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STUDY: VA SHOULD REVISE ITS METHODS FOR
EVALUATING
AND RATING PTSD IN VETERANS -- Institute of
Medicine tells
VA to get it together. If implemented,
recommendations could
mean more consistent ratings and higher
compensation.
The long-awaited IOM study on PTSD
compensation is out...and, it's not good news for the VA...but, it could
be good news for veterans.
If all the recommendations in this report
are implemented, and they probably will NOT be, it would cost the VA
billions and give veterans better and more consistent PTSD diagnoses and
higher compensation because ratings would be based on how PTSD affects
all aspects of a veteran's life, not just the ability to be employed.
At the time I put this together, the
report was not posted. If you can't find it at the IOM web site
(see press release below) and want a copy, just email me and I'll
forward it to you.
We have three stories...first from The
Washington Post...second the IOM press release and third an AP story.
WAPO story here...
http://www.washingtonpost.com/
wp-dyn/content/article/2007/05/08/AR
2007050801746.html?hpid=moreheadlines
WAPO story below:
---------------
VA Benefits System for PTSD Victims Is
Criticized
By Shankar Vedantam
Washington Post Staff Writer
The government's methods for deciding compensation for emotionally
disturbed veterans have little basis in science, are applied unevenly
and may even create disincentives for veterans to get better, an
influential scientific advisory group said yesterday.
The critique by the Institute of Medicine, which provides advice to the
federal government on medical science issues, comes at a time of sharp
increases in cases of post-traumatic stress disorder (PTSD) among
veterans and skyrocketing costs for disability compensation. The study
was undertaken at the request of the Department of Veterans Affairs amid
fears that troops returning from the wars in Iraq and Afghanistan will
produce a tidal wave of new PTSD cases.
Between 1999 and 2004, benefit payments for PTSD increased nearly 150
percent, from $1.72 billion to $4.28 billion, the report noted.
Compensation payments for disorders related to psychological trauma
account for an outsize portion of VA's budget -- 8.7 percent of all
claims, but 20.5 percent of compensation payments.
VA officials said they welcomed the report. "VA is studying the
findings, conclusions and recommendations of the report to determine
actions that can be taken to further enhance the services we provide,"
spokesman Matt Burns said in a statement.
The report suggested changes to VA policies, but the panel could not say
whether those changes would result in more or fewer PTSD diagnoses, or
in greater or lesser expense for taxpayers. "PTSD has become a very
serious public health problem for the veterans of current conflicts and
past conflicts," said psychiatrist Nancy Andreasen of the University of
Iowa, who chaired the panel. Noting the shortcomings of the VA system,
Andreasen added that "a comprehensive revision of the disability
determination criteria are needed."
She said the current VA system, in which PTSD compensation is limited to
those who are unable to hold a job, places many veterans in a Catch-22.
"You can't get a disability payment if you get a job -- that's not a
logical way to proceed in terms of providing an incentive to become
healthier and a more productive member of society," she said.
The practice is especially wrong, she added, because it is at odds with
VA policies for other kinds of injuries. To determine the compensation a
wounded veteran should get, the government assigns one a disability
score. Veterans who are quadriplegic, for example, can be assigned a
disability level of 100 percent even if they hold a job, whereas
veterans with PTSD must show they are unable to work to get
compensation.
Andreasen said the policies are "problematic, in the sense that they
require the person given compensation to be unemployed. This is a
disincentive for full or even partial recovery."
One solution suggested by the panel was to set a minimum compensation
level for veterans disabled by PTSD, which would allow those who can
seek work to do so.
"This is the report the VA didn't want," said Larry Scott, founder of
the group VAWatchdog.org, who
applauded the conclusions. If the IOM's recommendations are implemented,
he said, they will cost VA "billions of dollars -- more staff, more
staff training, more data collection, more clinical evaluations and
higher awards."
The report identified problems with both arms of VA's evaluation and
compensation procedures: A veteran currently undergoes an evaluation to
determine if he or she has PTSD, and the results are used by other
raters to determine the level of disability and the amount of
compensation.
The Institute of Medicine panel said the scale used to evaluate veterans
is outdated and largely designed for people who suffer from other mental
disorders. Andreasen and other members also said they had heard from
veterans who had received wildly different kinds of evaluations -- some
lasting 20 minutes while others took hours. The scientists said VA
should standardize the evaluations using state-of-the-art diagnostic
techniques.
While VA requires its experts to determine what proportion of a
veteran's disabilities were caused by particular traumatic experiences,
and to what extent overlapping symptoms are related to particular
disorders, the IOM said there is no scientific way to classify symptoms
in this manner.
"The VA's disability policies for veterans with PTSD were developed over
60 years ago and now require major, fundamental reform," said Chris
Frueh, a former VA clinician who is now a psychologist at the University
of Hawaii at Hilo and was not involved with producing the new report.
But even though better care is needed for veterans, Frueh said, it is
important not to assume that trauma always results in a mental disorder.
"Scientific evidence indicates that resilience is the most common human
response to trauma," he said. "Even for the most severe forms of trauma,
such as rape or combat, most people do not develop PTSD."
---------------
IOM press release here...
http://www.eurekalert.org/
pub_releases/2007-05/tna-vsr050807.php
Press release below:
---------------
Contact: Christine Stencel
news@nas.edu
202-334-2138
The National Academies
VA should revise its methods for evaluating and rating PTSD in veterans
WASHINGTON -- To ensure more consistent and appropriate disability
compensation for veterans, the U.S. Department of Veterans Affairs (VA)
needs to revise how it evaluates former military personnel for
service-connected post-traumatic stress disorder (PTSD) and determines
the payment amounts they merit, says a new report from the Institute of
Medicine and National Research Council. A surge in the number of
disability claims for PTSD has revealed inconsistencies in compensation
levels awarded across the country, raising questions about the
effectiveness of the VA's current ways of assessing and rating this
condition, and whether some veterans are getting payments that are too
low, too high, or unmerited.
The agency should develop new evaluation methods and rating criteria
specific to PTSD to replace current standards that yield a crude and
overly general assessment of PTSD disability, said the committee that
wrote the report. It urged the VA to base compensation decisions on how
greatly PTSD affects all aspects of a veteran's daily life, not just his
or her ability to be gainfully employed.
The agency also should ensure that all veterans applying for PTSD
compensation receive a thorough, initial evaluation by an experienced
clinical professional. These exams should be of sufficient duration to
provide a detailed picture of each veteran's condition so that
disability raters -- non-clinical personnel who determine whether a
disability is connected to military service and the level of impairment
it entails -- can make more consistent and better informed decisions
about the level of compensation each veteran merits. More thorough
evaluations also would enhance VA's ability to detect inappropriate
claims, though the committee confirmed that PTSD symptoms can manifest
many years after a traumatic event or may interfere with a veteran's
ability to function only later in life.
"As the increasing number of claims to the VA shows, PTSD has become
very significant public health problem, particularly for veterans of
current and past conflicts," said committee chair Nancy Andreasen,
Andrew H. Woods Chair of Psychiatry and director, Psychiatric
Neuroimaging Research Center, Carver College of Medicine, University of
Iowa, Iowa City. "Our review of the current methods for evaluating PTSD
disability claims and determining compensation indicates that a
comprehensive revision is needed."
Recent years have seen a spike in PTSD claims and a significant increase
in disability payments for the condition. The number of cases jumped
almost 80 percent between fiscal years 1999 and 2004, growing from
120,265 cases to 215,871. Payments for PTSD increased almost 150 percent
over the same period, rising from $1.72 billion to $4.28 billion. The
bulk of claims for PTSD compensation currently are coming from Vietnam
War veterans who comprise the majority of living veterans, but claims
also are being made by former service personnel of earlier conflicts as
well as personnel who served in the first Gulf War and in the current
conflicts in Iraq and Afghanistan. There likely will be many more claims
from the latter group in the future, so how this issue is resolved now
will eventually affect many active duty personnel.
A thorough, initial evaluation by an experienced professional is crucial
to improving PTSD compensation decisions, the committee said. These
exams determine whether former service members are experiencing PTSD and
how severe it is. Currently, the time devoted to the evaluations varies
widely as does the amount of detail examiners provide to the raters who
determine the appropriate level of compensation. Moreover, many veterans
denied compensation eventually receive it after applying for
re-evaluation, sometimes multiple times. Ensuring that every veteran
making a claim receives a comprehensive evaluation could make the
process more efficient.
The report offers a starting point to help VA devise new ratings
criteria specific to PTSD. The committee emphasized the need to rate
PTSD disability based on a fuller range of an individual's capacity to
function, not just on his or her ability to work. The focus on
occupational impairment in the current rating scheme penalizes veterans
who can and do work despite their symptoms, and may serve as a
disincentive to work, the report says.
Many disability claims are being submitted by veterans who have been out
of military service for several years, which has prompted questions
about how long after a traumatic event PTSD can manifest and whether
standardized tests could detect dissembling if someone tried to make a
fraudulent claim. The committee found abundant evidence that PTSD can
develop at any time after exposure to trauma. It also can manifest as a
relapsing condition or flare up after being suppressed and undiagnosed.
Aging, loss of mental acuity, the death of friends or spouses, and other
factors can trigger or exacerbate symptoms as well. Standardized tests
can be a useful part of an assessment, but they are no substitute for a
thorough clinical assessment by a trained professional, the committee
concluded.
Combat exposure is not the only potential trigger for PTSD among service
members; sexual assault is another form of trauma. The available
information suggests that female veterans are less likely to receive
compensation for PTSD, which may in part be due to the difficulty of
substantiating exposure to traumatic events unrelated to combat,
including sexual harassment or assaults that occurred during service. VA
should make a concerted effort to gather data and provide reference
materials to help disability raters better address the management of
PTSD claims related to sexual assault during military service, the
report says.
###
The study was sponsored by the U.S. Department of Veterans Affairs.
Established in 1970 under the charter of the National Academy of
Sciences, the Institute of Medicine provides independent, objective,
evidence-based advice to policymakers, health professionals, the private
sector, and the public. The National Research Council is the principal
operating agency of the National Academy of Sciences and National
Academy of Engineering. A committee roster follows.
Pre-publication copies of PTSD Compensation and Military Service are
available from the National Academies Press; tel. 202-334-3313 or
1-800-624-6242 or on the Internet at
http://www.nap.edu. Reporters may obtain a copy from the
Office of News and Public Information (contacts listed above).
[ This news release and report are available at
http://national-academies.org
]
INSTITUTE OF MEDICINE Board on Military and Veterans Health and NATIONAL
RESEARCH COUNCIL Division of Behavioral and Social Sciences and
Education Center for Studies of Behavior and Development
Committee on Veterans' Compensation for Post Traumatic Stress Disorder
Nancy C. Andreasen, M.D., Ph.D. (chair)
Andrew H. Woods Chair of Psychiatry, and Director
Neuroimaging Research Center
Carver College of Medicine
University of Iowa
Iowa City
Jacquelyn C. Campbell, Ph.D., R.N.
Anna D. Wolf Chair
School of Nursing
The Johns Hopkins University
Baltimore
Judith A. Cook, Ph.D.
Professor of Psychiatry, and Director
Center on Mental Health Services Research and Policy
University of Illinois
Chicago
John A. Fairbank, Ph.D.
Associate Professor of Medical Psychology
Duke University Medical Center, and Co-director National Center for
Child Traumatic Stress
Durham, N.C.
Bonnie L. Green, Ph.D.
Professor of Psychiatry, and Director of Research
Department of Psychiatry
Georgetown University Medical School
Washington, D.C.
Dean G. Kilpatrick, Ph.D.
Distinguished University Professor
Department of Psychiatry and Behavioral Sciences, and Director
National Crime Victims Research and Treatment Center
Medical University of South Carolina
Charleston
Kurt Kroenke, M.D.
Professor of Medicine
Division of General Internal Medicine and Geriatrics Indiana University,
and Senior Research Scientist and Director of Fellowship Training
Regenstrief Institute Inc.
Indianapolis
Richard A. Kulka, Ph.D.
Senior Vice President of Strategic Business Development Abt Associates
Inc., and Senior Research Scientist Center for Demographic Studies
Duke University
Durham, N.C.
Patricia M. Owens, M.P.A.
Independent Consultant
Minisink Hills, Pa.
Robert T. Reville, Ph.D.
Director
RAND Institute of Civil Justice
Santa Monica, Calif.
David S. Salkever, Ph.D.
Professor
Department of Public Policy University of Maryland, Baltimore County,
and Research Associate National Bureau of Economic Research
Cambridge, Mass.
Robert J. Ursano, M.D.
Professor of Psychiatry and Neuroscience; Chair Department of
Psychiatry; and Director Center for the Study of Traumatic Stress
Uniformed Services University of the Health Sciences
Bethesda, Md.
STAFF
David A. Butler, Ph.D.
Study Director
---------------
AP story here...
http://www.chron.com/
disp/story.mpl/ap/politics/4785166.html
Story below:
---------------
Better veterans stress testing urged
By RANDOLPH E. SCHMID Associated Press Writer
WASHINGTON — The surge in the number of veterans suffering
post-traumatic stress disorder requires development of better tests to
evaluate affected personnel and determine how best to compensate them, a
panel of medical experts said Tuesday.
"As the increasing number of claims to the VA shows, PTSD has become a
very significant public health problem," said Nancy Andreasen, chair of
the committee that prepared the report.
"Our review of the current methods for evaluating PTSD disability claims
and determining compensation indicates that a comprehensive revision is
needed," said Andreasen, head of the psychiatry department at Carver
College of Medicine, University of Iowa.
Claims increased from 120,265 in 1999 to 215,871 in 2004 and payments
jumped from $1.72 billion to $4.28 billion in the same period, a
combined committee from the Institute of Medicine and National Research
Council said.
While the largest share of claims is still coming from Vietnam War
veterans, there are expected to be many more claims in future from
personnel who served in the first Gulf War and in the current conflicts
in Iraq and Afghanistan, the panel said.
But the Veterans Affairs Department uses only crude criteria for rating
disabilities due to mental illness and is not consistent for relapsing
conditions, according to the report, which had been requested by the VA.
The panel urged the VA to develop new criteria based on the diagnostic
standards of the American Psychiatric Association and to establish
certification programs for workers who deal with PTSD claims.
The panel said the VA should base compensation decisions on how greatly
PTSD affects all aspects of a veteran's daily life, not just his or her
ability to be gainfully employed.
Andreasen noted that in the case of a paraplegic, compensation is based
on both ability to work and quality of life, while in the case of mental
illness, currently the ratings are tightly linked to the ability to be
employed.
The report also noted that PTSD can be triggered by trauma other than
combat, such as sexual assault. Female veterans are less likely to
receive compensation for PTSD, which may in part be due to the
difficulty of substantiating exposure to traumatic events unrelated to
combat, including sexual harassment or assaults that occurred during
service, the report said.
It urged the VA to gather data and provide reference materials to help
disability raters better address the management of PTSD claims related
to sexual assault during military service.
Dr. Robert J. Ursano, chairman of the department of psychiatry at the
Uniformed Services University of the Health Sciences in Bethesda, Md., a
member of the committee, said the recommendations are complex and the VA
will have to study how to implement them over time.
The Institute of Medicine and National Research Council are branches of
the National Academy of Sciences, an independent organization chartered
by Congress to advise the government on scientific matters.
___
On the Net:
National Academies:
http://www.nationalacademies.org
---------------
Larry Scott --
