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entitled 'Military Disability System: Increased Supports for
Servicemembers and Better Pilot Planning Could Improve the Disability
Evaluation Process' which was released on September 24, 2008.
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Report to Congressional Requesters:
United States Government Accountability Office:
GAO:
September 2008:
Military Disability System:
Increased Supports for Servicemembers and Better Pilot Planning Could
Improve the Disability Evaluation Process:
GAO-08-1137:
GAO Highlights:
Highlights of GAO-08-1137, a report to congressional requesters.
Why GAO Did This Study:
In February 2007, a series of articles in The Washington Post about
conditions at Walter Reed Army Medical Center highlighted problems in
the military’s disability evaluation system. Subsequently, the
Department of the Army, Department of Defense (DOD), and Department of
Veterans Affairs (VA) undertook initiatives to address concerns with
the disability evaluation process. In 2007, the Army took steps to
streamline its process, and DOD and VA began piloting a joint
evaluation system to address systemic concerns about timeliness and the
potential inefficiency of having separate disability evaluation
systems. GAO was asked to examine (1) recent actions by the Army to
help servicemembers navigate its disability evaluation process and (2)
the status, plans, and challenges of DOD and VA’s efforts to pilot and
implement a joint disability evaluation system. GAO interviewed Army,
DOD, and VA officials; visited Army treatment facilities; and reviewed
data from these sources.
What GAO Found:
The Army has taken a number of steps to help servicemembers navigate
the disability evaluation process through additional support mechanisms
and streamlining efforts, but faces challenges in meeting internal
goals and demonstrating impact. Most significantly, the Army has begun
hiring more staff to facilitate the process for servicemembers, such as
legal personnel, and setting staffing goals for key positions, such as
for board liaisons and physicians. However, the Army has not met its
internal staffing goals for board liaisons and physicians, and
continues to face shortages in legal personnel. The Army has also
struggled to meet timeliness goals for case processing and has even
experienced negative trends over the last year, despite streamlining
initiatives. Furthermore, the Army faces particular challenges in
meeting timeliness goals for completing reservists’ evaluations, due in
part to the challenge of obtaining complete personnel and medical
documents from nonmilitary sources. Besides staffing initiatives, the
Army has also taken steps to help servicemembers better understand and
navigate the process. However, we found that these efforts varied by
location, and that many servicemembers we spoke with were unaware of
the availability of expert legal counsel. To increase transparency of
the disability process, one location we visited afforded servicemembers
the opportunity to have the written summary of their medical conditions
explained to them, but not all Army locations have adopted this
practice. In general, the Army faces challenges in demonstrating that
its efforts to date have had an overall positive impact on
servicemembers’ satisfaction, because it has not implemented a survey
that adequately targets and queries servicemembers who are undergoing
disability evaluations.
Under direction from the agencies’ joint Senior Oversight Committee,
DOD and VA moved quickly to design and pilot a joint disability
evaluation process, but gaps remain in their plans to evaluate the
pilot and potentially implement a joint process on a larger scale. DOD
and VA have established a comprehensive mechanism for measuring key
aspects of the pilot. However, they have not yet decided on criteria
for determining whether the joint process is worthy of widespread
implementation. In addition, although DOD and VA are in the process of
developing surveys to measure servicemember and stakeholder
satisfaction, sufficient comparative data on servicemember satisfaction
may not be available when the pilot is scheduled to end. DOD and VA are
also in the process of tracking challenges that have arisen in
implementing the pilot, but they have not yet resolved several
challenges associated with expanding the joint process if the pilot is
deemed successful. Such challenges include determining who will perform
the single physical examination when a VA medical center is not nearby.
Beyond these concerns, DOD and VA may ultimately need to prepare for
challenges that come with implementing large-scale system changes—such
as those envisioned by the pilot. These challenges include sustaining
management attention to ensure that the changes are implemented well
and are producing the intended results. However, the Senior Oversight
Committee’s planned January 2009 end raises questions about whether
management attention will be maintained over the long term.
What GAO Recommends:
GAO recommends that the Army explore options for improving its
disability evaluation process and its servicemember satisfaction
survey, and that DOD and VA (1) establish criteria for determining
whether their pilot should be widely implemented and (2) take steps to
sustain management attention on pilot evaluation and implementation.
DOD and VA generally agreed with the recommendations.
To view the full product, including the scope and methodology, click on
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-08-1137]. For more
information, contact Daniel Bertoni at (202) 512-7215 or
bertonid@gao.gov.
[End of section]
Contents:
Letter:
Results in Brief:
Background:
Army Has Taken Steps to Help Servicemembers Undergoing Disability
Evaluation, but Faces Challenges:
DOD and VA Lack Complete Plans for Evaluating and Expanding the Joint
Disability Evaluation Pilot Process:
Conclusions:
Recommendations for Executive Action:
Agency Comments and Our Evaluation:
Appendix I: Objectives, Scope, and Methodology:
Appendix II: Additional Background Information about the Military
Disability Evaluation Process:
Appendix III: Comments from the Department of Defense:
Appendix IV: Comments from the Department of Veterans Affairs:
Appendix V: GAO Contact and Staff Acknowledgments:
Figures:
Figure 1: Major Differences between Current and Pilot Military
Disability Evaluation Processes:
Figure 2: Average Number of Servicemembers per Board Liaison at Army
Treatment Facilities, as of June 2008:
Figure 3: Location of Army Treatment Facilities with and without Legal
Staff Dedicated to Disability Evaluation Counsel, as of June 2008:
Figure 4: Average Time to Complete the Army MEB and PEB Processes for
Active-Duty and Reservist Servicemembers in 2007:
Figure 5: Decisions Made during the Military Disability Evaluation
Process:
Abbreviations:
AMAP: Army Medical Action Plan:
CBHCO: Community Based Health Care Organization:
DOD: Department of Defense:
MEB: medical evaluation board:
PEB: physical evaluation board:
PTSD: post-traumatic stress disorder:
TBI: traumatic brain injury:
TDRL: temporary disability retired list:
VA: Department of Veterans Affairs:
[End of section]
United States Government Accountability Office:
Washington, DC 20548:
September 24, 2008:
Congressional Requesters:
Over 32,000 servicemembers have been wounded in Operations Enduring
Freedom and Iraqi Freedom, as of July 2008.[Footnote 1] Due to improved
battlefield medicine, those who might have died in past conflicts are
now surviving, many with multiple serious injuries, such as
amputations, traumatic brain injury (TBI), and post-traumatic stress
disorder (PTSD). Beyond adjusting to their injuries, returning
servicemembers can face additional challenges within the military. In
February 2007, a series of articles in The Washington Post about
conditions at Walter Reed Army Medical Center highlighted problems in
the military's disability evaluation system.
Since that time, various reviews and high-level commissions have
identified substantial weaknesses in the disability evaluation system
that servicemembers must navigate. For example, in March 2007, the Army
Inspector General identified numerous weaknesses, including a failure
to meet timeliness standards for determinations and inadequate staff
training.[Footnote 2] Similarly, reports from several commissions
highlighted long delays and confusion that ill or injured
servicemembers experience as they navigate the military disability
evaluation system, and their distrust of a process perceived to be
adversarial.[Footnote 3] The commissions referred to prior GAO work,
including a March 2006 report in which GAO found that the services were
not meeting Department of Defense (DOD) timeliness goals for processing
disability cases, and that neither DOD nor the services systematically
evaluated the consistency of disability decisions.[Footnote 4] In
addition, in October 2007, the Veterans' Disability Benefits Commission
reported significant differences in disability ratings between the DOD
and the Department of Veterans Affairs (VA), with VA often assigning
higher disability ratings than DOD.[Footnote 5]
The Department of the Army, DOD, and VA have undertaken initiatives to
address concerns about delays and confusion with the disability
evaluation process. For example, in March 2007, the Army initiated the
development of the Army Medical Action Plan (AMAP). Broadly designed to
help the Army become more patient-focused, the plan includes several
tasks for improving its disability evaluation process. Apart from the
Army's initiatives, DOD and VA are piloting a joint disability
evaluation system to address more systemic concerns, such as the
timeliness and potential inefficiency and variable outcomes of DOD's
and VA's separate evaluation systems. Begun in November 2007, the pilot
involves a single physical examination performed to VA standards and a
rating prepared by VA for use by both DOD and VA in determining
disability benefits. The pilot is ongoing at three Washington, D.C.,
military treatment facilities, including Walter Reed Army Medical
Center, and is scheduled to last 1 year. The pilot is being conducted
under the direction of a joint DOD and VA body--the Wounded, Ill, and
Injured Senior Oversight Committee (Senior Oversight Committee)--that
was established in May 2007 to address problems associated with the
care and treatment of returning servicemembers.
At your request, we examined (1) recent actions taken by the Army to
help ill and injured servicemembers navigate its disability evaluation
process and (2) the status, plans, and challenges of DOD and VA's
efforts to pilot and implement a joint disability evaluation system. To
address the first objective, we analyzed staffing data and relevant
Army documents, such as policy memorandums and the March 2007 Army
Inspector General report. Out of the Army's 35 treatment facilities, we
visited 4--Walter Reed Army Medical Center (Washington, D.C.), Brooke
Army Medical Center (Fort Sam Houston, Texas), Carl R. Darnell Army
Medical Center (Fort Hood, Texas), and Madigan Army Medical Center
(Fort Lewis, Washington)--that are near the 3 sites where the Army
conducts disability evaluations to talk with Army officials about
efforts to improve the disability evaluation system for servicemembers,
and to obtain views from servicemembers about how these efforts are
affecting them. To help assess legal outreach and other supports to
servicemembers, we also spoke with officials from 5 treatment
facilities that are not near any of the Army's disability evaluation
sites. These 5 facilities were selected on the basis of varying size
(small, medium, and large) and representation from the different
geographic areas of the Army's medical organization. In addition, we
spoke with officials from the Army's Community Based Health Care
Organization (CBHCO) system and visited a CBHCO location in
Massachusetts to learn about issues for reservists entering the
disability evaluation process from the CBHCO system.[Footnote 6]
To examine DOD and VA's efforts to pilot a joint disability evaluation
system, we reviewed DOD and VA pilot planning and guidance documents.
We also visited the 3 facilities--Walter Reed Army Medical Center,
National Naval Medical Center, and Malcolm Grow Air Force Medical
Center--where the pilot is ongoing to speak with officials about the
status, plans, and challenges related to evaluating the disability
evaluation pilot and potentially implementing a joint system. In
addition, we spoke with officials from DOD and VA who are coordinating
pilot implementation and evaluation efforts, and reviewed weekly
reports that include the number of cases by phase of the process in the
pilot.
We conducted this review from July 2007 to September 2008 in accordance
with generally accepted government auditing standards. Those standards
require that we plan and perform the audit to obtain sufficient,
appropriate evidence to provide a reasonable basis for our findings and
conclusions based on our audit objectives. We believe that the evidence
obtained provides a reasonable basis for our findings and conclusions
based on our audit objectives. Additional information about our
objectives, scope, and methodology is provided in appendix I.
Results in Brief:
The Army has taken a number of steps to help servicemembers navigate
the disability evaluation process through additional supports and
streamlining efforts, but it faces challenges in meeting internal goals
and demonstrating impact. Most significantly, the Army has expanded
support to servicemembers by hiring more staff, such as board liaisons
to help servicemembers navigate the process and legal personnel to
counsel them during the process. Furthermore, the Army established
internal staff-to-servicemember goals for board liaisons as well as for
board physicians who are responsible for documenting servicemembers'
conditions. However, the Army has not met its internal staffing goals
for board liaisons and physicians, and it continues to face shortages
in legal personnel. The Army has also struggled to meet timeliness
goals for case processing and has even experienced negative trends over
the last year, despite streamlining initiatives such as reducing forms,
increasing automation in the process, and deploying a unit of mobile
medical staff to help address caseload surges at certain locations.
According to Army officials and data, longer case processing times have
resulted, in part, from increases in the number and complexity of
disability cases, as exemplified by the growing incidence of conditions
that require psychiatric evaluation. The Army faces particular
challenges in meeting timeliness goals for processing reservists'
cases, due in part to the challenge of obtaining complete personnel and
medical documents from nonmilitary treatment facilities. Besides
staffing and streamlining initiatives, the Army has also increased
supports to help servicemembers understand and navigate the process--
such as providing a standardized briefing about the disability process
and conducting specific outreach to explain the legal process. However,
we found that the briefing and outreach varied by location, and many
servicemembers we spoke with were unaware of the availability of expert
legal counsel. To increase transparency and improve servicemember
understanding and acceptance of the disability process, one location we
visited afforded servicemembers the opportunity to have the written
summary of their medical conditions explained to them. However, in part
due to staffing and resource constraints, not all Army locations have
adopted this practice. In general, the Army faces challenges in
demonstrating that its efforts to date have had an overall positive
impact on servicemembers' satisfaction, because it has not yet
implemented a survey that adequately targets and queries servicemembers
who are undergoing disability evaluation. The Army's goal was to field
such a survey by September 2007.
While DOD and VA moved quickly under direction from the agencies' joint
Senior Oversight Committee to design and pilot a joint disability
evaluation process, gaps remain in their plans to evaluate the pilot
and to potentially implement a joint process on a larger scale. DOD and
VA have established a comprehensive mechanism for measuring the pilot's
performance and have established methods for measuring a number of key
aspects of the pilot, such as appeal rates and the timeliness of
decisions. However, they have not yet decided on the criteria they will
use for determining whether the pilot has demonstrated enough
improvement to be deemed a success, and worthy of potential
implemenation on a large scale. Meanwhile, DOD and VA plan to survey
pilot and nonpilot participants, pilot participant family members, and
military and VA staff involved in the disability evaluation process to
measure their satisfaction with the pilot relative to the current
process, but only one survey--of servicemembers participating in the
pilot--has been developed and administered, and it is unclear when the
agencies will finalize and administer the other planned surveys.
Furthermore, sufficient servicemember satisfaction results, and
comparative results for servicemembers not participating in the pilot,
may not be available in time to inform a near-term determination of the
worthiness of the pilot concept. DOD and VA are tracking challenges
that have arisen in implementing the pilot, but they have not yet
resolved several challenges to implementing a joint process on a large
scale if the pilot is deemed successful. Such challenges include
estimating the additional resources needed, such as board liaisons and
VA nonclinical case management staff, and determining how to deal with
logistical arrangements, such as who will perform the single physical
examination. The latter challenge is particularly important because the
current pilot locations have access to a VA medical center where the
physical examinations are performed; however, not all military medical
facilities have comparable access to VA physicians, so alternative
arrangements may be necessary under an expanded system. Beyond these
concerns, DOD and VA may ultimately need to prepare for a number of
challenges that come with implementing large-scale system changes, such
as those envisioned by the pilot. These challenges include sustaining
management attention to ensure that the changes are well-implemented
and are producing the intended results. However, the Senior Oversight
Committee's planned January 2009 expiration date raises questions
regarding whether management attention will be maintained during
critical junctures leading to and including phased in, large-scale
implementation.
We are making several recommendations in this report for executive
action. To help address shortcomings in the timeliness of case
processing, we recommend that the Army consider developing additional
mobile units of medical board staff and explore approaches to improving
reservists' case development. To help reduce servicemembers' confusion
about the process, we recommend that the Army explore more widespread
implementation of promising practices for further improving
servicemembers' understanding of the written summary of medical
conditions that underlies the disability decision, and for ensuring
that servicemembers understand their rights to and are aware of the
availability of legal counsel during the evaluation process. In
addition, to help the Army assess the effectiveness of its support to
servicemembers undergoing disability evaluations, the Army should
survey a representative sample of servicemembers undergoing disability
evaluation, with questions to better assess legal outreach and support
throughout the process. Finally, to ensure that the evaluation of the
joint DOD-VA pilot is sound and its potential large-scale
implementation is well-managed, we recommend that DOD and VA (1)
identify criteria and develop plans to evaluate the pilot and guide
potential implementation decisions and (2) sustain collaborative
executive focus on the pilot by, for example, continuing the agencies'
joint Senior Oversight Committee. We provided DOD and VA with a draft
of this report, and they generally agreed with these recommendations.
Background:
The military's disability evaluation process begins with the
identification of a medical condition that could render the
servicemember unfit for duty. On the basis of medical examinations, a
medical evaluation board (MEB) documents any conditions that may limit
a servicemember's ability to serve in the military. The servicemember's
case is then evaluated by a physical evaluation board (PEB) to make a
determination of fitness or unfitness for duty.[Footnote 7] If the
servicemember is found to be unfit due to medical conditions incurred
in the line of duty, the PEB assigns the servicemember a combined
percentage rating for those unfit conditions using VA's rating system
as a guideline, and the servicemember is discharged from duty. This
disability rating, along with years of service and other factors,
determines subsequent disability and health care benefits from DOD.
[Footnote 8] Appendix II provides additional background information
about the MEB and PEB processes.
As servicemembers in the Army navigate DOD's disability evaluation
process, they interface with staff who play a key role in supporting
them through the process. MEB physicians play a fundamental role
because they are responsible for documenting the medical conditions of
servicemembers for the disability evaluation case file. In addition,
board physicians may require that servicemembers obtain additional
medical evidence from specialty physicians, such as a psychiatrist.
Throughout the MEB and PEB processes, a board liaison serves a key role
by explaining the process to servicemembers, and ensuring that the
servicemembers' case files are complete before they are forwarded for
evaluation by the PEB. The board liaison informs servicemembers of
board results and of deadlines at key decision points in the process.
The military also provides legal counsel to servicemembers in the
disability evaluation process. The Army, for example, has a policy to
provide legal counsel anytime upon request and to assign legal
representation at formal PEB hearings, although servicemembers may
retain their own representative at their own expense.
In addition to receiving benefits from DOD, veterans with service-
connected disabilities may receive compensation from VA for lost
earnings capacity.[Footnote 9] Although a servicemember may file a VA
claim while still in the military, he or she can only obtain disability
compensation from VA as a veteran. VA will evaluate all claimed
conditions, whether or not they were evaluated previously by the
military service's evaluation process. If VA finds that a veteran has
one or more service-connected disabilities with a combined rating of at
least 10 percent,[Footnote 10] the agency will pay monthly
compensation. The veteran can claim additional benefits over time, for
example, if a service-connected disability worsens or surfaces at a
later point in time.
In response to the deficiencies reported by the media, GAO, and the
Army Inspector General about the care its injured and ill
servicemembers received, the Army took several actions, including, most
notably, initiating the development of the AMAP in March 2007. The
plan, designed to help the Army become more patient-focused, includes
tasks for automating portions of the disability evaluation process and
maximizing coordination of efforts with VA. As part of the AMAP, the
Army also developed a new organizational structure--Warrior Transition
Units--to provide a more focused continuum of care and services to both
active-duty and reservist servicemembers.[Footnote 11] Within each
unit, the servicemember is assigned a primary care manager, a nurse
case manager, and a squad leader to manage the servicemember's medical
treatment and help ensure that the needs of the servicemember and his
or her family are met.[Footnote 12]
In May 2007, DOD established the Senior Oversight Committee to bring
high-level attention to addressing the systemic problems associated
with the care and treatment of returning servicemembers. The committee
is cochaired by the Deputy Secretaries of Defense and Veterans Affairs
and also includes the military service secretaries and other high-
ranking officials within DOD and VA. To conduct its work, the committee
established workgroups to address specific issues, including the
disability evaluation system.[Footnote 13] Originally intended to
expire in May 2008, the committee was extended to January 2009.
Under the direction of the Senior Oversight Committee, DOD and VA are
piloting a joint disability evaluation system to improve the timeliness
and resource use of DOD's and VA's separate disability evaluation
systems. Begun in November 2007, the pilot involves cases at three
Washington, D.C.-area military treatment facilities, including Walter
Reed Army Medical Center.[Footnote 14] Key features of the pilot
include (see fig. 1):
* a single physical examination conducted to VA standards as part of
the MEB;[Footnote 15]
* disability ratings prepared by VA, for use by both DOD and VA in
determining disability benefits; and:
* additional outreach and nonclinical case management provided by VA
staff at the DOD pilot locations to explain VA results and processes to
servicemembers.
Figure 1: Major Differences between Current and Pilot Military
Disability Evaluation Processes:
[See PDF for image]
This figure illustrates the major differences between current and pilot
Military Disability Evaluation Processes, as follows:
Current process:
Servicemember:
Board liaison provides support;
Medical Evaluation Board (MEB):
* Physical performed by military department;
Physical Evaluation Board (PEB):
* Military department determines disability rating used for computing
DOD disability benefits.
Separation:
Veteran:
* Receives DOD disability benefits if eligible; and;
* Develops claim for VA disability benefits:
- Comprehensive physical performed to VA standards;
- VA determines disability rating.
Pilot process:
Servicemember:
Board liaison and VA staff provide support;
Medical Evaluation Board (MEB):
* Comprehensive physical performed to VA standards;
Physical Evaluation Board (PEB):
* VA determines disability rating used for computing DOD disability
benefits;
Separation:
Veteran:
* Receives DOD disability benefits if eligible; and;
* Receives VA disability benefits shortly after leaving military if
eligible.
Sources: GAO analysis of DOD documents; Art Explosion (clip art).
[End of figure]
Army Has Taken Steps to Help Servicemembers Undergoing Disability
Evaluation, but Faces Challenges:
The Army has taken a number of steps to help servicemembers navigate
the disability evaluation process through additional supports and
streamlining efforts, such as expanding support to servicemembers by
hiring more board liaisons and legal personnel. In addition, the Army
has established a staffing ratio for board physicians who document
servicemembers' medical conditions. Nevertheless, the Army continues to
struggle with meeting internal goals for the staffing and timeliness of
processing disability evaluation cases. In addition, the Army's
increased staffing, outreach efforts, and other supports may be
insufficient to ensure that servicemembers understand the process and
are aware of their legal rights. The Army faces challenges in
demonstrating an impact on servicemember satisfaction, in part because
the Army has not yet implemented a satisfaction survey that adequately
targets and queries servicemembers who are undergoing disability
evaluation.
Army Has Increased Staffing for Servicemembers Undergoing Disability
Evaluation, but Struggles to Meet Its Internal Goals:
As part of the AMAP, the Army established staffing goals for staff who
are key to helping servicemembers navigate the disability evaluation
process. Specifically, the Army established caseload targets for board
liaisons and board physicians, and articulated the need to provide
servicemembers with access to legal counsel at the beginning of the
process. For board liaisons--who explain the disability process to
servicemembers and are responsible for ensuring that their disability
case files are complete--the Army established for the first time a
caseload target of 30 servicemembers per liaison in June 2007.[Footnote
16] At the same time, for board physicians--who evaluate and document
servicemembers' medical conditions for the disability evaluation case
file--the Army established a caseload target of 200 servicemembers per
physician. Although a caseload target was not set for legal counsel,
the Army proposed dedicating 57 additional legal staff at 19 of its 35
treatment facilities to help servicemembers gain access to legal
counsel prior to the formal board hearings when counsel is normally
assigned.
The Army has expanded hiring efforts for board liaisons, but it faces
challenges in keeping up with the increased demand for the liaisons'
services. From August 2007 to June 2008, the number of board liaisons
grew from 160 to 221--a 38 percent increase Army-wide--and the average
caseload per liaison declined from 46 to 29 servicemembers. However, as
of June 2008, the Army had not met its internal staffing goal of 30
servicemembers per liaison at 14 of its 35 treatment facilities, and
about 70 percent of servicemembers in the disability evaluation process
were located at facilities with shortages[Footnote 17] (see fig. 2).
Liaisons we spoke with at one of the locations with the highest average
caseloads had difficulty in making appointments with servicemembers,
which challenged their ability to provide timely and comprehensive
support. While the Army plans to hire additional board liaisons, it has
encountered difficulty in attracting qualified liaisons at some
locations due in part to their remote location. The Army's ability to
meet internal staffing goals is also affected by increases in demand.
According to Army data, the total number of servicemembers completing
the MEB increased about 19 percent from year-end 2006 to year-end 2007.
Figure 2: Average Number of Servicemembers per Board Liaison at Army
Treatment Facilities, as of June 2008:
[See PDF for image]
This figure contains a pie-chart and vertical bar graph depicting the
following data:
Percentage of servicemembers represented by facilities that are meeting
and not meeting the Army’s goal:
14 facilities not meeting Army goal: 70%;
21 facilities meeting Army goal: 30%.
Average Number of Servicemembers per Board Liaison at Army Treatment
Facilities, as of June 2008:
Army goal is 30 or fewer.
Treatment facility:
Average number of servicemembers per board liaison:
Treatment facility: Landstuhl, Germany;
Average number of servicemembers per board liaison: 50
Treatment facility: Bavaria, Germany;
Average number of servicemembers per board liaison: 49
Treatment facility: Fort Hood, Texas;
Average number of servicemembers per board liaison: 48
Treatment facility: Fort Gordon, Georgia;
Average number of servicemembers per board liaison: 47
Treatment facility: Fort Bragg, North Carolina;
Average number of servicemembers per board liaison: 43
Treatment facility: Fort Irwin, California;
Average number of servicemembers per board liaison: 42
Treatment facility: Fort Carson, Colorado;
Average number of servicemembers per board liaison: 40
Treatment facility: Fort Drum, New York;
Average number of servicemembers per board liaison: 40
Treatment facility: Fort Campbell, Kentucky;
Average number of servicemembers per board liaison: 39
Treatment facility: Fort Lewis, Washington;
Average number of servicemembers per board liaison: 38
Treatment facility: Fort Sam Houston, Texas;
Average number of servicemembers per board liaison: 35
Treatment facility: Fort Wainwright, Alaska;
Average number of servicemembers per board liaison: 35
Treatment facility: Fort Leonard Wood, Missouri;
Average number of servicemembers per board liaison: 34
Treatment facility: Fort Polk, Louisiana;
Average number of servicemembers per board liaison: 31
Treatment facility: Fort Jackson, South Carolina;
Average number of servicemembers per board liaison: 30
Treatment facility: Fort Riley, Kansas;
Average number of servicemembers per board liaison: 29
Treatment facility: Fort Eustis, Virginia;
Average number of servicemembers per board liaison: 27
Treatment facility: Fort Bliss, Texas;
Average number of servicemembers per board liaison: 27
Treatment facility: Fort Knox, Kentucky;
Average number of servicemembers per board liaison: 26
Treatment facility: Tripler, Hawaii;
Average number of servicemembers per board liaison: 25
Treatment facility: Fort Richardson, Alaska;
Average number of servicemembers per board liaison: 25
Treatment facility: Fort Belvoir, Virginia;
Average number of servicemembers per board liaison: 23
Treatment facility: West Point, New York;
Average number of servicemembers per board liaison: 21
Treatment facility: Fort Lee, Virginia;
Average number of servicemembers per board liaison: 21
Treatment facility: Fort Stewart, Georgia;
Average number of servicemembers per board liaison: 13
Treatment facility: Fort Huachuca, Arizona;
Average number of servicemembers per board liaison: 13
Treatment facility: Fort Rucker, Alabama;
Average number of servicemembers per board liaison: 13
Treatment facility: Fort Sill, Oklahoma;
Average number of servicemembers per board liaison: 11
Treatment facility: Heidelberg, Germany;
Average number of servicemembers per board liaison: 11
Treatment facility: Fort Leavenworth, Kansas;
Average number of servicemembers per board liaison: 9
Treatment facility: Fort Meade, Maryland;
Average number of servicemembers per board liaison: 9
Treatment facility: Fort Benning, Georgia;
Average number of servicemembers per board liaison: 9
Treatment facility: Walter Reed, Washington, D.C.:
Average number of servicemembers per board liaison: 8
Treatment facility: Fort Dix, New Jersey;
Average number of servicemembers per board liaison: 7
Treatment facility: Redstone Arsenal, Alabama;
Average number of servicemembers per board liaison: 5
Source: GAO analysis of Army data.
[End of figure]
Regarding MEB physicians, the Army has mostly met its goal for the
average number of servicemembers at each treatment facility, but
challenges with physician staffing remain. As of June 2008, the Army
met its goal of 200 servicemembers per board physician at 28 of 35
treatment facilities. However, 47 percent of servicemembers undergoing
disability evaluation are located at the 7 facilities that did not meet
the goal. In addition, according to Army officials, physicians are
having difficulty in managing their caseloads, even at locations where
they have met or are close to the Army's goal of 200 servicemembers per
physician. Several physicians and Army officials told us that the Army
could provide better service to servicemembers if more physicians were
available to conduct medical evaluations. To help improve case
processing, in July 2008 the Army changed the target staffing ratio for
board physicians from 200 servicemembers to 120 servicemembers per
physician. Some Army physicians told us that the ratio of
servicemembers per physician allows little buffer when there is a surge
in caseloads at a treatment facility, and that delays in case
processing result from these imbalances. A mobile unit--comprising a
board physician, a board liaison, and other staff--has been deployed
since 2004 in the Army's southeast region. According to an Army
official who works with the mobile unit, its deployment has helped
reduce backlogs where it has been deployed, but such units are not used
throughout the Army.
In addition to gaps in board liaisons and board physicians, staffing of
legal personnel who provide counsel to injured and ill servicemembers
throughout the disability evaluation process is currently insufficient.
According to the Army, servicemembers should receive legal assistance
upon request during both the MEB and PEB processes. While
servicemembers may seek legal assistance at any time, the Army's policy
is to assign legal staff to servicemembers when their case goes before
a formal PEB. As of June 2008, there were 28 total staff--20 attorneys
and 8 paralegals, located at 5 of 35 Army treatment facilities--
dedicated to providing assistance to servicemembers undergoing
disability evaluation[Footnote 18] (see fig. 3). In April 2008, the
Army recognized that the current staffing was insufficient and approved
the hiring of 36 permanent legal personnel--1 attorney and 1 paralegal
at each of 18 locations. Although these additional staff--which the
Army is in the process of hiring--will help, their number falls short
of the originally proposed 57 staff. According to an Army official
involved in legal staffing, the 36 additional staff will still be
insufficient to achieve the Army's goal of providing comprehensive
legal support early in the evaluation process. Moreover, some of the
legal personnel already in place serve on a temporary basis. Therefore,
their replacements will need to learn about military disability
evaluation regulations and processes, which involves a substantial
learning curve and could pose a challenge to service delivery and
quality of legal counsel.[Footnote 19] Army officials also told us that
an evaluation is being conducted to determine if additional attorneys
should be hired, and that they expect the evaluation to be completed by
year-end 2008.
Figure 3: Location of Army Treatment Facilities with and without Legal
Staff Dedicated to Disability Evaluation Counsel, as of June 2008:
[See PDF for image]
This figure is a map of the United States and Germany indicating the
location of Army treatment facilities with and without legal staff
dedicated to disability evaluation counsel. The locations with legal
staff dedicated to disability evaluation counsel are indicated as
follows:
Walter Reed, Washington, DC:
8 attorneys;
2 paralegals.
Fort Sam Houston, Texas:
5 attorneys;
3 paralegals.
Fort Carson, Colorado:
1 attorney.
Fort Lewis, Washington:
5 attorneys;
2 paralegals.
Tripler, Hawaii:
1 attorney;
1 paralegal.
Sources: GAO analysis of Army data; Map Resources (map).
[End of figure]
Although the Army generally meets DOD's timeliness goal for the PEBs to
process cases, it has had less success in meeting timeliness goals for
the MEBs. In 2007, the Army satisfied the DOD-standard that 80 percent
of PEB cases should be processed within 40 days. On average in 2007,
PEB cases were processed in 28 days. In terms of the MEBs, the Army has
a goal of completing 80 percent of cases within 90 days, and meeting a
DOD standard that the final administrative and counseling part of the
MEB process be completed within 30 days for at least 80 percent of
cases. From January to March 2008, 24 of 35 medical facilities did not
meet the Army's 90-day goal for the timely processing of MEB cases. In
addition, the percentage of cases Army-wide that have met the goal in a
recent 12-month period has trended downward; from April through June
2007, 68 percent of cases met the goal, compared with 55 percent from
January through March 2008. Similarly, from January to March 2008, 29
of 35 medical facilities did not meet DOD's 30-day goal for
transferring cases to the PEB.[Footnote 20]
According to Army officials, several factors have challenged the Army's
ability to complete medical board cases in a timely way. In addition to
the increase in the number of cases and the shortage of medical board
physicians, timely case processing is also challenged by the increasing
complexity of cases being evaluated and the shortages of specialist
physicians who help perform medical evaluations. For example, the
incidence of complex conditions, such as PTSD, that the Army must
evaluate has more than doubled, from 4.3 percent in 2005 to 9.5 percent
in 2007.[Footnote 21] According to Army officials, shortages of
specialist physicians, such as psychiatrists who can perform required
evaluations, have contributed to delays in case processing. According
to an Army official in charge of mental health staff planning, the Army
has plans to hire additional psychiatrists--which is consistent with
recommendations made by a DOD task force on mental health--but it faces
challenges in reaching its goals quickly, in part, due to the
difficulty of attracting psychiatrists to work for the Army.
The Army faces particular challenges in meeting timeliness goals for
completing reservists' MEBs and PEBs. In 2007, reservists comprised
about 20 percent of servicemembers undergoing disability evaluation in
the Army. The average time to complete the MEB and PEB processes in
2007 was 149 days for reservists, compared with 107 days for active-
duty servicemembers (see fig. 4). According to Army officials,
disability case processing for reservists is treated the same as that
for active component servicemembers, but reservist cases may take
longer due, in part, to the challenge of obtaining complete personnel
and medical documents. For example, reservists may have more difficulty
in obtaining a required commander letter--a key document that describes
the servicemember's duties and how his or her medical conditions affect
performance of those duties--than active-duty servicemembers because
reservists' command structure is more dynamic and the appropriate
commander may be difficult to track down. In addition, many reservists
receive care from non-Army physicians as opposed to receiving care at a
military treatment facility. According to Army officials, medical
documentation provided by non-Army physicians is more likely to contain
insufficient information, resulting in delayed case processing. One
indicator of the inadequacy of documentation prepared by non-Army
physicians is the number of cases received by the PEB that get returned
to the MEB for additional information. In 2007, about 30 percent of
reservist cases were returned because of incomplete information
compared with about 15 percent for active-duty servicemember cases. As
of June 2008, the Army had not taken steps to identify potential
actions that might mitigate this disparity.
Figure 4: Average Time to Complete the Army MEB and PEB Processes for
Active-Duty and Reservist Servicemembers in 2007:
[See PDF for image]
This figure is a horizontal bar graph depicting the following data:
Servicemember: Active duty;
Number of days, MEB: 84;
Number of days, PEB: 23;
Total number of days: 107.
Servicemember: Reservist;
Number of days, MEB: 105;
Number of days, PEB: 44;
Total number of days: 149.
Source: GAO analysis of Army data.
Note: The average times noted in this figure exclude any days when the
case is returned by the PEB to the treatment facility for additional
case development and servicemember transitions after the PEB decision.
Also, GAO previously reported deficiencies in internal controls for MEB
and PEB case processing data. According to Army officials, data quality
has improved due to computer system and process changes, but we did not
substantiate these assertions.
[End of figure]
The Army has taken steps to streamline processes to help servicemembers
better navigate the disability evaluation system. For example, in March
2008, the Army reduced the number of documents that could be used to
complete the PEB from 38 to 19. Also, the template for the commander's
letter became more detailed, which obviated the need for submitting
some forms, including servicemembers' recent physical fitness
examination results. In addition, the Army is developing a computer
system to automate the MEB process by replacing paper case files with
electronic files, thereby reducing case processing time and improving
case tracking. The computer system is being piloted at one facility,
[Footnote 22] and if the pilot is successful, the intent is to
replicate it throughout the Army by January 2009. According to the
AMAP, this automation project was to be completed by January 2008, but
the project was delayed and just began in April 2008. According to Army
officials, the late start was due, in part, to delays in finding a cost-
effective technology solution, receiving the necessary Army approvals,
and satisfying contracting procedures.
Army Has Increased Outreach and Other Supports for Servicemembers, but
Faces Challenges in Reducing Servicemember Confusion and Demonstrating
Improved Servicemember Satisfaction:
While the Army has taken steps to address the shortages of legal
personnel dedicated to the disability evaluation process, the Army's
outreach efforts may be insufficient to ensure that servicemembers are
aware of their rights and the availability of legal counsel earlier in
the process. Army policy is to advise servicemembers of the
availability of legal counsel at the initial briefing when a
servicemember begins the disability evaluation process, and to assign
servicemembers to attorneys once their case goes before a formal PEB.
However, the Army does not have a policy that legal staff attend the
initial briefing because, in part, 30 of 35 locations currently do not
have on-site legal staff dedicated to the disability process. To
address this gap, Army legal personnel who work specifically on
disability evaluation cases have begun conducting additional outreach
to servicemembers earlier in the process, including traveling in some
cases to facilities that lack such personnel. However, due to limited
resources, many facilities do not receive this outreach, while others
receive it infrequently. Since the Army hired additional staff in June
2007, 10 of the 30 facilities that do not have on-site legal staff
dedicated to disability evaluation counsel, have received outreach
during the MEB process as of June 2008. Even at the 3 sites we visited
that had dedicated legal staff, many servicemembers undergoing
disability evaluation with whom we spoke were not aware of the
availability of the legal staff or the need for legal counseling.
According to an Army official involved in legal staffing, if attorneys
counseled servicemembers early in the medical board process,
servicemembers could have a better understanding of what steps to take
to protect their rights. In addition, according to this same official,
early outreach could help to make the disability evaluation process
proceed faster if servicemembers receive counsel on how to prepare in
advance for the many steps in the process.
In addition to the staffing and outreach initiatives to bolster legal
support to servicemembers, the Army has made other supports available
to help educate servicemembers about the overall process, but these
supports are not without limitations. For example, although the Army
standardized the initial briefing that we previously mentioned, several
locations do not use the standardized version when briefing
servicemembers. Of the 9 facilities we visited or contacted by
telephone, staff at 3 of these locations used a different version when
briefing servicemembers and did not note the availability of legal
counsel for servicemembers during the briefing. In addition, the Army
created a Web site for each servicemember to track his or her progress
through the MEB and PEB processes, and created a link to information
about legal support. However, according to Army officials and some
servicemembers we spoke with, many servicemembers do not access the Web
site. Of the servicemembers we spoke with who had accessed the Web
site, many found it limited in answering their questions and at times
out of date. Finally, the Army developed and issued a handbook on the
disability evaluation process to help educate servicemembers about the
process. Although the handbook can be a helpful tool in describing a
complex process, many servicemembers we spoke with did not recall
receiving or reading the handbook, possibly due to the nature of their
conditions and medications, while some found the disability process
confusing despite having reviewed the handbook.
Two Army locations we visited provided an additional support that may
be successful at reducing servicemembers' confusion with the process,
but this support was not offered at other locations we visited.
Servicemembers we spoke with at each facility we visited said they
found the medical language in the written summary of their medical
conditions confusing. At the two locations we previously mentioned,
servicemembers were afforded the opportunity to have the written
summary explained to them by the physician in order to increase
transparency and improve servicemember understanding and acceptance of
the disability process. According to Army officials at these
facilities, the servicemembers who receive the explanation find the
medical board assessment less confusing. Officials at one of these
facilities also noted that servicemembers who do not understand the
written summary of their medical conditions are more likely to become
dissatisfied with the disability evaluation process, and that the
process can be delayed by late identification of additional medical
conditions. Despite its potential benefits, in part due to staffing and
resource constraints, the Army has not adopted this practice at all
locations.
While anecdotal evidence of servicemember confusion with the process is
not evidence of widespread or worsening problems, the Army has
struggled to assess servicemembers' satisfaction with the disability
evaluation process to help demonstrate the impact of its efforts over
time. To gauge servicemembers' satisfaction with the process, in June
2007, the Army added questions to a survey that targets servicemembers
at various stages in the Army's Warrior Transition Units. In part
because of the survey's timing and target respondents, the Army
experienced low response rates for the added questions and, therefore,
was unable to evaluate the impact of changes to the disability
evaluation process. As part of the AMAP, in April 2007, the Army set a
goal to improve the survey by September 2007, but delays in developing
survey questions postponed deployment until July 2008. The new survey
has two sections relevant to the disability evaluation process--one for
the MEB and another for the PEB parts of the disability evaluation
process. However, the surveys will continue to target servicemembers in
Warrior Transition Units. Because many servicemembers undergoing
disability evaluation are not in such units, survey responses will not
necessarily represent the population undergoing disability evaluation.
In addition, the Army may be challenged to identify weaknesses in some
supports due to the limited nature of some survey questions. For
example, according to an Army official involved in legal staffing, the
new surveys do not ask servicemembers questions regarding the
effectiveness of legal outreach and support during the MEB phase of the
process. Without a feedback mechanism, such as a valid survey, the Army
will be challenged to evaluate the effectiveness of planned increases
in legal support and current outreach to servicemembers.
DOD and VA Lack Complete Plans for Evaluating and Expanding the Joint
Disability Evaluation Pilot Process:
DOD and VA have made progress in developing and piloting a streamlined
disability evaluation process, but they have much work to do in key
areas. Gaps include a lack of clearly identified criteria for
determining whether the pilot has been successful and should be
implemented on a large scale. Also, although DOD and VA have begun
surveying servicemembers in the pilot, they have not yet completed
development of surveys to collect customer satisfaction data from
nonpilot servicemembers for comparison, or from DOD and VA staff
conducting the pilot. Furthermore, DOD and VA have yet to resolve
several challenges to expanding the joint process on a large scale if
the pilot is deemed successful. These challenges include ensuring that
DOD and VA have addressed staffing needs, determining logistical
arrangements associated with operating the pilot at additional
facilities, and sustaining top agency management focus on the pilot.
DOD and VA Are Collecting Information on Pilot Performance, but They
Lack a Complete Plan for Evaluating the Pilot's Success:
Since the pilot has been under way since November 2007, DOD and VA have
been focused on collecting detailed data on pilot performance. As we
noted in our February 2008 testimony, DOD and VA moved quickly and
collaboratively to design and implement the pilot, and have been
working toward a Senior Oversight Committee review of the pilot's
progress. DOD and VA officials expect this review to lead to a decision
of whether to expand the pilot to a few facilities beyond the current 3
facilities. According to DOD and VA officials, adding a small number of
facilities to the pilot would allow for collection of additional
information on pilot performance and to test pilot procedures in
different locations with varying servicemember populations and
disability evaluation resources. To this end, DOD and VA are in the
process of collecting data to compare potential sites for an initial
pilot expansion on the basis of several factors. After this initial
expansion, the agencies anticipate a decision regarding the worthiness
of the pilot process and whether it should become their standard
disability evaluation process. DOD is required to provide the Congress
with a final assessment of the pilot 3 months after its scheduled
November 2008 end.[Footnote 23]
DOD and VA have established methods for measuring certain key aspects
of the pilot, such as timeliness of decisions and appeal rates, and
have developed a comprehensive mechanism to track these and other
measures.[Footnote 24] The mechanism enables pilot planners to assess
their work relative to numerous goals that fall under the following six
initiatives: (1) improve disability evaluation policy and procedures,
(2) improve servicemember and stakeholder satisfaction with the
process, (3) establish an awareness and training program for evaluation
system stakeholders, (4) expand the pilot process, (5) meet pilot and
nonpilot milestones, and (6) ensure funding to support development of
an integrated system. For example, under the first initiative, pilot
planners intend to compare various case processing timeliness measures
against standards. These metrics include the percentage of MEB cases
completed within 80 days, and the percentage of VA benefits letters
issued within 30 days of separating from the military. By applying
agreed-upon weights to these and other measures, pilot planners will
assess whether they have met, partially met, or not met each objective,
and signal the overall status of the workgroup's efforts.
While DOD and VA have developed this mechanism to help measure pilot
performance, they have yet to finalize criteria for applying those
metrics to determine whether the pilot is worthy of eventual full-scale
implementation. Pilot planners have indicated that the timeliness of
decisions will be a factor in evaluating the effectiveness of the
pilot, but there are several potential measures of timeliness.
Furthermore, while they are collecting timeliness data from each
service to draw comparisons to the pilot process, it is unknown whether
comparisons will be made in aggregate; by service; or by subgroups,
such as Army reservists. Finally, DOD and VA have not yet decided how
much improvement must be demonstrated by the pilot as indicated by any
such comparisons.
One set of metrics to be used for evaluating the pilot is servicemember
and stakeholder satisfaction, and DOD and VA are in the process of
developing and administering several surveys to measure their
satisfaction; however, much work remains. Pilot planners intend to
survey the following four groups of people: (1) all pilot participants;
(2) a sample of servicemembers in the disability evaluation process
outside of the pilot; (3) a family member of each pilot participant;
and (4) select stakeholders involved in the pilot process, such as
board liaisons and VA nonclinical case managers. Surveying of the first
group--pilot participants--will be administered after three phases in
the process: the MEB; the PEB; and transition, including discharge from
the service. For example, the MEB phase survey asks pilot participants
about their satisfaction with the assistance provided by DOD and VA
liaisons, the thoroughness of their physical examination, and the
fairness of the board's decision.
Although pilot planners have begun to survey pilot participants, it is
unclear when they will be able to incorporate survey results of this
group and other groups into their decision making. Survey data from the
pilot's first year is expected to be available for analysis in December
2008. However, surveys of pilot participants only began in May 2008
and, according to pilot planners, it is unlikely that DOD and VA will
have sufficient responses in December, particularly from servicemembers
who have gone through the later pilot phases, to assess satisfaction
with the pilot process. Pilot planners estimate that about 100
servicemembers will have completed the PEB under the pilot by November
2008, but they are unsure if this number will be sufficient for
evaluation purposes. Relatedly, pilot planners intend to compare the
survey results for pilot participants against survey results for an
appropriate group of servicemembers who have undergone military
disability evaluation outside of the pilot. Such survey data would help
DOD and VA assess whether the pilot is improving servicemembers'
satisfaction with their experiences with disability evaluations.
However, this survey has not yet been deployed, and it is unclear when
DOD and VA will have sufficient responses from servicemembers outside
of the pilot to help measure any improvements in servicemember
satisfaction under the pilot process.
Pilot planners face further challenges associated with analyzing the
survey results. According to DOD officials, servicemembers outside of
the pilot who are to be surveyed will be selected to reflect a
proportional representation across certain characteristics, such as
branch of military service. However, as of the time of our review,
these officials had not yet decided how they will select a comparison
group with similar demographic and disability profiles as pilot
participants.[Footnote 25] Furthermore, pilot planners intend to survey
a family member of each pilot participant, but they do not have a clear
plan for assessing the results. For example, they do not plan to survey
a similar group of nonpilot family members, so the usefulness of family
member survey results may be limited.
Regarding these surveys, at the time of our review, pilot planners had
not sufficiently coordinated their design or development with other
surveys of wounded, ill, and injured servicemembers and their families.
Although DOD officials noted that they took steps to coordinate with
other survey efforts under the Senior Oversight Committee, coordination
has not occurred with service-specific survey efforts. For example,
Army officials told us that coordination has not occurred with their
initiative to survey servicemembers in the Army's disability evaluation
process. Without adequate coordination, these separate efforts could
lead to inefficiencies in collecting data from servicemembers and could
cause survey fatigue and potentially jeopardize response rates if
people are asked to participate in several surveys.
Finally, DOD and VA will be challenged to ensure the quality and
consistency of DOD fitness decisions and VA rating decisions prior to
determining the worthiness of the pilot concept. VA plans to review all
of its decisions on pilot cases as part of its Systematic Technical
Accuracy Review.[Footnote 26] Such reviews have not yet begun because,
according to VA, it has received few cases requiring disability
ratings. VA expects to begin conducting such reviews in October 2008
when it anticipates having a sufficient number of cases for statistical
analysis. Under the pilot design, the task of performing quality
reviews of PEB fitness decisions was given to DOD's Disability Advisory
Council.[Footnote 27] As of July 2008, the process of sampling
decisions for review, the criteria for assessing decisions, and the
mechanism for providing feedback to the PEBs have not been determined.
In terms of consistency, the agencies did not have plans yet to ensure
consistency of fitness decisions within each service or, ultimately, of
VA rating decisions across VA benefits offices.
DOD and VA Are Identifying, but Have Yet to Resolve, Key Challenges
Associated with Expanding the Joint Process:
As the pilot progresses, DOD and VA are collecting information that
could be used to identify resource needs and implementation challenges
if they decide to implement the pilot process on a large scale. For
example, DOD and VA are tracking pilot operational issues, for use in
refining pilot procedures and addressing operational problems, as well
as identifying challenges associated with implementation at additional
facilities. DOD and VA have conducted pilot review sessions with
stakeholders to discuss implementation challenges. In addition, VA has
been keeping a log of pilot implementation issues and the status of
their resolution. For example, VA staff at pilot sites reported
difficulties in ensuring that servicemembers report to scheduled
physical examinations. An update was issued to the pilot's guidance
requiring that servicemembers be present at their assigned pilot
medical facility for a long enough period to ensure their presence for
examinations and MEB processing. Also, VA staff have identified
problems with obtaining complete service medical records in some cases,
leading to another update to the pilot guidance.
Other key implementation challenges identified by DOD and VA officials
would be to adjust logistical arrangements to accommodate facility
differences and to potentially include other servicemembers in the
pilot process. For example, different facilities may require different
procedures for performing the single physical examination. While the 3
original pilot locations have physical examinations performed at a
nearby VA medical center, some military medical facilities are not near
a VA medical center and, therefore, lack comparable access. At such
facilities, examinations may need to be conducted by VA contract
physicians, DOD physicians, or private physicians under DOD's health
insurance program.[Footnote 28] DOD's pilot guidance allows for such
arrangements, provided that examinations are conducted according to VA
criteria. According to DOD and VA officials, one reason for an initial
pilot expansion beyond the original 3 facilities is to test alternative
arrangements where VA examiners are not as readily available. In
addition, the pilot process does not currently include servicemembers
who are being reexamined after being placed on temporary disability
retirement by a PEB.[Footnote 29] According to pilot planners,
inclusion of this group of servicemembers in the pilot would require
adjustments to pilot guidance and procedures.
Another significant implementation issue that has yet to be resolved is
estimating the additional resources, particularly DOD and VA case
management staff, required to ensure that the process flows smoothly at
additional facilities. VA officials stated that they are tracking VA
resource needs at the pilot facilities, particularly VA nonclinical
case managers, and have estimated VA resource needs for potential large-
scale pilot expansion. In addition to seeking additional VA nonclinical
case managers, VA is considering assigning VA service representatives
to pilot sites.[Footnote 30] According to VA officials, this assignment
is because VA nonclinical case managers have some claims processing
functions in the pilot, such as creating claim folders and scheduling
physical examinations, which are normally the responsibilities of VA
service representatives. Also, according to pilot planners, they have
formed a working group to estimate financial resources needed for large-
scale implementation of a joint disability evaluation process,
including administrative costs and any increases in DOD and VA
disability benefit payments. According to VA officials, they are in the
process of developing these estimates to help prepare VA's 2010 budget.
In addition to anticipating challenges and resource requirements,
successful implementation of the pilot process on a larger scale would
require sustained management focus to help ensure that needed resources
are identified, implementation challenges are overcome, and focus on
achieving intended results is maintained. Currently, that focus is
provided by the Senior Oversight Committee, which was scheduled to last
1 year through May 2008, but was extended to January 2009.[Footnote 31]
Anticipating the committee's dissolution, DOD and VA have been planning
to move its functions, including operation of the disability evaluation
pilot, to the DOD-VA Joint Executive Council.[Footnote 32] According to
DOD and VA officials, they are working to incorporate the pilot into
the Joint Executive Council's strategic plan--which is currently silent
on the pilot and on how the functions of the Senior Oversight Committee
would be transferred to the council. According to DOD and VA officials,
the next strategic plan, scheduled for approval in October 2008, is
expected to include the disability evaluation pilot. In the meantime,
concerns have been raised about whether the Joint Executive Council
will be able to provide as much management attention as it currently
provides. According to DOD and VA officials, the Senior Oversight
Committee differs from the Joint Executive Council because the former
has full-time staff detailed from DOD and VA. Furthermore, decisions
have not been made regarding whether staff currently working under the
Senior Oversight Committee will continue their roles and
responsibilities of overseeing the pilot under the Joint Executive
Council, and for how long. Without knowledgeable staff and continued
management focus, especially during the critical junctures leading to
and potentially including phased in, large-scale implementation, the
pilot may lack sufficient oversight and cross-agency coordination,
which raises risks to the sound evaluation of the pilot, and successful
implementation of potential widespread changes to the disability
evaluation process.
Conclusions:
For those servicemembers whose military service was cut short due to
illness or injury, DOD's disability evaluation is an important issue
because it affects their employment and, in many cases, whether they
will receive DOD benefits such as retirement pay and health care
coverage. Despite several initiatives, many servicemembers remain
confused by the military's process for making these important
determinations and are unaware of the potential benefit of consulting
with an attorney during the process. Once they become veterans, VA's
disability evaluation also affects cash compensation and other
disability benefits that they may receive. Going through two complex
disability evaluation processes can be difficult and frustrating for
servicemembers and veterans. Delayed decisions and confusing policies
have eroded the credibility of the system. The Army is struggling to
develop effective strategies to address growing and shifting demand for
disability evaluations and to meet timeliness goals--overall, but
especially for reservists. Even if the Army is able to match the supply
of medical board staff to the changing demand for its services, without
a strategy to address the particular challenges of documenting
reservists' cases, the Army will not be able to evaluate their
conditions in a timely way. In addition, without a concerted approach
to ensuring transparency throughout the process, especially regarding
the medical basis of the disability decision and the availability of
legal support, servicemembers will remain confused by and dissatisfied
with the process. Surveying servicemembers who have gone through the
Army's disability evaluation process will help the Army track whether
its hiring efforts and other initiatives are benefiting servicemembers
and addressing their confusion. However, even if the Army is able to
overcome challenges and demonstrate improvements in the evaluation
process, its efforts will not address the systemic problem of having
two consecutive evaluation processes that can lead to different
outcomes.
To address identified systemic problems, DOD and VA are collaborating
on a disability evaluation pilot that has potential for reducing the
time it takes to receive a decision from both agencies, improving the
consistency of evaluations for individual conditions, and simplifying
the overall process for servicemembers and veterans. Expanding the
pilot to a few more locations may be prudent as a way of testing the
process under different conditions, such as at locations lacking easy
access to a VA medical facility for physical examinations. However, a
much larger expansion would entail some risks; planners should be
transparent about, and prepared for, such risks. Without finalizing
criteria and related analysis plans well before assessing whether the
pilot is successful and merits larger expansion, DOD and VA may
ultimately make significant implementation decisions without sufficient
data on whether the pilot is producing the desired results. Criteria
could include comparative metrics that help the agencies measure the
pilot's performance against the current process, including whether
decision timeliness and servicemember and veteran satisfaction has
improved. Even if the pilot is proven successful, DOD and VA's ability
to implement significant changes on a large scale is unknown. Adjusting
pilot resource needs and logistical arrangements could prove
challenging as a revised process is rolled out to more DOD and VA
facilities. Without sufficient planning for and focused management
attention on widespread implementation of a joint process that would
dramatically change business processes across many locations at both
agencies, DOD and VA could jeopardize the systems' successful
transformation, and potentially exacerbate confusion and frustration
among servicemembers in the process.
Recommendations for Executive Action:
We recommend that the Secretary of Defense direct the Secretary of the
Army to take the following actions:
* To help reduce delays in MEB case processing due to shortages of
board physicians and caseload surges at particular treatment
facilities, the Army should consider developing more mobile units of
medical board staff, including physicians who could be flexibly
deployed to treatment facilities where servicemembers are experiencing
case processing delays.
* To address the disparity in timeliness of MEB and PEB case processing
for reservists compared with active-duty servicemembers, the Army
should explore approaches to improving reservists' case development,
such as ensuring adequate documentation of their military duties and
medical conditions.
* To further reduce servicemember confusion about and distrust of the
disability evaluation process, the Army should explore more widespread
implementation of promising practices for:
- ensuring that servicemembers understand their rights to and are aware
of the availability of legal counsel during the disability evaluation
process, such as having legal counsel present at in-briefings where
feasible; and:
- improving each servicemember's understanding and acceptance of the
written summary of medical conditions that underlies his or her
disability evaluation, such as affording servicemembers an opportunity
to review the summary with the physician who prepared it before the
summary is finalized.
* To help the Army assess the effectiveness of its outreach and
supports available to servicemembers undergoing disability evaluations,
it should administer existing surveys to a representative sample of
servicemembers undergoing the MEB and PEB processes, and consider
developing additional questions to better assess outreach and support
provided by Army legal staff throughout the process.
We also recommend that the Secretary of Defense and the Secretary of
Veterans Affairs take the following actions:
* To ensure that the evaluation of the DOD-VA pilot process is sound,
and that any decisions on large-scale implementation of it are well-
founded, DOD and VA should develop complete plans to evaluate the
pilot's success and guide potential large-scale expansion decisions.
Such plans should include criteria for determining how much improvement
should be achieved under the pilot on various performance measures--
such as decision timeliness and servicemember satisfaction--to merit
implementing the joint process throughout DOD and VA.
* To ensure that pilot evaluation and any large-scale implementation of
the joint disability process is done successfully, DOD and VA should
sustain collaborative executive focus on the pilot and retain
knowledgeable staff by, for example, continuing the agencies' joint
Senior Oversight Committee or transferring the responsibilities to an
equally staffed structure with the same level of executive commitment.
Agency Comments and Our Evaluation:
We provided a draft of this report to DOD and VA for review and
comments. The agencies provided written comments, which are reproduced
in appendixes III and IV. DOD and VA generally agreed with our
recommendations.
With respect to the Army's disability evaluation process, DOD agreed
with all of the recommendations, but partially agreed with one of them.
DOD also commented on relevant steps that the Army is taking on each
recommendation, as follows:
* In response to our recommendation that the Army consider developing
more mobile units of medical board staff that could be flexibly
deployed where servicemembers are experiencing case processing delays,
DOD agreed and stated that it planned to conduct a study on the
effectiveness of a mobile MEB team by January 1, 2009.
* In response to our recommendation that the Army explore approaches to
improving reservists' case development to address the disparity in the
timeliness of MEB and PEB case processing for reservist servicemembers
versus active-duty servicemembers, DOD agreed and stated that the Army
is attempting to automate the MEB process for all of its
servicemembers, but indicated that reservists typically have unique
challenges in obtaining necessary information. As we noted in our
report, DOD may need a broad strategy to address these challenges for
reservists and, therefore, should explore approaches to improving
reservists' case development.
* In response to our recommendation that the Army explore more
widespread implementation of promising practices to ensure that
servicemembers understand their rights to and are aware of the
availability of legal counsel during the disability evaluation process,
DOD partially agreed. They agency noted that having legal counsel
present at in-briefings could diminish their capacity to provide actual
counsel to other servicemembers who are further along in the process,
and that the in-briefing forum does not lend itself to a confidential
exchange of information between servicemembers and legal counsel. DOD
noted alternative methods for raising servicemembers' awareness of
their legal rights and available services, including screening a
relevant video that the Army is in the process of developing.
Alternative methods could successfully address our recommendation if
they are widely implemented.
* In response to our recommendation that the Army explore more
widespread implementation of promising practices to improve
servicemembers' understanding and acceptance of the written summary of
their medical conditions, DOD agreed. The agency mentioned multiple
emerging best practices--such as having the servicemember present when
the physician dictates the summary to enable timely discussion--that,
if widely implemented, could help ensure that all servicemembers
benefit from them.
* In response to our recommendation that the Army administer existing
satisfaction surveys to a representative sample of servicemembers
undergoing MEBs and PEBs and consider developing additional questions
to better assess legal support, DOD agreed and indicated that the Army
was in the process of launching a modified survey. However, DOD's
comments indicated that the new survey will not be representative of
servicemembers undergoing disability evaluation by the Army because the
survey will exclude servicemembers who are undergoing disability
evaluation, but are not assigned to a Warrior Transition Unit. Because
many servicemembers--particularly reservists--are not assigned to a
Warrior Transition Unit, excluding them from the survey will generate
information that is not representative of all servicemembers undergoing
disability evaluation by the Army and, therefore, may yield skewed
data.
With respect to DOD and VA's efforts to pilot a joint disability
evaluation system, the agencies agreed with our recommendations and
provided additional comments, as follows:
* In response to our recommendation that DOD and VA develop criteria to
inform decision making on potential expansion of the pilot process, DOD
and VA agreed. They stated that their balanced scorecard--the mechanism
that they are using to track pilot performance--will help them
accomplish this objective. Although a mechanism like the balanced
scorecard is useful for tracking certain key measures, at the time of
our review, the balanced scorecard did not identify minimum levels of
performance improvement that should be achieved for certain metrics
before the pilot is considered successful and merits widespread
implementation.
* In response to our recommendation that DOD and VA sustain
collaborative executive focus on the pilot and retain knowledgeable
staff, DOD and VA agreed. VA officials have reported that, with DOD,
they have developed a legislative proposal for a new coordinating
organization, the Senior Executive Oversight Committee, that would
replace both the Senior Oversight Committee and Joint Executive
Council. To the extent that oversight of the pilot transitions to a new
organization, DOD and VA will need to guard against the potential loss
of continuity in pilot monitoring activities, such as planning,
resource allocation, and evaluation. As part of their sustained
executive focus, DOD and VA leadership should, to the extent possible,
retain staff who are knowledgeable about the history and management of
the pilot to provide continuity to pilot management and oversight.
Without such continuity and sustained focus, sound implementation and
assessment of the pilot may be jeopardized.
We are sending copies of this report to relevant congressional
committees, the Secretary of Veterans Affairs, the Secretary of
Defense, and other interested parties. We will also make copies
available to others upon request. In addition, the report will be
available at no charge on GAO's Web site at [hyperlink,
http://www.gao.gov].
Please contact me at (202) 512-7215 or bertonid@gao.gov if you or your
staffs have any questions about this report. Contact points for our
Offices of Congressional Relations and Public Affairs may be found on
the last page of this report. Key contributors to this report are
listed in appendix V.
Signed by:
Daniel Bertoni:
Director, Education, Workforce, and Income Security Issues:
List of Requesters:
The Honorable Steve Buyer:
Ranking Member:
Committee on Veterans' Affairs:
House of Representatives:
The Honorable John Hall:
Chairman:
Subcommittee on Disability Assistance and Memorial Affairs:
Committee on Veterans' Affairs:
House of Representatives:
The Honorable Harry Mitchell:
Chairman:
Subcommittee on Oversight and Investigations:
Committee on Veterans' Affairs:
House of Representatives:
The Honorable John F. Tierney:
Chairman:
Subcommittee on National Security and Foreign Affairs:
Committee on Oversight and Government Reform:
House of Representatives:
The Honorable Jason Altmire:
House of Representatives:
The Honorable Michael Arcuri:
House of Representatives:
The Honorable Nancy Boyda:
House of Representatives:
The Honorable Bruce Braley:
House of Representatives:
The Honorable Christopher Carney:
House of Representatives:
The Honorable Kathy Castor:
House of Representatives:
The Honorable Yvette Clarke:
House of Representatives:
The Honorable Steve Cohen:
House of Representatives:
The Honorable Joe Courtney:
House of Representatives:
The Honorable David Davis:
House of Representatives:
The Honorable Joe Donnelly:
House of Representatives:
The Honorable Keith Ellison:
House of Representatives:
The Honorable Brad Ellsworth:
House of Representatives:
The Honorable Gabrielle Giffords:
House of Representatives:
The Honorable Kirsten Gillibrand:
House of Representatives:
The Honorable Phil Hare:
House of Representatives:
The Honorable Baron Hill:
House of Representatives:
The Honorable Mazie Hirono:
House of Representatives:
The Honorable Paul Hodes:
House of Representatives:
The Honorable Hank Johnson:
House of Representatives:
The Honorable Steve Kagen, M.D.
House of Representatives:
The Honorable Ron Klein:
House of Representatives:
The Honorable Nick Lampson:
House of Representatives:
The Honorable David Loebsack:
House of Representatives:
The Honorable Tim Mahoney:
House of Representatives:
The Honorable Jerry McNerney:
House of Representatives:
The Honorable Chris Murphy:
House of Representatives:
The Honorable Patrick Murphy:
House of Representatives:
The Honorable Ed Perlmutter:
House of Representatives:
The Honorable Ciro Rodriguez:
House of Representatives:
The Honorable John Sarbanes:
House of Representatives:
The Honorable Joe Sestak:
House of Representatives:
The Honorable Carol Shea-Porter:
House of Representatives:
The Honorable Heath Shuler:
House of Representatives:
The Honorable Albio Sires:
House of Representatives:
The Honorable Zack Space:
House of Representatives:
The Honorable Betty Sutton:
House of Representatives:
The Honorable Timothy Walz:
House of Representatives:
The Honorable Peter Welch:
House of Representatives:
The Honorable Charles Wilson:
House of Representatives:
The Honorable John Yarmuth:
House of Representatives:
[End of section]
Appendix I: Objectives, Scope, and Methodology:
The objectives of our review were to examine (1) recent actions taken
by the Department of the Army to help ill and injured servicemembers
navigate its disability evaluation process and (2) the status, plans,
and challenges of the Department of Defense (DOD) and the Department of
Veterans Affairs' (VA) efforts to pilot and implement a joint
disability evaluation system.
To address the first objective, we analyzed relevant documents,
including Army forms, Army policy memorandums, relevant DOD directives,
and a related Army Inspector General report.[Footnote 33] We reviewed
staffing and case processing data related to disability evaluation
initiatives established in the Army Medical Action Plan (AMAP). We did
not verify the accuracy of these data. However, we interviewed agency
officials knowledgeable about the data, and we determined that they
were sufficiently reliable for the purposes of this report. Out of the
Army's 35 treatment facilities, we visited 4--Walter Reed Army Medical
Center (Washington, D.C.), Brooke Army Medical Center (Fort Sam
Houston, Texas), Carl R. Darnell Army Medical Center (Fort Hood,
Texas), and Madigan Army Medical Center (Fort Lewis, Washington)--that
are near the 3 sites where the Army conducts physical evaluation boards
(PEB) to talk with Army officials about efforts to improve the
disability evaluation process for servicemembers, and to obtain views
from servicemembers about how these efforts are affecting them. To help
assess legal outreach and other supports to servicemembers, we also
spoke with officials from 5 treatment facilities that are not located
near any of the Army's PEB sites. These 5 facilities were selected on
the basis of varying size (small, medium, and large) and representation
from the different geographic areas of the Army's medical organization.
These facilities were Bassett Army Community Hospital (Fort Wainwright,
Alaska), Dwight D. Eisenhower Army Medical Center (Fort Gordon,
Georgia), Keller Army Community Hospital (West Point, New York), Munson
Army Health Center (Fort Leavenworth, Kansas), and Tripler Army Medical
Center (Honolulu, Hawaii). In addition, we spoke with officials from
the Army's Community Based Health Care Organization (CBHCO) system and
visited a CBHCO location in Massachusetts to learn about issues that
concern reservists entering the disability evaluation process from the
CBHCO system.
To address DOD and VA efforts to pilot a joint disability evaluation
system, we reviewed these agencies' pilot guidance documents, and
visited the 3 original pilot facilities--Walter Reed Army Medical
Center (Washington, D.C.), National Naval Medical Center (Bethesda,
Maryland), and Malcolm Grow Air Force Medical Center at Andrews Air
Force Base, Maryland. We spoke with DOD and VA officials to learn about
the status, plans, and challenges related to evaluating the disability
evaluation pilot and to potentially implementing a joint system. Our
interviews with DOD officials included officials of the Office of the
Under Secretary of Defense (Personnel and Readiness) and its pilot
contractor, Booz Allen Hamilton; officials of the services' Surgeon
General offices and officials responsible for their disability
evaluation processes; and officials of the original pilot facilities,
including medical evaluation board (MEB) and PEB members, and board
liaisons. We also discussed pilot surveys with officials of the Defense
Manpower Data Center, which is developing and administering the surveys
to help evaluate the pilot. In VA, we spoke with officials of the
Compensation and Pension Service, Veterans Benefits Administration,
which is responsible for VA's pilot activities. To analyze pilot
implementation issues, we reviewed records from DOD and VA pilot
stakeholder meetings--including pilot review, expansion planning, and
stakeholder training sessions--and reviewed the Wounded, Ill, and
Injured Senior Oversight Committee records related to the pilot.
Furthermore, we reviewed weekly reports that included the number of
cases by phase of the process in the pilot.
We conducted this review from July 2007 to September 2008 in accordance
with generally accepted government auditing standards. Those standards
require that we plan and perform the audit to obtain sufficient,
appropriate evidence to provide a reasonable basis for our findings and
conclusions based on our audit objectives. We believe that the evidence
obtained provides a reasonable basis for our findings and conclusions
based on our audit objectives.
[End of section]
Appendix II: Additional Background Information about the Military
Disability Evaluation Process:
The military disability evaluation process involves two phases: the MEB
and the PEB. There are a number of steps in the process and several
factors that play a role in the decisions that are made at each
step[Footnote 34] (see fig. 5 and the text that follows the figure).
There are four possible outcomes in the disability evaluation process.
A servicemember can be:
* found fit for duty;
* separated from the service without benefits--servicemembers whose
disabilities were incurred while not on duty or as a result of
intentional misconduct are discharged from the service without
disability benefits;
* separated from the service with lump sum disability severance pay,
or:
* retired from the service with permanent monthly disability benefits
or placed on the temporary disability retired list (TDRL).
Figure 5: Decisions Made during the Military Disability Evaluation
Process:
[See PDF for image]
This figure illustrates the decisions made during the Military
Disability Evaluation Process, as follows:
Medical Evaluation Board (MEB) Decision:
Based on:
* Medical evidence;
* DOD/service regulations;
Member with medically limiting injury/condition:
Does the member meet retention standard?
Yes: Return to duty;
No: Move to PEB process.
Physical Evaluation Board (PEB) Decision:
Based on:
* Medical evidence;
* Member’s injury/condition;
* Occupational specialty;
* Performance;
Is the member fit for duty?
Yes: Return to duty;
No: Go to next process.
Physical Evaluation Board (PEB) Decision:
Based on:
* Line of duty determination;
* For injury/condition existing prior to service—whether member has at
least 8 years of active-duty service;
Is the disability compensable?
No: Disposition: Separate without benefits;
Yes: Go to next process.
Physical Evaluation Board (PEB) Decision:
Based on:
* Medical evidence;
* VA “Schedule for Rating Disabilities” guidance;
* DOD rating guidance;
What is the disability rating (injury/condition’s
severity)?
* 0-20%; Members years of active or equivalent service, less than 20
years: Disposition: separated with lump sum disability severance;
* 0-20%; Members years of active or equivalent service, greater than or
equal to 20 years: Disability is not stable: Disposition: Placed on the
Temporary Disability Retired List (TDRL);
* 0-20%; Members years of active or equivalent service, greater than or
equal to 20 years: Disability is stable: Disposition: Placed on
Permanent Disability Retirement (Separated with monthly disability
retirement benefits);
* 30% or higher: Disability is not stable: Disposition: Placed on the
Temporary Disability Retired List (TDRL);
* 30% or higher: Disability is stable: Disposition: Placed on Permanent
Disability Retirement (Separated with monthly disability retirement
benefits).
Source: DOD documents.
[End of figure]
Medical Evaluation Board:
The disability evaluation process begins at a military treatment
location, when a physician identifies a condition that may interfere
with a servicemember's ability to perform his or her duties.[Footnote
35] On the basis of a physical examination, and specialty consultations
if necessary, the physician prepares a narrative summary detailing the
servicemember's injury or conditions. This evaluation is used to
determine if the servicemember meets the military's retention
standards, according to each service's regulations.[Footnote 36] This
process is referred to as "the MEB." Servicemembers who meet retention
standards are returned to duty, and those who do not are referred to
the PEB.
Physical Evaluation Board:
The PEB is responsible for determining whether servicemembers have lost
the ability to perform their assigned military duties due to injury or
illness, which is referred to as being "unfit for duty." If the member
is found unfit, the PEB must then determine whether the condition was
incurred or permanently aggravated as a result of military service.
While the composition of the PEB varies by service, it typically
comprises one or more physicians and one or more line officers. Each of
the services conducts this process for its servicemembers. The Army has
three PEBs located at Fort Sam Houston, Texas; Walter Reed Army Medical
Center in Washington, D.C.; and Fort Lewis, Washington. The Navy has
one PEB located at the Washington Navy Yard in Washington, D.C. The Air
Force has one PEB located in San Antonio, Texas.
The first step in the PEB process is the informal PEB--an
administrative review of the case file without the presence of the
servicemember. The PEB makes the following findings and recommendations
regarding possible entitlement for disability benefits:
* Fitness for duty: The PEB determines whether the servicemember "is
unable to reasonably perform the duties of his or her office, grade,
rank, or rating," taking into consideration the requirements of a
member's current specialty. Fitness determinations are made on each
medical condition presented. Only those medical conditions that result
in the finding of "unfit for continued military service" will
potentially be compensated by DOD. Servicemembers found fit must return
to duty.
* Compensability: The PEB determines if the servicemember's injuries or
conditions are compensable, considering whether they existed prior to
service (referred to as "having a preexisting condition") and whether
they were incurred or permanently aggravated in the line of duty.
[Footnote 37] Servicemembers found unfit with noncompensable conditions
are separated without disability benefits.
* Disability rating: When the PEB finds a servicemember unfit and his
or her disabilities are compensable, it applies the medical criteria
defined in the Veterans Administration Schedule for Rating Disabilities
to assign a disability rating to each compensable condition. The PEB
then determines (or calculates) the servicemember's overall degree of
service-connected disability. Disability ratings range from 0 (least
severe) to 100 percent (most severe) in increments of 10
percent.[Footnote 38] Depending on the overall disability rating and
number of years of active-duty or equivalent service, the servicemember
found unfit with compensable conditions is entitled to either monthly
disability retirement benefits or lump sum disability severance pay.
In disability retirement cases, the PEB considers the stability of the
servicemember's condition. Unstable conditions are those for which the
severity might change, resulting in higher or lower disability ratings.
Servicemembers with unstable conditions are placed on TDRL for periodic
PEB reevaluation at least every 18 months. While on TDRL, members
receive monthly retirement benefits. When members on TDRL are
determined fit for duty, they may choose to return to duty or leave the
military at that time. Members who continue to be determined unfit for
duty after 5 years on TDRL are separated from the military with monthly
retirement benefits, discharged with severance pay, or discharged
without benefits, depending on their condition and years of service.
Servicemembers have the opportunity to review the informal PEB's
findings and may request a formal hearing with the PEB; however, only
those found unfit for duty are guaranteed a formal hearing. The formal
PEB conducts a de novo review of referred cases and renders its own
decisions based on the evidence. At the formal PEB hearing,
servicemembers can appear before the board, put forth evidence,
introduce and question witnesses, and have legal counsel help prepare
their cases and represent them. If servicemembers disagree with the
formal PEB's findings and recommendations, they can, under certain
conditions, appeal to the reviewing authority of the PEB. Once the
servicemember either agrees with the PEB's findings and recommendations
or exhausts all available appeals, the reviewing authority issues a
final disability determination concerning fitness for duty, disability
rating, and entitlement to benefits.
[End of section]
Appendix III: Comments from the Department of Defense:
Office Of The Under Secretary Of Defense:
Personnel and Readiness:
4000 Defense Pentagon:
Washington, D.C. 20301-4000:
August 27, 2008:
Mr. Daniel Bertoni:
Director, Education, Workforce, and Income Security Issues:
U.S. Government Accountability Office:
441 G Street, N.W.
Washington, DC 20548:
Dear Mr. Bertoni:
This is the Department of Defense (DoD) response to the GAO draft
report, GAO-08-876 [now GAO-08-1137], "Military Disability System:
Increased Supports for Service Members and Better Pilot Planning Could
Improve the Disability Evaluation Process," dated July 24, 2008 (GAO
Code 130663).
The DoD concurs with one, concurs with comment to four, and partially
concurs with one of the six draft report recommendations. The
rationales for our positions are included in the enclosure.
We appreciate the opportunity to comment on the draft report. My point
of contact for this effort is Major William H. Torrico, (703) 602-7033,
ext. 108, william.torrico@wso.whs.mil.
Sincerely,
Signed by:
Michael L. Dominguez:
Principal Deputy:
Enclosure: As stated:
GAO Draft Report - Dated July 24, 2008:
GAO Code 130663/GAO-08-876 [now GAO-08-1137]:
"Military Disability System: Increased Supports for Service Members and
Better Pilot Planning Could Improve the Disability Evaluation Process"
Department Of Defense Comments To The Recommendations
Recommendation 1: The GAO recommends that the Army consider developing
more mobile units of medical hoard staff including physicians who could
be flexibly deployed to treatment facilities where Service members are
experiencing case processing delays.
DOD Response: Concur with comment. Though the concept of mobile medical
board units has merit, further evaluation is required to determine
optimal composition and deployment strategy. The Southeast Regional
Medical Command (SERMC) piloted a response team composed of 1 Medical
Evaluation Board (MEB) Physician, 1 Nurse Case Manager, 1
transcriptionist, and 5 Physical Evaluation Board Liaison Officers
(PEBLOs). This team was effective in decreasing identified backlogs;
however, their impact on MEB timeliness across the SERMC was minimal.
An effective team should be flexibly configured to respond to a medical
treatment facility's (MTF's) unique processing issues. If delays are
caused by a lack of experienced PEBLOs or MEB Physicians, a team
composed of such individuals would be effective in alleviating
processing delays. The team must include specialty providers if delays
are encountered in completing the clinical phase or dictating specialty
narrative summaries (NARSUMs) -- as is the case with Psychiatry or
Orthopedics. The MTFs or installations may also experience processing
delays caused by lack of legal counsel, delays in completing the
physical examination, or transcription delays. Due to the complexity of
responding to such diverse needs, the Army Medical Department believes
their first priority should be to continue building core MEB
capabilities at each installation. We will conduct a study of the
effectiveness of the mobile MEB team by I January 2009 to determine if
this model should be further developed/expanded.
Recommendation 2: The GAO recommends that the Army explore approaches
to improving reservists' case development, such as ensuring adequate
documentation of their military duties and medical conditions.
DOD Response: Concur with comment. The Army is attempting to automate
the entire MEB process with the goal of more efficiently processing all
cases, both active and reserve. A key aspect of this process is the
integration/interface with other source data collection systems.
Typically, reserve component cases are delayed due to the complexity of
obtaining required performance data and unique reserve component items
such as Retirement Points Statement, orders, approved Line of Duty
Investigations, etc.
Recommendation 3: The GAO recommends that the Army explore more
widespread implementation of promising practices for:
* ensuring that the Service members understand their rights to and are
aware of the availability of legal counsel (luring the disability
evaluation process, such as having legal counsel present at in-
briefings where feasible; and;
* improving each Service member's understanding and acceptance of the
written summary of medical conditions that underlies his or her
disability evaluation, such as affording Service members an opportunity
to review the summary with the physician who prepared it before it is
finalized.
DOD Response: (First Bullet): Partially concur with comment. The Army
agrees that Service members should be advised of their rights to legal
counsel upon entering the disability evaluation system. As the report
notes, the Army has engaged the Physical Evaluation Board Liaison
Officers (PEBLOs) and created standardized briefing materials advising
of the availability of counsel, which provide notice at the outset of
the process. In addition, the Army has increased its outreach efforts
through mobilizing and hiring additional legal counsel, adding 26 legal
personnel in the past 18 months. The ongoing hiring actions for 38
additional legal professionals to be fielded throughout the Army will
provide significantly enhanced outreach capabilities. The Army
continues to expand its legal outreach efforts beyond the standardized
in-brief. In addition to outreach visits and video-teleconferences,
Army counsel created an informative Medical Evaluation Board (MEB)/PEB
legal website which is linked to Army Knowledge Online to inform
Service members of the availability of counsel. An informative video is
being developed to provide information that can he used in a variety of
electronic mediums. The Army disagrees that an attorney needs to he
present at in-briefings as this would decrease counsel's efficiency and
availability for legal advice to Service members already in the
disability process. Moreover, the in-brief format does not lend itself
to the confidential exchange of information and legal advice critical
to an attorney-client relationship. Accordingly, the Army believes that
ensuring PEBLOs make legal counsel contact information available
achieves the intent of the recommendation ("ensuring that Service
members understand their rights to and are aware of the availability of
the legal counsel") without the necessity of attorneys sitting through
the in-briefings.
(Second Bullet): Concur with comment. Several hest practices for
increasing NARSUM understanding have been identified. One such practice
has the Soldier present in the room as the MEB physician types the
NARSUM or dictates it using word recognition software. This practice
allows for real-time discussion, correction of errors, and an
opportunity to immediately address the Soldier's concerns. While not
all of the Soldier's concerns may be satisfied, they can at least he
explained. This process is utilized at several MTFs and is well
received by the MEB participants. Also, NARSUM review is occurring
within some Warrior Transition Units (WTUs) where Primary Care Managers
(PCMs) have assumed the task of explaining the NARSUM to their assigned
WTU Soldier. The PCM provides an unbiased second opinion, serves as a
sounding hoard, and advocates for the Soldier when appropriate.
Recommendation 4: The GAO recommends that the Army administer existing
surveys to a representative sample of Service members undergoing
medical evaluation boards and
physical evaluation boards, and consider developing additional
questions to better assess outreach and support provided by Army legal
staff throughout the process.
DOD Response: Concur with comment. The contract for the Army's WTU
Survey has been modified to accomplish separate surveys for Soldiers
assigned to the WTU who are going through the MEB or PEB process. Legal
questions will be added to the surveys. The modified surveys should be
implemented by 20 August 2008. Service members undergoing MEBs and PEBs
but not assigned to a WTU will not he surveyed. In addition, OTJAG
under statutory responsibilities of Article 6, Uniform Code of Military
Justice, inspects legal offices across the Army. Feedback from
commanders during these inspections provides OTJAG an accurate
assessment of how Army legal offices are supporting their missions.
Survey feedback could be an additional tool to ensure continued quality
legal support in the disability evaluation process.
Recommendation 5: The GAO recommends that the DoD and VA develop
complete plans to evaluate pilot success and guide potential large-
scale expansion decisions. Such plans should include criteria for
determining the worthiness of the pilot process and how much
improvement should be achieved under the pilot on various performance
measures - such as decision timeliness and Service member
satisfaction -- to merit implementation throughout DoD and VA.
DOD Response: Concur with comment. The DoD and VA completed their plans
to evaluate pilot success and guide potential large-scale expansion
decisions. The DoD and VA Line of Action 1 balanced score card plans
include criteria for determining the worthiness of the pilot process
and how much improvement should be achieved under the pilot on a number
of performance measures- such as decision timeliness and Service member
satisfaction - to merit implementation throughout DoD and VA.
Recommendation 6: The GAO recommends that the DoD and VA sustain
collaborative executive focus on the pilot and retain knowledgeable
staff by, for example, continuing the agencies' joint Senior Oversight
Committee or transferring the responsibilities to an equally staffed
structure with the same level of executive commitment.
DOD Response: Concur.
[End of section]
Appendix IV: Comments from the Department of Veterans Affairs:
The Secretary Of Veterans Affairs:
Washington:
August 25, 2008:
Mr. Dan Bertoni:
Director:
Education, Workforce and Income Security:
U. S. Government Accountability Office:
441 G Street, NW:
Washington, DC 20548:
Dear Mr. Bertoni:
The Department of Veterans Affairs (VA) has reviewed the draft report,
Military Disability System: Increased Supports for Servicemembers and
Better Pilot Planning Could Improve the Disability Evaluation Process
(GAO-08-876)[now GAO-08-1137], and concurs with your recommendations.
The enclosure specifically addresses GAO's recommendations and provides
additional discussion and comments to the draft report. VA appreciates
the opportunity to comment on the draft report.
Sincerely yours,
Signed by:
James B. Peake, M.D.
Enclosure:
Department of Veterans Affairs (VA) Comments to Government
Accountability Office (GAO) Draft Report:
Military Disability System: Increased Supports for Servicemembers and
Better Pilot Planning Could Improve the Disability Evaluation Process
(GAO-08-876) [now GAO-08-1137]:
Recommendation 1: To ensure that the evaluation of the DOD-VA pilot
process is sound, and any decisions on large-scale implementation are
well-founded, DOD and VA should develop complete plans to evaluate
pilot success and guide potential large-scale expansion decisions. Such
plans should include criteria for determining the worthiness of the
pilot process and how much improvement should be achieved under the
pilot on various performance measures-such as decision timeliness and
servicemember satisfaction-to merit implementation throughout DOD and
VA.
Concur - Via the joint Senior Oversight Committee (SOC) and the
Overarching Integrated Product Team (OIPT), the Disability Evaluation
System (DES) is currently accomplishing balanced scorecards performance
measures, as well as surveys of servicemembers and stakeholders to
ascertain the worthiness of the Pilot process and future improvements
of the DES. The DES is being aligned under the Benefits Executive
Council (BEC), objective 3.1 b and incorporated into the Joint
Strategic Plan (JSP) for FY 2009-2011. The VA and DoD working group
associated with this objective will work together to establish a plan
to evaluate the success of the pilot and guide potential large-scale
expansion decisions. DES surveys have been agreed to by VA and DoD and
are being conducted under a DoD contract. Meaningful survey data is not
expected to be available for review until the summer of 2009. The
August 12, 2008, SOC meeting mandated guidelines for potential large-
scale expansion decisions.
Recommendation 2: To ensure that pilot evaluation and any large-scale
implementation of the joint disability process is done successfully,
DOD and VA should sustain collaborative executive focus on the pilot
and retain knowledgeable staff by, for example, continuing the
agencies' joint Senior Oversight Committee or transferring the
responsibilities to an equally staffed structure with the same level of
executive commitment.
Concur: VA is working with DoD to ensure the Wounded, Ill, and Injured
Senior Oversight Committee's (SOC) current endeavors continue. VA and
DOD have proposed that the SOC and the Joint Executive Council (JEC) be
integrated into a new organization - the DoD/VA Senior Executive
Oversight Committee (SEOC). The SEOC will consolidate short-term
tactical actions of the SOC with the long-term objective of the JEC as
mandated by title 38 United States Code, § 8111. This maturation of the
SOC to the SEOC will also ensure continuity of current VA's SOC staff
office personnel's institutional knowledge, allowing a high level of
success, dedicated staff, and rigorous oversight of the VA/DoD
collaborative efforts.
[End of section]
Appendix V: GAO Contact and Staff Acknowledgments:
GAO Contact:
Daniel Bertoni, (202) 512-7215, bertonid@gao.gov:
Staff Acknowledgments:
Michele Grgich (Assistant Director), Joel Green (Analyst-in-Charge),
Bryan Rogowski, Barbara Steel-Lowney, and Greg Whitney made significant
contributions to this report. Walter Vance and Cindy Gilbert provided
assistance with research methodology and data analysis. Bonnie
Anderson, Rebecca Beale, Elizabeth Curda, and Anna Kelley provided
subject matter expertise. Susannah Compton helped draft the report, and
Mimi Nguyen provided assistance with graphics. Roger Thomas provided
legal counsel.
[End of section]
Footnotes:
[1] The data include Active, Reserve, and National Guard servicemembers
wounded in action from October 7, 2001, to July 5, 2008. Over two-
thirds of these servicemembers were in the Department of the Army. Of
these Army servicemembers, 24 percent were from the Reserve or National
Guard.
[2] Department of the Army, Office of the Inspector General, Report on
the Army Physical Disability Evaluation System (Washington, D.C.: Mar.
6, 2007).
[3] Independent Review Group, Rebuilding the Trust: Report on
Rehabilitative Care and Administrative Processes at Walter Reed Army
Medical Center and National Naval Medical Center (Arlington, Va.: April
2007); Task Force on Returning Global War on Terror Heroes, Report to
the President (April 2007); and President's Commission on Care for
America's Returning Wounded Warriors, Serve, Support, Simplify (July
2007).
[4] GAO, Military Disability System: Improved Oversight Needed to
Ensure Consistent and Timely Outcomes for Reserve and Active Duty
Service Members, [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-06-
362] (Washington, D.C.: Mar. 31, 2006).
[5] Veterans' Disability Benefits Commission, Honoring the Call to
Duty: Veterans' Disability Benefits in the 21st Century (October 2007).
[6] We use the word "reservist" in this report to refer to reserve
component members.
[7] There are five PEB sites across the military. The Army has three
PEBs located at Fort Sam Houston, Texas; Walter Reed Army Medical
Center, Washington, D.C.; and Fort Lewis, Washington. The Navy has one
PEB located at the Washington Navy Yard in Washington, D.C. The Air
Force has one PEB located in San Antonio, Texas.
[8] Servicemembers who separate from the military with a DOD disability
rating of 30 percent or higher receive health care benefits for life,
regardless of their years of service.
[9] Concurrent receipt of military retired pay and VA disability
compensation is permitted under certain circumstances.
[10] VA determines the degree to which veterans are disabled in 10
percent increments on a scale of 0 to 100 percent.
[11] Previously, the Army had separate structures to care for active-
duty and reservist servicemembers whose injury or illness prevented
them from working in their assigned unit during recovery. Ill or
injured active-duty servicemembers were placed in "Medical Hold"
status, and ill or injured reservists were placed in "Medical Holdover"
status.
[12] As of June 2008, 57 percent of servicemembers undergoing
disability evaluation were in a Warrior Transition Unit. Some
servicemembers in Warrior Transition Units are not undergoing
disability evaluation because their conditions have not yet healed or
stabilized.
[13] Additional workgroups are examining case management, TBI and PTSD
matters, and data sharing between DOD and VA, among other issues.
[14] The three pilot locations are Walter Reed Army Medical Center,
Washington, D.C.; National Naval Medical Center, Bethesda, Maryland;
and Malcolm Grow Air Force Medical Center, Andrews Air Force Base,
Maryland.
[15] For the current pilot locations, examinations are conducted at the
Washington, D.C., VA Medical Center.
[16] DOD established a caseload target of 20 servicemembers per board
liaison in May 2007, but the Army believes its caseload target of 30
servicemembers per liaison is sufficient.
[17] Also as of June 2008, 24 of the Army's 35 treatment facilities--
with about 90 percent of servicemembers in the Army disability
evaluation process--do not satisfy DOD's caseload target of 20
servicemembers per board liaison.
[18] These staff are located at the 3 facilities with Army PEBs as well
as Tripler, Hawaii, and Fort Carson, Colorado. According to Army
officials, there are approximately 350 other attorneys assigned to
provide various forms of legal assistance to servicemembers. However,
these attorneys are not dedicated exclusively to the disability
evaluation process, and, according to Army officials, many of these
attorneys do not have experience with the process, which limits their
ability to counsel servicemembers.
[19] In June 2008, the Army replaced 18 reservist legal personnel who
were staffed a year prior--to help meet increasing demand for legal
support during the disability evaluation process--with 18 new
reservists. According to Army officials and a Disabled American
Veterans representative with extensive experience in counseling
servicemembers during the evaluation process, frequent rotations and
turnover of Army attorneys working on disability cases limit their
initial effectiveness in representing servicemembers, due to the
complexity of disability evaluation regulations.
[20] We have previously reported that the Army has few internal
controls to ensure that case processing data were complete and
accurate. According to Army officials, data quality has improved due to
modifications to the computer system and greater care being taken
during the data input process, but we did not substantiate these
assertions.
[21] Diagnosing PTSD is time-consuming because it involves psychiatric
evaluation over time. Furthermore, PTSD symptoms may arise months after
the disability evaluation process has begun.
[22] The facility is the Brooke Army Medical Center, Fort Sam Houston,
Texas.
[23] Pursuant to the National Defense Authorization Act for Fiscal Year
2008, enacted January 28, 2008, the Secretary of Defense is required to
submit a pilot status report not later than 180 days after an initial
report, which was submitted on April 30, 2008. The Secretary's final
pilot report, due not later than 90 days after the pilot ends, is to
represent a final pilot evaluation and assessment, including any
recommendations for legislative or administrative action. Pub. L. No.
110-181, § 1644(g).
[24] The Senior Oversight Committee requested that each of its
workgroups develop such a mechanism to help report its work status and
progress.
[25] Having a comparison group with similar demographic and disability
profiles would be important to do to the extent that pilot cases have
characteristics that are different from nonpilot cases. Walter Reed--
the Army pilot location--has facilities for the care and rehabilitation
of amputees, and other severely wounded servicemembers, whereas other
Army facilities may serve different populations.
[26] Under this program, samples of VA disability compensation and
pension decisions are assessed for case processing and decision
accuracy.
[27] The DOD Disability Advisory Council was established in 1999 to
review DOD disability evaluation policies and procedures, among other
purposes. The council includes representatives of DOD-wide and military
service health and personnel organizations who are stakeholders of the
military disability evaluation system.
[28] Through the TRICARE program, DOD provides medical care to
servicemembers and other eligible beneficiaries, including their
dependents and military retirees. Beneficiaries may receive care at
military treatment facilities or from civilian health care
professionals.
[29] A PEB places servicemembers on a temporary disability retired list
when they are deemed unfit for duty, but their conditions are deemed
unstable for rating purposes. Servicemembers on temporary disability
retirement receive a medical reevaluation at least once every 18 months
up to 5 years until a final determination is made.
[30] At VA regional benefits offices, VA service representatives, also
known as veterans service representatives, perform numerous functions,
including establishing claims files; developing evidence to support
claim decisions, including obtaining medical examinations and VA and
DOD medical records; processing benefits; and handling public contacts
with veterans.
[31] Pending legislation, if enacted, would extend the Senior Oversight
Committee's operations through fiscal year 2011. National Defense
Authorization Act for Fiscal Year 2009, S. 3001, § 1067.
[32] The Joint Executive Council was authorized by the Congress to
coordinate DOD and VA cooperative efforts in a number of medical care,
benefits administration, and information technology areas. The Joint
Executive Council's Benefits Executive Council is responsible for
coordinating efforts in the disability benefits area.
[33] Department of the Army, Office of the Inspector General, Report on
the Army Physical Disability Evaluation System (Washington, D.C.: Mar.
6, 2007).
[34] GAO described this process in its report, Military Disability
System: Improved Oversight Needed to Ensure Consistent and Timely
Outcomes for Reserve and Active Duty Service Members, [hyperlink,
http://www.gao.gov/cgi-bin/getrpt?GAO-06-362] (Washington, D.C.: Mar.
31, 2006).
[35] A physician is required to identify a condition that may cause the
member to fall below retention standards after the member has received
the maximum benefit of medical care. In addition, there are specific
conditions listed in DOD regulations that require a servicemember to be
referred to the disability evaluation system.
[36] According to DOD Instruction 1332.38, retention standards are the
physical standards or guidelines that establish those medical
conditions or physical defects that may render a member unfit for
further military service and, therefore, are cause for referral of the
member into the disability evaluation process.
[37] For more information on the eligibility criteria for DOD
disability benefits, see 10 U.S.C. § 1201(b).
[38] For more information on the VA rating schedule, see DOD
Instruction 1332.39 (Nov. 14, 1996).
[End of section]
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