur, we continue to urge VA to measure and limit inconsistency through systematic study, targeted improvements, and concerted performance measurement. And I would be happy to answer any questions you might have. MR. BRADLEY. Thank you. [The statement of Ms. Bascetta appears on p. 66] MR. BRADLEY. Mr. Staley, do you have an opening statement? MR. STALEY. No, sir. MR. BRADLEY. In that case, we will go right to questions. Mr. Wooditch, you indicate that one of the factors in the variances of decisions is insufficient medical exam reports. What is your sense of the working relationship between VBA and VHA? Are there clear guidelines between the two on what is needed to adjudicate a claim? MR. WOODITCH. I believe that VHA and VBA have made a lot of progress in the last few years to standardize templates in order to do medical examinations for rating purposes. As our report points out, very few people have access to these templates, but I know they are working together to improve the omission of data that has existed in past examination reports that is needed for rating purposes. And I think that they are making progress. MR. MILLER. [Presiding] I apologize for being late. We have been at a hurricane briefing for the State of Florida. Ms. Berkley, would you like to go ahead and ask your questions. MS. BERKLEY. Thank you, Mr. Chairman. I spent a lot of time with my veterans in Las Vegas, one, because I want to and, two, because they trust me and because of my position here on this Committee. They have grown to know that they can trust me and that I have their best interest at heart at all times. I meet with my disabled veterans a lot and I have had occasion to meet with those that have really suffered severe mental illness because of their service to this country. I admit one of the first veteran's cases that we took when I first came to Congress was at a town hall meeting where a Vietnam vet came to me with a stack of correspondence he had had with my predecessors who kept kicking back to him the same letters that we were getting from the VA that he was only 50 percent disabled as opposed to 100 percent disabled. And when he came to see me, it was very apparent within the first five minutes that this guy really had a serious problem and that we were doing a tremendous disservice to him because we never reviewed his case. We never looked at his case. We just kicked back the same stuff that was initially put in his file and nobody took the time to look behind that and see what was going on with this person. And after a whole lot of effort, we ended up ensuring that he was 100 percent disabled and I think that should have been the appropriate diagnosis from the beginning. And that was the first of many veterans that I have tried to help when it came to their rating for disability, especially when it comes to their mental health. This is an area that people do not like to acknowledge. It is an area that is subjective in many ways. I mean, you do not see an open wound. You do not see blood. You do not see broke bones. But you have a broken person in front of you. So I think it is a little more difficult to adjudicate. I do not know how much time you have spent with veterans, especially those with PTSD, but I have spent a considerable time. Did the IG expect that the VA would terminate benefits of veterans whose claims were reviewed? I mean, walk me through this. When we do this review of the 72,000 veterans that are 100 percent disabled, how do we do this and what do we expect from the veterans? And did we expect to terminate their benefits that they were accustomed to receiving? What was the thinking? MR. WOODITCH. The review started with trying to understand why the variance existed. We determined that 100 percent PTSD ratings was a primary contributor to that. When we looked behind it, we found what we called a 25 percent error rate in 2,100 cases. As I mentioned in my opening statement, the error rate is not an indicator of fraud. It is just an indicator of VBA not complying with its rules and regulations. The basis in doing the 72,000 review is to find out what the magnitude of the total population is with respect to this error rate. MS. BERKLEY. Are you going back and looking at cases where they were denied or people that have been adjudged 50 percent and maybe they are entitled to 100 percent? MR. WOODITCH. We did not look at denials. Denials did not contribute to the average payments in the state, so denial was not an issue for us. We just looked at approved claims. We did not look at the rating level to see whether or not it was an accurate rating level. All we looked at was whether or not the documentation that was required by law was, in fact, in the claims' folder to support the rating. MS. BERKLEY. And under what legal authority did we do that? MR. WOODITCH. The IG, under the "IG Act'' authority, has the mandate to look at compliance with rules and regulations. So it was a compliance issue. MS. BERKLEY. Well, according to 38 USCS Section 511, it says that the Secretary shall decide all questions of law and fact and that the Secretary's decision shall be final and conclusive except with a few exceptions. But I do not see how this fits into any of the exceptions. So how are we going about it? After these cases are adjudged and they are final, how do we go back and add additional stress to these veterans who are barely getting by on a day-to-day basis and tell them that they may not be entitled to this? How do you do that? Why would we be doing that? MR. WOODITCH. To go back and answer one of your earlier questions, our intent was never to terminate benefits. Our intent was to work with the veterans and their representatives to review unit records and other sources of information in order to come up with the documentation that was required by law in order to justify their ratings. MS. BERKLEY. Now, people with PTSD have high rates of suicide. We just heard of a tragic case in New Mexico. In recommending the review of finally-decided claims, did the IG take into account the risk of potential suicide or other violent behavior by asking the veterans to revisit their stressors? MR. WOODITCH. First of all, I am sorry to hear about that. It is a tragic incident. I think the problem here is information control. Our recommendation to review 72,000 cases was not intended to go out to all veterans and say we are going to review 72,000 cases. A lot of the review work can be done by looking at data systems or records within VA. In doing so, many of those cases could be eliminated from review. It is unfortunate that that impression is out there, this misinformation needs to be dealt with. MS. BERKLEY. Rather than go back and have these veterans who have already suffered serious stress because of their service in the military, why not develop the appropriate indicators for future cases? It would seem to me that the VA has the issue, not the veterans who have already been adjudicated to have PTSD at a 100 percent level. I mean, does it matter that they would be 95 or 90 percent? Does it save this country that much money that we would create additional burdens on these people who have already suffered so much? MR. WOODITCH. I agree with what you are saying. I think maybe if you just reviewed the 2,100 cases that VBA is doing, it would help to identify parameters for how we look at future cases. I think that the issue is worthy of discussion. we need to make a decision what we are going to do. MS. BERKLEY. And I would join with my colleagues in New Mexico and call for a halt to this. I think you have enough information and we have caused enough anguish. Thank you very much. MR. WOODITCH. Thank you. MR. MILLER. Mr. Bradley. MR. BRADLEY. Thank you very much, Mr. Miller. Ms. Bascetta, how do your findings regarding inconsistencies with VBA's decisions compare to the Social Security Disability system? MS. BASCETTA. We have spent an equal amount of time looking at both systems and in both cases, we find that neither SSA nor VA has tackled the consistency problem adequately in our view. In the Social Security case, it is a little bit different because their focus has been on looking at inconsistency between their appellate and their initial level. But we find in earlier work that they also among their disability determination services experience considerable inconsistency at the initial award level. The bottom line is that both agencies tell us that they are doing things to improve consistency such as improving training or tightening guidance to their offices. But neither one of them has actually measured how consistent their decisions are. And until they do that, we believe that program integrity just is not where it should be. MR. BRADLEY. You indicate that in applying the DeLuca criteria there have been substantial improvements in the joint and spine medical examination reports. Do you have recommendations as to how similar improvements can occur in PTSD exams? MS. BASCETTA. We actually looked at the CPEP report because in the DeLuca case, what the CPEP report shows is that the quality of medical exams certainly is an input that could be contributing to inconsistency. Actually, in the PTSD case, the data from CPEP show that they are doing pretty well in that domain with a couple of exceptions. At the initial review level, 25 percent of exams had problems in assessing the DSM-IV criteria and at the subsequent review level, almost two-thirds were inadequate with regard to an assessment of remission or readjustment capacity. So there is certainly something to look at in the medical exam area. But overall in that area, they were at 89 and 92 percent adequacy. So we think that to the extent that there is inconsistency in the PTSD decisions, something else, some other root cause must be driving it. So we go back to our broader recommendation and suggest that VA take a look at both awards and denials to find out where adjudicators may be weighing information differently or using different factors in ways that would create inconsistent outcomes. And perhaps the use of performance measures or other impairment-specific strategies would be helpful in eliminating or reducing the inconsistency. MR. BRADLEY. Thank you very much. MR. MILLER. Mr. Udall. MR. UDALL. Thank you, Chairman Miller. I'm trying to understand, Mr. Wooditch, first of all, what was your motivation for looking at PTSD and stressors? Was there some indication that came to you that there was some problem here or was this just something that was dreamed up in your shop? I mean, did somebody come forward and say we have a serious problem with the way the VA is doing this and that's what initiated it or was it an internal issue with your operation? MR. WOODITCH. It was an internal issue with the IG. We reviewed data from the 15 major body systems that disability ratings occur in. And as I mentioned earlier, we determined that in the mental disorder system -- MR. UDALL. I am trying to say what inspired. So it was an internal issue, you are saying, that you were looking at things to review? It wasn't that somebody from the outside came and told you there is a big problem here with the way the documentation is working on stressors in the file? MR. WOODITCH. That is true. MR. UDALL. Okay. I just want that one part established. Now what I am trying to figure out is, you did your look into it and you found there wasn't adequate documentation on the stressors, correct? MR. WOODITCH. Yes, sir. MR. UDALL. And after you did that, was your expectation that the VA under the current legal authority and how they are required to review these cases that they were going to go out and reopen 72,000 cases based on your report or was your intent more to tell them, look, you have got problems with what you have done in the past, you ought to try and look at future cases and make the documentation better? MR. WOODITCH. I think our intent was to cover both of those areas. I think our intent was to go look at cases that have been approved and if the documentation was not available and it was determined that the individual receiving the benefits was not entitled to the benefits under law, an appropriate review process should take place. MR. UDALL. And you are aware of the legal authority, aren't you? Congresswoman Berkley read to you the legal authority with which the Secretary has the ability to review cases. And just let me cite that again. It says the decision of the Secretary as to any such matter shall be final and conclusive and may not be reviewed by any other official. And so if you have a decision that has been made to grant PTSD, unless there is fraud or unless there is what is called in the law a clear and unmistakable error, then the Secretary cannot touch that decision at all; isn't that correct? MR. WOODITCH. Yes, sir. MR. UDALL. And so really the standard here is very, very high for the Secretary in terms of his ability to open this up. I mean, we have set a very high barrier in the law and in the regulations basically telling the Secretary, after you decide one of these cases, unless there is fraud or a clear and unmistakable error, you should not be opening these things up. And, yet, what they have done is they have gone back to the individual veterans and said to the veteran, you have a problem with your documentation in your file. You come forward as a veteran and prove to us that these stressors which occurred to cause the PTSD maybe ten and fifteen years ago, that they have to prove the Veterans' Administration that there was actually a stressor. I mean, under the legal standard, don't you find that a little bit incredible what the agency is doing and how they are abusing veterans? MR. WOODITCH. I was not aware that VBA had reached out and opened up any of these cases. Again, our intent was to basically comply with the rules and regulations for documentation. And I agree with the citation that you just mentioned, that the only basis for denying payment is under clear and indisputable evidence that the individual is not entitled to the benefits or fraud. But in doing the review, in order to gain the documentation to meet the rules and regulation compliance procedures in the department, if they do find instances where an individual is not entitled to the benefits or fraud, then we do expect that that be dealt with. But our intent was not to have any other benefits terminated. MR. UDALL. And, you know, your kinds of reports, I think, are very valuable to agencies. I am not attacking that in any way. But I think the thrust of what you have said is that we should look forward and as we do documentation, rather than going back based on the legal standards that are there and force veterans to dredge up incidents ten and fifteen years ago and come in and prove to the Veterans' Administration when they don't have to do that unless there is fraud or clear and unmistakable error. Sorry to run a little bit over, Mr. Chairman. Appreciate it. MR. MILLER. You were 34 seconds over. MR. UDALL. You can take it out of my hide the next time around. MR. MILLER. Ms. Brown-Waite, do you have any questions? MS. BROWN-WAITE. Yes, I do, Mr. Chairman. Thank you very much for holding this hearing. You know, one of the things that I have heard in the south is that northerners are very quick to say, well, this is the way we did it up north and we need to get over that. Well, one of the things that I regularly hear and that I believe is that in other parts of the country that the various disabilities are treated much differently than what they happen to be in Florida, particularly the VA disabilities. And when you are talking about reopening or reviewing 72,000 cases, I think the natural question has to be, what is this going to do to those already in the pipeline? That would be question number one. Question number two, when I walked in and my colleague, Ms. Berkley, was telling the story, I believe, about where, you know, nobody would go back and really review the veteran's disability case, I had exactly the same situation where I had to say, listen, this guy really was a Navy Seal. I actually got the VA to issue a letter of apology because of all the grief they put him through because as he said, he said, yes, the money would be helpful, yes, the 100 percent disability rating. He said but more importantly, I think that the VA owes me an apology. And I insisted that they write a letter of apology to him and they did. But how are the ongoing cases which are already so long in the pipeline, are they going to be affected at all by this review? MR. WOODITCH. I don't know how extensive the 72,000 case review will be. I know that there is a lot that could be done by looking at information that is currently in VBA's information systems to eliminate the great majority of those cases. I mean, the evidence exists in the systems. So I don't suspect that they will reopen 72,000 cases. I think it will be a much smaller number than that. And I know there is a quality concern as well and that any additional workload obviously has an impact on VBA, but timeliness of processing is not the only issue that the IG is involved in. We also want quality of rating decisions. MS. BROWN-WAITE. And I think uniformity of rating systems sure would help. MR. WOODITCH. Yes, ma'am. MS. BROWN-WAITE. Let me ask another question. I had another veteran that the staff just totally were beating their head against the wall contacting VA. It was a disability claim that we had sent in and I finally reached somebody in VA Disability who was able to really help me to understand what the problems were. Initially when I called, he said I am sorry, we don't have that document. I said, no, you do have that document because we sent it in. He said, ma'am, hold on. Let me go to another program. He went to a second program and he said, well, it is not there, but let me go to another program. After four different programs, he told me, oh, yes, we did receive that document. He had to each time -- it was not just another screen. It was another program. This is part of the frustration, I believe, in the whole disability system. I said to him, so you mean to tell me that when my staff was calling in or when a veteran was calling in that depending on what screen they first pulled up, they may or may not have the information, that there is no consolidation of this information. The information is held in different programs. I only got to four. I do not know. Maybe there is eight or twelve. I do not know. But it is, like, it is no wonder that veterans cannot get answers because depending on what screen the person that they happen to call pulls up, sometimes it has the information there. From what he said -- and I will never reveal his name because he was so darn helpful, you would probably consider him a whistle-blower -- but from what he said that, you know, a lot of people just do not go to the other screens. And so sometimes this information is kind of lost out there. Help me to put together why you cannot have or why the VA -- and maybe I should be asking this to, you know, auditor of the Inspector General -- why isn't there a consolidated system there that is going to help with those disability benefits? MR. WOODITCH. The IG and as well as the Veterans' Benefits Administration knows that the IT systems are out of date. They need to be updated. We need to have consolidated systems that have veteran benefits' files that are easily accessible electronically. But -- MS. BROWN-WAITE. Sir, answer me this. Was he correct? Is that part of the problem? I think you did not answer my question. Are there, like, at least four different programs that the disabilities people have to deal with and it is not consolidated? Is that an accurate statement? MR. WOODITCH. I do not know. You will have to ask the Veterans' Benefits Administration. I do not know how many systems there are. MS. BROWN-WAITE. Okay. I would ask that staff follow-up on that. It is no wonder, Mr. Chairman, that, you know, veterans who truly have disabilities who filed claims are frustrated over this. As I said, you know, he told me there were at least four systems and that does not work very well without some sort of integration of those systems. MR. MILLER. Very good. MS. BROWN-WAITE. I have a submission. MR. MILLER. Your time is expired. [The statement of Ms. Brown-Waite appears on p. 48] MR. MILLER. There is a vote that has been called. I would like to go ahead and finish the questioning for this panel. So, Ms. Berkley, if you would like to go ahead. MS. BERKLEY. Let me ask Mr. Wooditch first. Do you have any idea how much the cost of conducting these reviews are? I mean, we have witness after witness, including the VA Secretary, sitting where you are begging us for more money because there is not enough money in the VA budget. We are not adequately treating the veterans we have. Are we taking desperately needed resources that could go to the veterans and spending it on reviewing cases that do not much matter anyway? MR. WOODITCH. I do not know what the cost of these reviews will be, but obviously it will be something. We do not know how many cases will need to be reopened, so we do not have an estimate for that. MS. BERKLEY. Why do we need to reopen any more cases? MR. WOODITCH. I think that 25 percent error rate and lack of documentation is pretty significant and -- MS. BERKLEY. Wouldn't it make sense for us to start to direct the VA to fix the way they do their adjudication rather than going back over 72,000 cases? Isn't that a better use of our time and resources and efforts given the fact that the VA does not have enough personnel anyway? Doesn't that make sense to you? MR. WOODITCH. It seems like it makes a lot of sense. It is a viable option which should be pursued. MS. BERKLEY. And I would love to ask more. So you agree with me that we should just move on with it and fix the problem without possibly endangering the lives and mental health of our veterans, PTSD veterans? MR. WOODITCH. With the caveat that if there are veterans who are receiving benefits that they are not entitled to under the law, I think that we need to identify those and take appropriate action. MS. BERKLEY. Yes. But according to the law, the Secretary's decision is final and conclusive unless you can establish fraud. And how are you going to do that unless you reopen every single case? It makes no sense. We are not dealing with people that are 100 percent well, that are 100 percent adjudged mentally disabled or with PTSD. I mean, we are dealing with a nuance that does not seem to make any sense to me. Let me ask you something. Your testimony raised an antenna for me. You said that you had recommended that they review not only those that were receiving benefits but those that had been denied benefits? MS. BASCETTA. That is correct. MS. BERKLEY. Then how come that is not taking place? MR. WOODITCH. How come we are not reviewing claims that were denied? Well, it is because it was not part of our review. Again, we are trying to understand what caused the variances in payments. Denied claims have no impact, so it just was not a factor in our review. MS. BERKLEY. Explain to me what you are suggesting. MS. BASCETTA. Well, I can understand why the administration would want to look at awards because of the impact on not only the total proportion of people on the rolls with that diagnosis but the proportion of payments. But we do not know, for example, what the total increase was for applications for PTSD. There could have been a disproportionate number denied. So for program integrity purposes, we would be very concerned about a review that only looked at awards. You would want to know about the denials as well. MS. BERKLEY. Thank you. MR. MILLER. Mr. Udall. MR. UDALL. So, Ms. Bascetta, basically what you are saying is to just look at the awards without looking at the denials is an effective way in which to move forward? To be balanced about it, you ought to be looking at the denials also? MS. BASCETTA. Looking at the awards is only one part of the story. You want to see that awards are consistently awarded and that denials are consistently denied. MR. UDALL. And the VA is not looking at the denials? MS. BASCETTA. I believe I heard at one point that they thought that they should look at denials at some point, but I do not think they have made a commitment to do that. They are definitely starting with the awards. MR. UDALL. You know, our understanding that the announcements that they have made is with regard to the awards and the 72,000. There is no suggestion that they are taking a look at denials or moving forward with denials at this point. At least that is, I think, our understanding. I mean, your agency looks at good governance and how to deal with things. I mean, here you are dealing with veterans that have a severe set of psychological problems. They are given 100 percent disability. And then the government comes in when it has no legal authority and basically starts sending people out to talk to these veterans without, as far as I can tell, consulting psychologists on how to deal with this situation. And they send them out and start challenging them and saying you have to come forward and prove the stressors because there is not adequate documentation even when this is ten and fifteen years ago. Does that sound like a good policy to you? MS. BASCETTA. Well, no, it certainly does not. The issue of stressors raises something else in my mind. And, you know, this is a good example of why you really have to be fact based and data driven in your analysis of what is going on here. Our look at the CPEP data actually showed that the medical exams were, you know, up in the low 90s for compliance with documentation of a stressor. So there is a disconnect somewhere between what the IG is finding in their documentation and what the CPEP report indicates. It is another good reason why you have to dig deeper for the root cause of what the inconsistency is. Is it that in the totality of the evidence, the stressor that the adjudicator is looking at is being weighed differently or not carrying as much weight as something else? Is that what is driving the inconsistency? And, again, for both awards and denials. MR. UDALL. How do we get to the bottom of that inconsistency? What is the best way to do that? MS. BASCETTA. Well, in the absence of an administrative database, it would help -- you know, they do not have the automated systems to do quick analysis. So I think they have to pull case files and get adjudicators together and find out what their decision-making process was and how they arrived, what their rationale was for those decisions. It is a very difficult problem. We are not trying to, you know, minimize how hard this is. Disability decisions, particularly those that are less objective, are hard decisions. But in the absence of measuring consistency on hard cases like PTSD and pain and other impairments that are less objective, the department is vulnerable to exactly these kinds of problems, that, you know, there are allegations of fraud, that there are allegations, you know, that there are people who are unfairly awarded or unfairly denied because they simply do not have the data to prove that they are doing a good job in this area. MR. UDALL. And there is no doubt these are hard decisions. And it just seems to me when you are dealing with a veteran with severe psychological problems, trying to go back ten or fifteen years and figure out what went on with a stressor even makes it more difficult and more complicated. And I do not know how it moves the process forward in any way. I mean, these veterans take this personally. I mean, these veterans are - - and it is not just the ones that have been asked. All of them take this on a personal basis. And I think you are going to hear that from Secretary Garcia and some of the other witnesses. Thank you, Mr. Chairman. MR. MILLER. Thank you very much. I appreciate the panel coming in and testifying today. What we will do now is recess until 12:45 and give folks an opportunity to take a break and we will come back. Again, thank you again very much. MR. WOODITCH. Thank you, sir. [Recess.] MR. MILLER. Thank you, everybody, for your indulgence. I hope you were able to maybe get out and have a slight break. I would like to go ahead and proceed with the next panel. Panel two is a one-person panel. Mr. Garcia, thank you for being with us today. He is the Secretary of New Mexico's Department of Veterans' Services. You can proceed with your testimony, sir. STATEMENT OF JOHN M. GARCIA, SECRETARY, NEW MEXI- CO DEPARTMENT OF VETERANS' SERVICES MR. GARCIA. Mr. Chairman, members of the Committee, on behalf of Governor Bill Richardson and the veterans of the great State of New Mexico, as a Vietnam veteran, it is an honor and opportunity to testify regarding the U.S. Department of Veterans' Affairs' review process of posttraumatic stress disorder, PTSD, claims. In 2003, the New Mexico Service Commission became the New Mexico Department of Veterans' Services, a cabinet-level agency tasked with serving and ensuring that our veterans are receiving the benefits that they have earned. New Mexico has 180,000 veterans. During the Vietnam War, we were number one in drafting percent, third highest in casualty rate. Half of our Vietnam veterans in the State of New Mexico are combat veterans. And just last year, approximately 59,000 veterans received some form of health care from the VA. The veterans in New Mexico are strongly supported by the benefits they have earned through their service. And I and my staff are proud to serve them. Unfortunately the recent action taken by the VA has been a great disservice to these men and women. In the original VA IG report, 2,100 PTSD claims were reviewed of which 300 were from the State of New Mexico. After being identified for further review, letters were sent to each veteran. The letters that were sent threatened two possibilities for benefit losses. First, the letter implied benefits would be lost unless specific proof of PTSD was presented, a proof that for many veterans requires reliving horrific events during times of war and combat. Second, the letter implied that benefits would be lost if a veteran was not under current treatment. This policy of retroactive inspection has been received by the entire veteran community as an assault on every veteran, not just those for review. And it is clearly seen by both individual veterans and by veteran service organizations as yet a further requirement of proof of their service and their dedication to our nation. And it is being inflicted upon these veterans who have experienced tremendous traumas, stress, and pain. Make no mistake about it. This is a serious problem. On October 8th, last week, a brother Vietnam veteran of New Mexico committed suicide. He was a 100 percent service connected PTSD, unemployability combat veteran who had earned and been awarded a Purple Heart. While he was not one of New Mexico's veterans selected for review, the issue was on the forefront of his mind. He was found with information of the retroactive report which was laying in front of him next to his Purple Heart medal. And one of the last discussions he had with other veterans was about the review process. He is clearly a casualty of this flawed process. Why is it that the entire veteran community is being affected by this review when it is directed at only a small percentage of them? The answer is because an attack on one veteran is an attack on all of us. And let me make this clear. This review policy is perceived as an attitude, an attack, and a personal assault on the honorable service of all veterans. It has forced veterans with PTSD, who have suffered and sacrificed because of their service to our nation, to yet again prove themselves to the VA. And I believe that this is wrong, it is horrible, it is a travesty, and it is an insult to the veteran and to his family. Last week, Mr. Chairman, members of the Committee, I received a letter from a Mrs. Lane De Priest, the wife of another brother Vietnam veteran who is suffering from PTSD. Her letter was a plea for help that expressed concern, sadness, and outrage with the PTSD review. And she spoke with passion on how this was so directly affecting their lives. And if I may, I would like to read you excerpts of this letter. The letter is dated October the 7th, 2005. She writes, "Recently my husband received a letter from the Department of Veterans' Affairs. This letter indicated that he was under determination for his benefits. He was given 60 days to respond. He was, in effect, asked to prove all over again what he has spent the last 36 years trying to prove. At this time, he is receiving 100 percent benefits for his PTSD." "As a result of this letter, I have spent the last three nights watching him walk the floor, scared his benefits are going to be cut off. He turned in all of his paperwork as asked on Monday, October the 3rd, and was told by representatives at the VA Regional Office in Albuquerque that he would receive a call from that office on Monday afternoon. He is still waiting for that call." "Many attempts to contact that office have been futile. The young lady who was to call him back this afternoon is either not in, away from her desk, or unavailable. And I find this unacceptable.'' She continues to write, "This morning, I went to work and when I called my husband to inform him that I was safe at work, he told me he was going to fix everything. I left work and when I returned home, he had called his brother to pick two guns that he owned.'' "I immediately contacted the VA hospital and spoke to Dr. Mike Burger. He calmed my husband down and promised he would look into the VA Administration and gather information. Then he would call us back.'' "I guess what I want you to know is that there are a large number of veterans in New Mexico who have received this same letter. They and their families are going through much the same thing that my family is. This has affected me, our children, and our grandchildren.'' "Something needs to be done to stop this madness. Our veterans are feeling they are worthless and they are being called liars. How many veterans will succeed where my husband did not this morning? This is very painful and I can't stress enough how important these veterans are to us. This is my life, my husband's life, and our family.'' Mr. Chairman, distinguished members of the Committee, on behalf of veterans in the State of New Mexico and over 26 million veterans of this country, I thank you for allowing me to express our concerns. This concludes my statement and I am happy to respond to any questions. MR. MILLER. Thank you very much. [The statement of Mr. Garcia appears on p. 79] MR. MILLER. Mr. Udall, I will let you ask the first questions and then I will have some of my own. MR. UDALL. Thank you very much, Mr. Chairman. I appreciate that courtesy. Let me just say once again how happy we are that Secretary Garcia is here. He has a distinguished record of service. He served in the U.S. Army in the Central Island of South Vietnam and received a number of citations. We very much appreciate your service and appreciate having you here today. Secretary Garcia, I want to first of all ask you about the disconnect between the facts and the figures. You sat here and listened to the testimony and people talking facts and figures. And the human element, the veterans' side, could you comment on the effect on families, on the impact in these communities where these things are occurring? MR. GARCIA. Yes, sir. Mr. Chairman, Mr. Udall, I think what people are forgetting is that there is a human element involved here. For years when Vietnam veterans -- and I would suspect, I would bet the 72,000 cases being reviewed are probably 90 percent or more Vietnam veterans. As a Vietnam veteran, coming home from Vietnam, it took me over 30 years myself to get enough nerve and courage to go to the VA. And many of the Vietnam veterans came home from Vietnam and did not go to the VA because the VA of my father was not taking care of my needs nor my brother's needs. And many veterans finally had enough courage and nerve to go back to the VA, the Vietnam era veteran, and his needs were starting to be taken care of. And the word came out about 15 years ago that veterans are going to be looked at that are suffering from PTSD because when Vietnam veterans came home from Vietnam, the VA did not know what to call this PTSD syndrome. When they finally figured it out, veterans were encouraged to go to the VA for service and treatment. If you received a Bronze Star, Silver Star, Combat Infantry Badge, it was almost an automatic for PTSD. An administrative error more than likely, yes, has been created, but you cannot fix it on the backs of the veterans. It is causing veterans to kill themselves. We had a veteran fortunately who did not kill himself. But how many other veterans of the country are going to be doing that? And that is the question I have. I had a veteran in my office before I came here who just got 50 percent of a PTSD disability and, yet, he has the Combat Infantry Badge and a Bronze Star, and he was asking me why didn't they give him his 100 percent. All I could tell him is they are afraid to give you the 100 percent now, and just to hang in there. We are working very closely with the Vet centers, the VA Regional Office, the VA Hospital, trying to inform the veterans that your benefits are not going to be taken from you. But the veteran community, as you know, it is a very tight community. It is a brotherhood that you do to one, you do to all of them. And in my opinion, this effort has to stop. MR. UDALL. Secretary Garcia, when you talk about the brotherhood and how tight the community is, even though the numbers that are being reviewed are a small amount of the 72,000, do you think the, I guess, the 2,100, but the additional subtract out from the 72,000, the additional veterans in this group, that they are feeling this personally? MR. GARCIA. I believe so. Mr. Chairman, Mr. Udall, they are feeling it personally. In New Mexico, we have 180,000 veterans. Thirty-one thousand are receiving some form of comp and pen right now. That means I have got at least 150,000 of the veterans out there that my service officers who have been trained to go out and reach out these veterans to get them to file for the disability probably have a fear factor of not filing now. And I just think there is going to be major ripples of repercussions. One, discouraging the veterans to come into the VA. But I think more outreach needs to be done. Yes, sir. MR. UDALL. Secretary Garcia, you said in your testimony that you had to get up the nerve to go in. The Veterans' Administration for Vietnam veterans was not viewed as a friendly Veterans' Administration, right? MR. GARCIA. Mr. Chairman, Mr. Udall, that is correct. MR. UDALL. And so now what we have happening the Veterans' Administration, I think, did work very hard to build back the trust and put these programs in place and get disability to veterans. And now, I think what is coming back to veterans it sounds like is their memories of the way the Veterans' Administration used to be with this kind of behavior by the Veterans' Administration. MR. GARCIA. Mr. Chairman, Mr. Udall, I would say that is correct. It has taken years, I think, for -- the VA today is not the same VA as it was for our fathers. It is not the same VA when I got home from Vietnam in 1970. And there has been great strides and effort for the VA to be user friendly to our veterans. And there was great outreach done to encourage our veterans to come in and file for the PTSD disability on their comp and pen. And for most veterans, this is all the income they have in the family. And when you start challenging that and taking it away from them, you are not just impacting the veteran. You are hurting the family and you are hurting the family members. You know, awarding a PTSD disability to some veterans, and I am talking about the Vietnam era veteran, it is more a validation of his service to country. You all know what the Vietnam veterans went through when they came home from Vietnam. All of a sudden now, after 30 years of going back to the VA and they are getting their PTSD claim, only to be reevaluated again, and when they did receive that, it was a validation to them that what they did was honorable. It has nothing to do with the money. But when you take that away from that spouse and those children, what is the veteran left with? In our case in New Mexico, we had a veteran commit suicide, leaving the Purple Heart on his bed and documentation of this review analysis. That is wrong. That is totally wrong. And it is an insult to the integrity of the men that served honorably with me in Vietnam. MR. UDALL. Thank you very much. Appreciate the courtesy, Mr. Chairman. MR. MILLER. Mr. Secretary, following up on the veteran who committed suicide, you said clearly he was a casualty of the PTSD review. Is it the same person? MR. GARCIA. Yes, sir. MR. MILLER. And this person had paperwork in his possession and that leads you to make that statement that the fact was he was not up for review? His case was not going to be reviewed? MR. GARCIA. Mr. Chairman, members of the Committee, this veteran that killed himself with his Purple Heart next to him was not under review. He felt the same pain that many Vietnam veterans feel. And this gentleman should not have killed himself. When you hurt one veteran, you hurt them all. And this gentleman was not under review, but he felt the process of the review was wrong. He felt that they were going to take his disability away. And the conclusion we come to why he felt that was because just prior to the day he committed suicide, he was talking about the review process. And near him was documentation about this review analysis of the PTSD claims to be withdrawn. So to me, he is a casualty of this process. So whether you are receiving at 50 percent or you are 100 percent or you are one of the 300 cases in New Mexico that is being reviewed, you are being challenged all over again. You have to revalidate what you did as a service to your country. It goes deeper than just trying to fix an administrative error. I believe fix administrative error but not on the backs of the veterans. Fix it from here on out. But I also believe what is happening is the regional offices, there is probably a fear factor going on where most veterans, most cases are probably being looked at more carefully and more stringent where proof of burden again is on the veteran. MR. MILLER. Can you explain to me what your office is doing -- and you kind of alluded to this -- as far as letting the veterans know what the PTSD review process is and that, you know, why they are doing it? MR. GARCIA. Mr. Chairman, members of the Committee, my office, Department of Veterans' Services, works very closely with the veteran centers in Albuquerque and in Santa Fe. We have been working closely with the regional office and the VA and the veterans' service organizations explaining to veterans when they e-mail me, when they call me, or when they call the vet centers, telling them your PTSD benefits are not going to be withdrawn. We are trying to calm the veterans down. They are upset. Their e-mails are flying back and forth across the state and across the country. The network is pretty tight as a lot of you are probably aware of with the veterans in your own region. We are doing our best to inform the veteran community based on the information that we are picking up. I have not had any particular briefing, though, regarding this particular status of the PTSD benefits. MR. MILLER. Would you provide this Committee the evidence of what your organization is doing in regards to letting the veterans know? MR. GARCIA. Yes, sir. MR. MILLER. I would appreciate seeing how the state would be handling that. And you talked about that this may be an administrative error. MR. GARCIA. Yes, sir. MR. MILLER. In your office, if somebody was awarded a salary increase or some type of an increase and you found out later that it was an administrative error, how would you handle that? MR. GARCIA. Again, you are looking at apples and oranges. If this was a bank, if this was a business -- MR. MILLER. I am talking about you. MR. GARCIA. Well, in my office, I do make the adjustment. It is either that or I have to eat the error myself and pay the penalty myself. MR. MILLER. And would the error that you are eating yourself, if you will, would that affect others and could it affect other employees in their ability to get future increases? MR. GARCIA. No, because then I would correct my error from there on out. MR. MILLER. But the person, they would no longer have that raise though? They would go back to -- MR. GARCIA. That would be correct. I would correct that. Well, I would correct that error. But here again with the PTSD issue, you are dealing with people with mental disorder. MR. MILLER. Wait. And please understand that I understand the subject very well and we all know people personally. You are drawing a conclusion that every single one of them has PTSD. The fact of the matter is they may not. And that is what the review is all about, is it not, to find out if they were, in fact, adjudicated correctly to receive their benefits? So you are saying without question that they all suffer from PTSD at 100 percent. And we do not know that. You yourself -- MR. GARCIA. No. That is correct. We do not know that. MR. MILLER. Okay. MR. GARCIA. Right. But you are also talking about trying to fix an administrative error on the backs of veterans that are very sensitive that have some form of PTSD. MR. MILLER. Some form, but maybe not 100 percent. MR. GARCIA. Maybe not 100 percent, but veterans that have 50 percent, 20 percent, 30 percent, I have had them in my office with a fear factor that they are going to lose their benefits. And that is wrong. MR. MILLER. And then your explanation back to them -- MR. GARCIA. Is they are not. MR. MILLER. -- is that you only adjudicate -- no. I heard you say that you were only adjudicating 50 percent because VA is afraid to give you 100 percent. Did you actually say that to a veteran? MR. GARCIA. In the case of the veteran that came into my office before I got here, who was a combat veteran with a Combat Infantry Badge, it surprised me that the VA gave him a 50 percent evaluation when in most cases, I have seen veterans with a Combat Infantry Badge at 100 percent. MR. MILLER. You mean everybody that has a Combat Infantryman's Badge should be 100 percent disabled with PTSD? MR. GARCIA. The word that we have gotten is that if a veteran suffers from PTSD or has a CIB, a Combat Infantry Badge, a Bronze Star, Silver Star, it is almost an automatic that he will be given or granted 100 percent. If he does not have that, he has to go through the process where he has to do his statement. MR. MILLER. That is a question that I certainly will ask the Veteran Benefits Administration. MR. GARCIA. Yes, sir. MR. MILLER. That is hard to believe. But thank you. Thank you for your service. MR. GARCIA. And I would be glad to, if my statement is incorrect, to get the right answer. MR. MILLER. Well, a lot of times, statements are made to this Committee in particular -- MR. GARCIA. Yes, sir. MR. MILLER. -- in ways to try to move the discussion in one direction or another. And all we are trying to do as members of this Committee from both sides of the aisle is to fix a problem that may or may not be out there. There may not be a problem. I mean, nobody on this Committee has said that there is. But for you being down at the state line, it is very important. And we appreciate the work that you do and the people that work with your agency do. And, again, thank you for your service to our country. Ms. Berkley, you are next. MS. BERKLEY. Thank you very much, Mr. Chairman. Let me ask you a quick question because there seems to be a little confusion here. Doesn't the rating depend on the veteran's symptoms? MR. GARCIA. Yes, ma'am. MS. BERKLEY. All right. So they are rated according to how they show during their evaluation? MR. GARCIA. As I understand it, yes. MS. BERKLEY. When I was in law school, we were taught that you take the victim as they are. And there are times that you say, well, how could this little accident have caused such a catastrophic problem in this person. And the reality is every person is different. With our veterans, there are some veterans like my dad who went to the World War II, he came home. He never thought about it again. He has got friends. He is 80 years old now and he has never looked back. He has got friends that I know very well from my childhood until now that their World War II service and what they experienced was a defining moment in their lives. I see it time and again with our Vietnam veterans when they come home mentally damaged. They either saw their friends torn apart, they experienced or seen things that most of us do not get to see, thank heavens, and they have come back and they are adversely affected in a very serious way. So when they are adjudicated 100 percent disabled because of PTSD, there are those that when they hear that there may be some sort of review, that they would not think twice about it. There are others who because of what they have experienced and because of who they are would commit suicide because of their fear of having their benefits and their validation taken away from them. Would you agree with that? MR. GARCIA. I would, yes, ma'am. MS. BERKLEY. Now, before the Chairman came in, I mentioned that I had an experience when I first came to Congress with a Vietnam veteran who was 50 percent disabled PTSD from the Vietnam era. And he came to me with a stack of papers, Mr. Chairman, this big, notebooks of correspondence he had with my two predecessors explaining his condition, explaining that he had only been interviewed for 20 minutes, only examined for 20 minutes, and after that 20 minute examination was given 50 percent disability. He believed all these years since he could not work, he had flashbacks, he could not sleep, he wet his bed, he was dysfunctional, that he should be 100 percent disabled. And all the computer kept doing, the VA computer, whenever any of my predecessors contacted them on behalf of this veteran was kick out the same information they had because nobody takes the time to go beyond what is in the files. And we were able to get him 100 percent disabled. So the fact that they are disabled, I think 100 percent indicates, since that is such a difficult rating to acquire, that they have got some serious problems. So when this particular group of people hear that they are going to be readjudicated or rereviewed or they have to provide information about their stressors, I think it has in many instances an adverse effect. Now, do you think there might be some others, judging from your experience with your veterans and those that have PTSD and the experience with the veteran that committed suicide with his Purple Heart and his information next to him, do you think there is a possibility if we continue these evaluations that that might happen again? MR. GARCIA. Yes, I do. MS. BERKLEY. And on what do you base that? MR. GARCIA. As I stated earlier, whether a veteran is receiving his 100 percent PTSD disability or a 70 percent PTSD or 50 percent, the veterans that I am seeing, that is calling me are 50, 60, 70 percenters as well as 100 percenters that are asking me the same question, are they going to lose their benefits. We reassure them they are not. We had 300 veterans in New Mexico receive these letters. I have got 180,000 veterans. I have got veterans in my state that are afraid that they are going to lose their benefits because of this. The gentleman that committed suicide, he was not even on the list, but he is that percentage that you just talked about. But there are other veterans out there that I just want to make sure that they do not get into that box. MS. BERKLEY. May I just ask one more question? MR. MILLER. We have only 35 minutes; we have a full Committee hearing that we need to move to. So we will come back around again. MS. BERKLEY. Then I would want to speak to Mr. Garcia. MR. MILLER. Can you explain or do you know that the veteran who committed suicide, since he keeps getting brought up in conversation, what treatment he was receiving? MR. GARCIA. No, sir, I do not. I know he was going to the Vet center for PTSD counseling. He was very active in the veteran community is what I know. He came by our office several times, volunteered to help in Northern New Mexico on some veteran activities. He was involved with his Veterans' Service organization. MR. MILLER. I do not know if there is a way we can, but I would like for staff to find out for the members of the Committee this particular case and maybe it is an issue that we cannot. But maybe there is a way that we can find out because it is obviously a compelling story. Mr. Udall, do you have any other questions, because Ms. Berkley really wants to ask -- MR. UDALL. No. MS. BERKLEY. And thank you, Mr. Chairman, for your courtesy. How long have you been doing what you are doing? MR. GARCIA. I was appointed in 2003 and I have been involved in veterans since I came home from Vietnam, but more actively in 1980 when I put together and found with other veterans the Vietnam Veterans of New Mexico and Vietnam Veterans of America that came into our state. I was the Deputy Director for a program called the Vietnam Vet Leadership Program here in Washington, D.C. that worked from 1982 to 1985. MS. BERKLEY. So I would say that at least half of your life has been spent in the service of veterans. MR. GARCIA. Yes, ma'am. I believe I am who I am because of my service. MS. BERKLEY. Then with your life breadth of experience and knowledge of how veterans think and feel and having experienced it yourself as a Vietnam veteran, have you -- MR. GARCIA. Let me just clarify. I am not the VA. I am the State Director of Veterans' Services. And I do not understand all the VA and I am trying to understand it. MS. BERKLEY. Okay. Thank you for that clarification. Have you seen any evidence in the veterans you assist that they are exaggerating their symptoms of PTSD to gain monetary compensation benefits as suggested by the IG? MR. GARCIA. I have had veterans in my office exaggerating symptoms, yes, I have. But I do not make a judgment on them. My job is to provide service to all my veterans. I have trained service officers. I have 20 field officers out in the State of New Mexico that work directly with our veterans that help them just file their forms. And then they are assigned a Power of Attorney with the National Veterans' Service Organization that represents the National Service Organization and the VA that helps the veteran process his claim properly through the regional VA office. We do not make any judgment on any veteran that walks in my office. And I have had some doozies walk in. MS. BERKLEY. Okay. Thank you. MR. MILLER. Thank you very much, Mr. Garcia. MR. GARCIA. Mr. Chairman, members of the Committee, it is an honor to be here. And thank you again, sir. MR. MILLER. Thank you, sir. If the last panel could come forward and we will get name cards out in front of you. But while we are doing that, I would like to just go ahead and let the Committee know and for the record, Steven Brown is the Director of the VA Compensation and Pension Examination Project based in Nashville. Mr. Ron Aument is the Deputy Under Secretary for Benefits at the Veterans Benefits Administration. He is accompanied today by Ms. Ren�e Szybala, Director of VBA's Compensation and Pension Service. Dr. Brown, if you would, please proceed. STATEMENTS OF STEVEN H. BROWN, DIRECTOR, COMPENSATION AND PENSION EXAMINATION PROGRAM, DEPARTMENT OF VETERANS AFFAIRS; RONALD R. AUMENT, DEPUTY UNDER SECRETARY FOR BENEFITS, VETERANS BENEFITS ADMINISTRATION; ACCOMPANIED BY RENE� SZYBALA, DIRECTOR, COMPENSATION AND PENSION SERVICE, VETERANS BENEFITS ADMINISTRATION STATEMENT OF STEVEN H. BROWN DR. BROWN. My name is Steven Brown. I have been the Director of the Compensation and Pension Exam Program, or CPEP, since its inception in 2001 when the Under Secretaries for Benefits and Health executed a Memorandum of Agreement which established, staffed, and funded a joint initiative to improve C&P exams. The goal of improving compensation and pension exam quality fits hand in glove with the goal of reducing variation among the exams. CPEP's strategy is to reduce variation by continuously improving quality. Our goal is to ensure that VHA provides consistently high-quality exams. CPEP has adopted a pragmatic approach to quality improvement based on reliable and actionable baseline and ongoing performance data, accountability, and prioritization of effort. We targeted the top ten most frequently requested exam types which account for approximately two-thirds of our workload. These exam types are General Medical, Joints, Spine, Foot, Skin, Mental Disorders, both the Initial and the Review PTSD, Audiology, and Eye. CPEP initially developed reliable and valid methodologies for measuring C&P exam quality based on the VBA Compensation and Pension Service's exam worksheets and the rating regulations and used these methodologies to measure baseline C&P exam quality. CPEP data were generated by a structured, standardized quality review process. Our reviewers answered specific questions about each exam. We refer to these specific questions as quality indicators. An example of a quality indicator is, "does the exam describe noise exposure during military service?" Once an exam has been reviewed, we gave it a score, exactly like a test in school. Exams that scored 90 percent or better were considered to be of "A" quality, just like in school. And the more "A's," the better. CPEP used quality indicators and the idea of "A" quality work to determine the baseline quality of VHA C&P exams. In the August 2003 VISN-level report, CPEP found that the baseline percentage of "A" quality exams for all VISNs was 53.5 percent with a range from 46 to 67 percent. This information was shared with the examining sites and VISNs as well as VHA and VBA leadership. In response to these results, CPEP, with the strong support of senior VHA and VBA leadership, implemented a number of quality improvement initiatives. These initiatives have, over time, contributed to a decrease in variation in VHA C&P exams and an improvement in quality. I would like to outline for you a number of the initiatives that VHA, CPEP, and the examining sites undertook to improve performance. CPEP began by taking steps to ensure that all sites were provided with the tools necessary for process improvement. All sites conducting C&P exams were required to participate in a "Collaborative Breakthrough Series" in which sites formed teams that were guided through a multi-month quality improvement exercise by subject matter experts and quality improvement coaches. The CPEP Program was assisted in this effort by the VHA Quality Scholars Program. Each collaborative project included two two-day learning sessions separated by a six-month work period. During the first learning session, the teams were taught how to improve the quality of their exams and how to develop specific action plans to implement improvements. In the six months between learning sessions, support was provided to participants through monthly conference calls, monthly coaching calls, and an electronic chat room. At the final learning session, the teams shared with each other specific strategies and the results of their efforts via presentations and posters. The collaborative teams improved overall quality scores for each of the top ten exams and improved overall timeliness at the same time. To help sites strategically organize and prioritize their improvement initiatives, all VHA facilities performing C&P exams were required by senior management to submit a Facility Quality Improvement Plan using a CPEP template which was based on the principles and techniques they learned during the collaborative breakthrough series. Plans included mandatory sections regarding implementation of quality monitoring via CPEP quality indicators, clinician orientation and ongoing education, clinician feedback, organizational reporting, leadership and resource support. Facility QI plans required the approval and signature of the VISN Director, the Facility Director, and the Chief of Quality Management. CPEP reviewed each plan and provided constructive feedback as appropriate. To further support the exam sites, CPEP developed and distributed videos and computer-based training to all VHA facilities on General Medical, Musculoskeletal, Foot, Heart, Diabetes, Skin/Scar, Muscle, and Respiratory exams. CPEP conducted video conferences on topics such as DeLuca v. Brown, exam templates, and quality measurement techniques. We conducted face-to-face training sessions for quality improvement teams, clinicians, administrators, and template super users. We have made these educational tools available to every site that conducts C&P exams. Finally, we coordinated a conference for VBA and VHA on "Improving the C&P Exam Process Together." CPEP is collaborating with the VHA Office of Information and the VBA C&P Service and Office of Field Operations to computerize all 57 disability worksheets in order to eliminate errors of omission via structured data entry. As of April 2005, an initial version of each of the templates have been installed at all exam facilities. Finally, VHA leadership has set higher goals for the quality of exams by establishing a performance target in the Network Directors' performance plans. For Fiscal Year 2004 and 2005, the performance measure targets were 64 percent of exams being of "A" quality to be fully successful and 75 percent to be exceptional. In 2006, the proposed targets have been increased to 83 percent and 86 percent. In support of leadership's decision to establish performance targets, CPEP developed routine monthly reports on the quality of C&P exams utilizing the same structured quality review process that was developed for baseline review. This information has helped the VISNs and examining sites by providing immediate feedback on performance. This information is used by the sites to identify specific areas needing improvement. The efforts I have just outlined have led to dramatic improvements in the quality of C&P exams. Improvements of VHA C&P exam quality have increased over the last two years. Since CPEP began monthly monitoring in October of 2003, the national average performance measure score has improved. The national average percentage of "A" quality exams for all VISNs was at 80 percent in June of 2005, an increase of 32 percent. The positive results noted in this testimony come as the result of a concerted effort at all levels of VA, including clinicians in the field, the CPEP staff, and VHA and VBA leadership. Much has been accomplished and additional gains can be achieved. We look forward to the opportunity to face these challenges. Mr. Chairman, this concludes my statement. I am now available to answer any questions that you or other members of the Committee may have. Thank you. MR. MILLER. Thank you, Dr. Brown. [The statement of Dr. Brown appears on p. 86] MR. MILLER. Mr. Aument, we will go to you and then we will ask questions. STATEMENT OF RONALD R. AUMENT MR. AUMENT. Mr. Chairman, members of the Subcommittee, thank you for the opportunity to review with you the issue of variance of VA disability compensation claims decisions. I am pleased to be accompanied by Ms. Renee Szybala, Director of VA's Compensation and Pension Service. In October 2001, the Secretary's Claims Processing Task Force delivered its report containing 34 recommendations to improve VA claims processing. The Task Force, which was chaired by Admiral Cooper, found that the most significant issue to be addressed was the need for greater accountability and consistency in our benefit delivery operations. Over the last three and a half years during Admiral Cooper's tenure as Under Secretary for Benefits, the Veterans' Benefits Administration has worked hard to address this need. Through the implementation of the Task Force recommendations, VBA has achieved major improvements in the delivery of benefits, including the quality of our benefits decisions, and we have laid the basic groundwork that will continue to bring more consistency in our decisions. We have made all regional offices consistent in organizational structure and work processes. Specialized teams were established to reduce the number of tasks performed by decision makers and to incorporate a triage approach to incoming claims. We are also consolidating processes in certain types of claims to provide better and more consistent decisions. We have established an aggressive and comprehensive program of quality assurance and oversight to assess compliance with VA policy and procedures and assure consistent application. Included are regular oversight reviews by Headquarters' staff. Training is also key to improving decision quality and consistency. New hires receive comprehensive training through a national centralized program. Standardized computer-based tools have been developed for training decision- makers and training letters and satellite broadcasts on the proper approach to rating complex issues have been provided to all field stations. Over the past year, new articles, particularly those of the "Knight-Ridder News Service'' and the "Chicago Sun Times,'' highlighted the existence of variations in the amount of annual compensation paid to veterans by state. As a result, the IG was asked to review this issue. The IG did not identify a single causative factor to explain the variance in the amount of compensation paid among the different states. Rather, the IG found a number of factors, including demographic factors, that directly contribute to compensation variances. The IG also identified PTSD, its prevalence and its evaluation, including the grant of individual unemployability ratings based on PTSD, as a major contributor to variability in compensation. The IG found insufficient evidence to support the grant of service connection for PTSD in some cases; thus, VA's decision to award benefits was premature. Where VA had not fully developed the cases and verified the stressors as required, the IG was not able to validate entitlement to the service-connection awards. VBA has agreed, because of the strong recommendation of the IG, to conduct a review of PTSD claims in which the veteran was awarded a 100 percent disability rating or IU rating in the past five years. In that review, we expect that the majority of the claims will be found sufficient and will not require further development. We acknowledge and are concerned that there are variances across the system with respect to average annual benefit payments. We do not, however, agree that average annual payments should be the singular measure by which we judge consistency. Measurement of consistency is complex and cannot be discerned based upon a single measure of state-by-state comparisons of average disability payments. We will continue our efforts to better understand this complex and difficult issue and to identify and reduce inappropriate variability in our decisions. Our objective is to ensure that all regional offices are generating consistently accurate decisions that provide the maximum benefits to which veterans are entitled. We believe that veterans should get the same treatment and same result based upon the same set of facts regardless of the state in which they reside or the regional office that decides the claim. Our efforts are directed to that end. Mr. Chairman, this concludes my testimony. I respectfully request that my complete written statement be included in the record. I greatly appreciate being here today and look forward to answering your questions. MR. MILLER. Thank you, sir. Without objection, both of your statements will be placed in the record in full as well. [The statement of Mr. Aument appears on p. 91] MR. MILLER. Dr. Brown, we will go back to you. You had said that during the IG's review that a majority of the raters, I think, that were surveyed were unfamiliar with CPEP's template being used. What efforts are being done now to provide outreach to the regional offices to make sure that they are familiar with the templates? DR. BROWN. The first thing that we are doing is we now have the templates rolled out. And, of course, they had not seen it because at that time, we were just finishing getting the product into the field for the first version. So it does not come as a terrible surprise that they had not seen the cases come by that were done using the templates. We also now have a group, the OFO, reviewing the template formats so that they also become more familiar and give us more feedback on how they want it structured. It really is an issue of they did not see it because it was just getting out there. MR. MILLER. What is OFO, please? DR. BROWN. I am sorry. It is the Office of Field Operations within VBA. MR. MILLER. But still my question is, what now is being done to ensure that they are familiar with the template? DR. BROWN. We are working on the VHA side to increase use and use is increasing. We are now up to about ten percent. We do not have specific educational effort within VBA to see the reports that come out from the templates. We are working with the VHA. We have a Clinical Advisory Board that is helping us get the word out about the templates as well as providing us with feedback to make them better.. MR. MILLER. Thank you. Ms. Berkley. MS. BERKLEY. Is there a requirement that the doctors use the templates? They are being provided, but is there a requirement that the doctors actually use them? DR. BROWN. There is no national mandate to do that. My understanding is that in a couple of medical centers, that has gone forward. MS. BERKLEY. In your experience, do medical examinations which follow a recommended format show more consistency than examinations that do not? DR. BROWN. All of our examinations should be following the recommended format. MS. BERKLEY. So there is a written format that the doctors use -- DR. BROWN. Yes. MS. BERKLEY. -- in evaluating patients? DR. BROWN. Yeah. Now the C&P Service maintains something called worksheets which are one- to three-page textual descriptions of what is expected of the doctors. MS. BERKLEY. And how long do evaluators usually spend with PTSD, possible PTSD patients? DR. BROWN. I do not have any data on what that would really be around the country. MS. BERKLEY. But there is no consistency with that? It could be 20 minutes? It could be two hours? There is no -- DR. BROWN. Again, I really do not have any data to say one way or the other. I would be surprised if it were 20 minutes. But, again, no data. MS. BERKLEY. Well, from what I understand, best practices say that there should be a minimum of three to four hours before any determination is made. Between November of 2004 and March of 2005, the Board of Veterans' Appeals remanded almost 10,000 claims for problems involving medical examinations. Have you looked into any correlation between VISNs in which you found poor quality examinations and regional offices with large numbers of medical examination remands? And I say that with Las Vegas being part of VISN 22 that has the fourth highest remand rate. DR. BROWN. No. We have not looked into a correlation between the matrix of exam quality and remand rate. And one important thing to keep in mind is that by the time it gets to remand, that would have taken a pretty long time. So it could be a couple of years. So we better have process measures that are a little bit more actionable. Also it is a filtered group that gets to remanded exams. And, you know, there are folks who appeal. It has gone through a number of filters by that time too. So I think there are more direct ways to approach it. MS. BERKLEY. Mr. Aument, if I may ask you. It is my understanding that neither a disagreement as to the sufficiency of the evidence nor a change in diagnosis are adequate to support a determination of CUE. What legal authority does the VA have for requesting additional information from veterans whose claims for service connection have been finally decided? MR. AUMENT. Congresswoman Berkley, before we even began planning for any sort of a review, one of the first steps we had taken was to seek guidance from our general counsel as to the legal authority for undertaking that type of review. The primary focus of this review is going to be looking at whether or not the evidence was sufficient, whether or not the required documentation was in place. The General Counsel informed us again that if we exhausted all efforts to make sure that documentation was available that could verify the stressor, then that could constitute a finding of clear and unmistakable error. I would defer right now saying I am not the attorney on this issue, but we did seek and obtain guidance from general counsel. MS. BERKLEY. If they are not supposed to reopen cases that the Secretary has adjudicated final and there are four exceptions and none of these reasons fall into the exceptions, I realize you are not the legal authority -- MR. AUMENT. Right. MS. BERKLEY. -- but I am having trouble finding the legal authority to force veterans to provide this information. MR. AUMENT. I think we just recently brought to the Committee the legal opinion that we obtained from general counsel on this. I might turn to my colleague, Ms. Szybala, to amplify that somewhat, but indeed they have given us an opinion citing a legal authority. MS. BERKLEY. One final question. Are you aware of any assessment made by the VA as to the risk of increased suicides as a result of the current and proposed review? MR. AUMENT. I am aware of no such assessment, no. The event that we have just discussed today in New Mexico certainly was tragic. And I know my heart goes out to the veteran's family and friends on this. But, again, this veteran, as Mr. Garcia mentioned, was not, in fact, contacted by us. The one thing that I think this has brought to our attention is that before we would undertake any larger review, we probably need to do a better job of outreach to individuals, informing them of the facts and what the review consists of, who would be subjected to review, and what it would mean to individuals. I am afraid much of the information that has gone out to date has been a combination of fact and opinion. And at the same time, we realize we need to do a better job. We have recently had conversations with the Veterans' Health Administration, including the leadership of the Vet Center Program. And I think that before undertaking any further review, we would try to put the information out that would help assuage any concerns that veterans might have. MS. BERKLEY. I appreciate your sensitivity to this because I think it is a potential -- MR. AUMENT. Yes. MS. BERKLEY. -- tragic problem. And I would hope that they would stop at 2,100 and move forward and not condemn our veterans to any more stress than they have already had. Thank you. MR. MILLER. Mr. Udall, any other questions? MR. UDALL. Thank you, Mr. Chairman. Mr. Aument, it appears that in your review of these cases that you have come up with this figure 90 percent have an adequate stressor and then the IG has come up with 75 percent had an adequate stressor in the file, which is a significant variance or significant discrepancy. How do you explain this discrepancy? Do you think the IG is just flat wrong or -- MR. AUMENT. Well, Congressman, we have not really completed our review. When we did our first cut, looking at the 2,100 cases that the Inspector General had reviewed, we pretty much substantiated the Inspector General's findings by looking strictly at the ratings. And we found that roughly 25 percent of the cases we looked at had stressor deficiencies. Since going back to the individual regional offices for the next steps and further development, we have eliminated a number of those cases from further review for a number of reasons. For example, we have found in roughly 20 to 25 percent of the cases that the Inspector General looked at, the ratings were protected, which means that the time period between today and the day in which they received their determination of service connection was of sufficient duration that this case was no longer subject to any review. So those cases were immediately closed. We found in a number of other cases that the file itself contained missing evidence, but it was just not reflected in the rating decision. So that particular group of cases was closed. It is my guess that we are going to find something closer to the 90 percent figure that we have spoken of, but we are not there yet because the review has not yet been completed. MR. UDALL. And do you plan to review all 72,000 cases? MR. AUMENT. Well, as it stands right now, we are acting in accordance with the Inspector General's very strong recommendations. The IG brought to our attention failure on the part of the Veterans' Benefits Administration to adequately support these cases where we have already made grants of service connection. As administrators of this particular program, and in the interest of the program integrity, we need to move forward until somebody tells us to stop. MR. UDALL. When would that be? MR. AUMENT. Well, I understand that the Congress is looking at it very closely, number one. And I think we have already heard the Inspector General today suggest that they would revisit that decision if, after completion of our review of the 2,100 cases, they believe that would change their recommendation. MR. UDALL. And you are right about the Congress moving forward. There is a provision in one of the bills in the Senate prohibiting you from moving forward. I would hope that the administration would step out in this situation and say we have reviewed the 2,100. That is enough. Let us stop the review and let us deal with the future situation. So you did not answer the question. Do you have the authority to say I am only going to look at the 2,100 or does it go up to the next level? MR. AUMENT. I believe that would be a decision that would be made collectively by the leadership of VA. Sitting at this table today, I do not have the authority to say that we are going to stop that review. MR. UDALL. This is just my personal view. I would just urge you to take a very hard look at what you have seen today and what you have done in the review of the 2,100. You realize you are dealing with a very, very sensitive situation. These veterans and the other ones that are not included in the 2,100, all of them at this point, I think, have been alerted and they are under extreme psychological stress anyway. So I think it is the right thing to do to terminate it with the 2,100 and then move forward with new procedures if you believe that is warranted based on the 2,100, but to not subject these veterans to that. So I hope you take that message back. In light of this sensitive situation, when you decided to go out and have these regional offices ask veterans to document their stressors and to step forward, did you consult psychiatrists, psychologists, people within your agency about how to properly do this and how to do it in a way that would lessen the impact on not only those veterans personally but the other veterans that are being swept in here, the 72,000? MR. AUMENT. I do not believe that we did perceive the widespread breadth of interest that you have just described, Congressman. Let me say again with respect to the Albuquerque regional office, acting in very good faith, I believe they got ahead of the program somewhat and wrote letters on their own prior to being given complete guidance that later followed from our Compensation and Pension Service. We believe that the communications, the letters, formats, etc. that were provided by C&P Service are much more sensitized to these types of concerns. So I think that there were a number of letters that came out of the Albuquerque office that probably unduly alarmed the veterans upon their receipt. And, as part of the learning process, learning as we go, I believe, is one of the reasons why we are undertaking this 2,100 case review before moving on to any larger group. MR. UDALL. Thank you. And thank you, Mr. Chairman. MR. MILLER. Thank you very much for everybody's testimony today. I would like to enter into the record a memo from General Counsel 022 to the Under Secretary for Benefits, subject: Review of Awards of Total Disability Rating for PTSD. [The attachment appears on p. 153] MR. MILLER. There is no doubt that we all play a large role in assuring the claims adjudication process from beginning to end serves our core constituency with accurate rating decisions. This Subcommittee expects to see VBA and VHA work very closely together because we often hear the term "one VA." But sometimes when we get out in the field, that is not exactly what is taking place. We owe it to the sick, to the disabled veterans to not just provide them with a check, but rather we must make certain the VBA works with VHA to treat the veteran so he or she may live their life to their fullest potential. I have concerns not about the quality of staff of VBA's regional offices, but they may not have the resources and the training necessary to achieve the mission that they have been tasked with. We will explore this more fully at next week's Subcommittee hearing. Without objection, the statements from the following organizations will be entered into the record: The American Legion; the Disabled American Veterans; Paralyzed Veterans of America; and Veterans of Foreign Wars. [The statement from the American Legion appears on p. 101] [The statement from the Disabled American Veterans appears on p. 112] [The statement of the Paralyzed Veterans of America appears on p. 122] [The statement of the Veterans of Foreign Wars of the United States appears on p. 132] MR. MILLER. And with nothing further, this hearing is now adjourned. [Whereupon, at 1:50 p.m., the Subcommittee was adjourned.] <GRAPHICS NOT AVAILABLE IN TIFF FORMAT>