Veterans' Compensation: Medical Reports Adequate for Initial Disability Ratings but Need to Be More Timely

Published by the Government Accountability Office on 1990-05-30.

Below is a raw (and likely hideous) rendition of the original report. (PDF)


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                     United States
GAO                  General Accounting Office
                     Washington, D.C. 20648

                     Human Resources Division


                     May 30,199O

                     The Honorable G.V. (Sonny) Montgomery
                     Chairman, Committee on Veterans’ Affairs
                     House of Representatives

                     The Honorable Bob Stump
                     Ranking Minority Member
                     Committee on Veterans’ Affairs
                     House of Representatives

                     As you noted in your February 1, 1989, letter, medical evidence is the
                     most critical element in adjudicating veterans’ claims for disability

                     This report responds to your request that we determine

                   . whether regional offices of the Department of Veterans Affairs (VA) are
                     requesting medical examinations for the appropriate impairment for
                     veterans applying for disability benefits; and
                   . whether the medical reports received from VA medical centers are ade-
                     quate, complete, and timely for eligibility determinations.

                     Our review of a nationwide sample of veterans’ initial claims for disabil-
Results in Brief     ity compensation showed that (1) VA regional offices requested medical
                     examinations for the appropriate medical impairment and (2) the medi-
                     cal reports addressed all claims for compensation made by veterans. The
                     medical reports contained diagnoses that were adequately supported by
                     clinical tests and procedures and physical examinations performed by VA
                     physicians. With few exceptions, these reports provided sufficient medi-
                     cal evidence to VA medical and nonmedical rating board specialists to
                     make a judgment about the extent of a veteran’s disability and assign
                     disability ratings for compensation. On the other hand, medical reports
                     frequently do not meet VA timeliness standards.

                     Veterans having diseases or injuries resulting from their military service
Background           are eligible to apply for disability compensation. Claims for compensa-
                     tion are handled by VA regional offices and submitted to a rating board
                     consisting of a physician and two nonphysician rating specialists. When
                     evaluating a claim, the board determines whether the medical evidence
                     in the veteran’s file is sufficient for it to make a rating determination. If
                     not sufficient, the board forwards a request for a medical examination

                     Page 1                            GAO/‘HRJS9@11K Vetemn.4   Disability   Compensation
              (Form 2507) to a VA medical center. Medical center physicians then per-
              form the necessary examinations and tests and submit medical reports
              to the rating board. The board then considers the medical report and
              other available evidence in the veteran’s file, including employment his-
              tory and educational background.

              VA’S  Schedule for Rating Disabilities is the official guide for converting
              clinical findings into standard diagnostic codes, covering diseases or
              injuries and degrees of severity of impairment.’ Rating specialists con-
              vert diagnoses in medical reports to diagnostic codes in the rating sched-
              ule and select the appropriate degree of severity from the schedule.
              Severity is measured in percentages ranging from 0 to 100 (in incre-
              ments of 10 percent)-100 percent being totally disabled.

              To review VA medical reports, we randomly selected a nationwide sam-
Scope and     ple of cases from VA’S April 1989 disability compensation payment file.
Methodology   We reviewed 160 cases that we estimate are part of a universe of about
              29,600 cases that had initial awards on or after January 1, 1988. The
              160 cases included 34 in which disability determinations were made
              based on information received from non-VA physicians or medical cen-
              ters. In these cases, rating specialists determined that there was suffi-
              cient medical evidence in the veteran’s file to make a determination
              without a report from a VA medical center. The remaining 126 determi-
              nations were made by rating specialists after receiving a report from a
              VA center.

              We reviewed the 160 cases to determine whether the medical reports
              were adequate, complete, and timely as measured by VA criteria. Our
              chief medical advisor reviewed the medical reports and their supporting
              documentation to determine whether there was sufficient information
              for the rating specialists to make the disability rating in accordance with
              VA’S rating schedule. Our review did not include an evaluation of the
              actual ratings given to each veteran. Also, our findings apply only to
              VA’S initial claims approved during our sample period and not to claims
              that were reopened or denied and required a medical report during the

              Our review was made in accordance with generally accepted govern-
              ment auditing standards. We sought the views of responsible VA officials

              ‘We recommended needed improvements to the r&ii      schedule in Veterans’ Benefits: Need to Update
              Medical Criteria Used in VAkDisability Rating Schedule (GAO/HRD89-28,      Dec. 29,19SS).

              Page 2                                      GAO/HRD90-116      Veterans’ Disability   Cknnpensation

                       during our work and incorporated their comments where appropriate.
                       (A more detailed discussion of our scope and methodology is contained
                       in app. I.)

                          regional offices are requesting examinations that address medical
Regional Offices       VA
                       impairments claimed by veterans in their initial applications for disabil-
Request Examinations   ity compensation. In the 126 cases that contained requests for examina-
for Appropriate        tions generated by rating boards, we compared the veterans’ claimed
                       impairments as listed in their applications for compensation with (1) the
Impairment             VA Form 2507 (Request for Physical Examination) and (2) the impair-
                       ments listed at the time of examination. In each instance, the informa-
                       tion in the veterans’ claims matched the information contained in the
                       rating board’s request and in the “complaints” section of the medical
                       report (VA Form 2546). In addition, our chief medical advisor determined
                       that the medical reports addressed each of the claimed impairments con-
                       tained in these documents.

                       Murray Grant, M.D., D.P.H., our chief medical advisor, reviewed the
Medical Reports Are    medical reports contained in the 160 cases and determined that in all but
Complete and           3 cases, the reports contained diagnoses that were adequately supported
Adequate for           by clinical tests, procedures, and physical examinations and contained
                       sufficient information about the condition’s severity. These reports pro-
Disability             vided sufficient medical evidence to VA medical and nonmedical rating
Determinations         specialists to make a judgment about the extent of a veteran’s disability
                       and assign a disability rating for compensation purposes. On a nation-
                       wide basis, we estimate that about 2 percent, or about 550, of the 29,600
                       cases did not meet VA criteria for adequate and complete medical

                       VA has established general guidance for rating board specialists concern-
                       ing what information should be contained in medical reports for them to
                       be considered complete and adequate for rating purposes. The criteria

                       1. The report must include both a medical and an occupational history.

                       2. The report must contain appropriately documented results of a gen-
                       eral medical or specialist examination, including all tests and procedures

                       2We are 96.percent confident that cases not meeting VA criteria for adequate and complete medical
                       reports do not exceed 4.4 p+went or about 1,300 cases.

                       Page 3
                        performed in diagnosing a given condition and any significant limitation
                        of function resulting from the condition.

                        3. Any disagreements or conflicts concerning the diagnosis of a given
                        condition or interpretation of test results must be resolved.

                        4. All medical reports must, be signed by the examining physician and
                        reviewed by an appropriate screening physician, signed, and dated. The
                        screening physician certifies that the report is adequate for rating pur-
                        poses from the medical viewpoint.

                        In reviewing our 160~casesample, our chief medical advisor found defi-
                        ciencies in 3 cases based on the criteria outlined above. In 2 cases, the
                        medical evidence in the report did not adequately support the final diag-
                        nosis, nor did it adequately address the severity of the condition for rat-
                        ing purposes. In the third case, he determined that although the
                        diagnosis of the condition was adequately supported, insufficient infor-
                        mation existed about the severity of the condition to make a rating

                        Reviews of medical reports by screening physicians are an important
                        internal control mechanism required by VA to ensure that reports are
                        complete and adequate for rating purposes. Of the 126 cases where
                        examinations were conducted by VA medical centers, 24 percent lacked
                        screening physician approval of the medical reportsz Despite this lack
                        of review, however, our medical advisor judged the medical reports in
                        these instances to be adequate for rating purposes.

                                               -.                                     -
                        Many cases in our sample did not meet VA’S timeliness standards. VA’s
Timeliness of Medical   criteria for timeliness are outlined in the form of performance standards
Reports Does Not Meet   set for the medical centers. For the period of our review, timeliness was
VA Standards            measured by the percentage of medical examinations that are completed
                        in a given period. Table 1 compares the timeliness of medical reports in
                        our sample with VA timeliness standards.

                        3We are Sbpercent confident that cases lacldng screening physician approval ranged between 16 and
                        32 percent, or abut 4.7or1 to 9,400 cases.

                         Page 4                                    GAO/HRDSO-116      Veterans’ Disability   Compensation
Table 1: Compartron of GAO Sample
With VA Timeliness Standards            Days to complete               VA standard       GAO sample result               Sampling error
                                        medical exams                     (percent)             (percent)           (percentage points)
                                        300rless                                  65                         32                        +9
                                        60 or less                                90                         61                        +7
                                        160orless                                100                         99                        T2

                                        Based on our sample, the average elapsed time was 63 days for the med-
                                        ical centers to schedule and complete medical examination reports4

                                        VA has instituted new timeliness criteria, effective in fiscal year 1990,
                                        which establish criteria for each step in the process. These new stan-
                                        dards set the number of days in which these activities must be com-
                                        pleted as follows:

                                    . Schedule exam after request received-5 days.
                                    l Complete exam after request received-45 days.
                                    l Document exam after completion-5 days.
                                    l Return exam to requester-7 days.

                                        In addition, VA is currently field-testing a new information exchange sys-
                                        tem, which, if successful, VA believes should eliminate virtually all the
                                        current delays involved in mailing documents between regional offices
                                        and medical facilities. The first element of this exchange process uses
                                        computerized links between the various installations allowing electronic
                                        transmission of requests for examinations and written medical reports.
                                        Supporting test results, for example, X rays, are then forwarded by

                                        A second element in this new system is the development of standardized
                                        examination reports for various body systems. These reports are
                                        designed to capture data elements based directly on specifics contained
                                        in VA’S rating schedule that are necessary to determine the type and
                                        degree of severity of a given condition. Currently, 40 such examination
                                        reports have been developed, with 20 more in the planning stage.

                                        We are sending copies of this report to appropriate congressional com-
                                        mittees; the Secretary of VA; the Director, Office of Management and
                                        Budget; and other interested parties.

                                        4We are 96.percent confident that the actual average number of days falls somewhere between 66
                                        and 70.

                                        Page 6                                     GAO/HRB!WllK       Veterans’ Disability   Compensation

Please call me on (202) 275-6193 if you or your staffs have any ques-
tions about this report. Other major contributors to the report are listed
in appendix II.

Joseph F. Delfico
Director, Income Security Issues

 page 6                           GAO/HBDsol16   Vettmws   Disability   Compensation
Page 7   GAO/EIBDw)-116   Veterans’ Disability   c.m~~ti.,,,
Appendix I

Scopeand Methodology

             VA  provided us with a random sample of 5 percent of all disability com-
             pensation and pension cases (approximately 3.6 million) on VA’s pay-
             ment file, as of April 24, 1989. From this 5-percent sample, we identified
             1,750 compensation cases in which, according to the automated file, the
             initial award was made on or after January 1,1988, and the veteran was
             alive as of the April 1989 payment date. We selected a random sample
             of 180 of these 1,750 cases for a detailed review.

              We included 160 of the 180 selected cases in our detailed review. VA
              could not provide the claims files for 4 of the 180 cases sampled when
              we needed them for review. In reviewing the remaining 176 case files,
              we found that in 16 cases the initial award had been made before Janu-
              ary 1, 1988. The estimates presented in this report are generalizable to
              all of the estimated 29,600 veterans who were initially awarded disabil-
              ity compensation between January 1,1988, and April 24,1989, and who
              were alive as of the April 1989 payment date. Because our estimates are
              based on a sample, each estimate is subject to a sampling error. The
              sampling errors for estimates cited in this report are computed at a 95
              percent confidence level. They are noted where appropriate.

              In keeping with the objectives of this request, we looked only at the
              medical reports submitted to rating boards used as a basis for the diia-
              bility determination. We did not review the rating board’s determination
              of whether a specific diagnosed condition was service connected. We
              reviewed the adequacy of medical reports with respect to aI1 conditions
              determined to be service connected, even if the disability rating given
              was 0 percent. We did not, however, examine the accuracy or appropri-
              ateness of the disability rating percentage because this determination
              can be influenced by evidence contained not in the medical report but
              elsewhere in the veteran’s file.

               Page 8                          GAO/HlW9@116   Veterans   Dhbility   Compe~tion
Appendix II

Major Contributors to This Report

                          James F. Walsh, Assistant Director, (202) 233-5281
Human Resources           John C. Boyd, Assignment Manager
Division,                 Murray Grant, M.D., D.P.H., Chief Medical Advisor
Washington, D.C.          Clarita A. Mrena, Social Science Analyst
                          Irma E. Arispe, Social Science Analyst

                          Margaret A. McGregor, Evaluator-in-Charge
Philadelphia   Regiona1   John Kirstein Site Senior
Office                    Frank Foley, iechnical Advisor

(106703)                  Page 9                         GAO,‘HRB9S116   Veterans’ Disability   compensation
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PO& OffIce Bar 6016

Telephone 202-276-6241
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