Military Sexual Trauma:

Improvements Made, but VA Can Do More to Track and Improve the Consistency of Disability Claim Decisions

GAO-14-477: Published: Jun 9, 2014. Publicly Released: Jun 9, 2014.

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What GAO Found

The Veterans Benefits Administration (VBA), within the Department of Veterans Affairs (VA), has taken several steps to improve decision-making on disability claims involving military sexual trauma (MST) and to rectify past errors. In 2011, VBA began assigning MST-related claims to adjudicators with expertise in complex cases and required them to receive MST-specific training, such as on the broadened scope of evidence allowed since 2002. In 2012, the Veterans Health Administration (VHA) also provided some optional training to medical examiners who provide key input into decisions for such claims. Noting that some MST-related claims may have been erroneously denied prior to the specialization and training of staff, VBA in April 2013 invited 2,667 veterans with denied claims for post-traumatic stress disorder (PTSD) to resubmit them.

According to VBA data, national approval rates for claims based on MST have markedly increased since fiscal year 2010, a change that agency officials attributed to the additional training and a better general understanding of MST requirements. However, GAO found wide variation in approval rates among regional offices, which ranged from 14 to 88 percent in fiscal year 2013. Half of the offices had approval rates close to the average (between 40 and 60 percent), but the rest were higher or lower. While variation does not necessarily signify inconsistency, staff GAO interviewed from four of five offices described ongoing difficulty applying the broadened standards, and GAO found several instances of widely varying interpretations. Both VBA and VHA staff also described variation in the thoroughness of VHA medical exams used by adjudicators to reach decisions. Some VHA medical examiners GAO spoke with required more evidence than others to establish that an MST incident occurred. VBA and VHA staff in almost every office GAO contacted said that further training would be useful, feedback that is consistent with good practices previously identified by GAO and others for reinforcing training. More recently, VHA has decided to make upcoming training on MST-related exams required for all medical examiners who conduct them. With respect to reviewing previously denied claims, VBA was only able to contact veterans whose claims had been denied since September 2010, although those with older claims can also resubmit. VBA's national outreach to other affected veterans was limited to two group meetings with veteran service organizations.

While VBA has taken some steps to evaluate decisions for MST-related claims, its quality reviews and analyses of claim decisions have shortcomings. For example, a 2013 quality review focusing on consistency may under-estimate challenges associated with adjudicating MST claims. Also, due to varying methods and samples, quality reviews conducted to date are insufficient to measure improvement over time—a standard part of internal control. In addition, while VBA analyzes data on national approval rates to gauge the effect of process improvements, GAO's analysis of approval rates by regional office and veteran gender found wide variation. VBA also does not systematically collect data on the number of exams received or why claims are denied—information that could help VBA identify potentially problematic trends. VBA officials said the agency's many competing priorities have precluded additional data collection and analysis to date, but added that they plan to review variations in approval rates in the near future.

Why GAO Did This Study

In 2012, 1 in 5 female and 1 in 100 male veterans told VA that they had experienced sexual abuse in the military. Referred to as military sexual trauma or MST, such abuse can result in disabling conditions like PTSD, which may entitle a veteran to VA benefits. Yet, establishing that MST occurred—a prerequisite for approving these claims—can be difficult, given that servicemembers may be unwilling to file formal complaints. In 2002, VA broadened the scope of allowable evidence for MST-related claims to include indicators, such as behavioral changes. Beginning in 2011, VBA took additional steps to clarify the 2002 changes. GAO was subsequently asked to review these actions.

This report examines: (1) steps VA took to improve MST-related decisions, (2) results of its actions, and (3) the extent it is evaluating the quality of claim decisions. GAO reviewed relevant federal laws, regulations, and guidance; analyzed VA data on MST-related claim decisions (fiscal years 2010-2013); interviewed national VBA and VHA officials, key advocates, and stakeholders, VBA officials at 5 of 57 regional offices (with varying workloads and quality review scores), and VHA examiners associated with 3 of these offices; and reviewed a non-generalizable sample of 18 claim files completed in 2013 for examples of how evidence was evaluated.

What GAO Recommends

GAO is recommending that VA improve training, conduct more outreach, and enhance its MST-related quality reviews and analyses. VA concurred with all of GAO's recommendations.

For more information, contact Daniel Bertoni at (202) 512-7215 or bertonid@gao.gov.

Status Legend:

More Info
  • Review Pending-GAO has not yet assessed implementation status.
  • Open-Actions to satisfy the intent of the recommendation have not been taken or are being planned, or actions that partially satisfy the intent of the recommendation have been taken.
  • Closed-implemented-Actions that satisfy the intent of the recommendation have been taken.
  • Closed-not implemented-While the intent of the recommendation has not been satisfied, time or circumstances have rendered the recommendation invalid.
    • Review Pending
    • Open
    • Closed - implemented
    • Closed - not implemented

    Recommendations for Executive Action

    Recommendation: The Acting Secretary of Veterans Affairs should direct the Under Secretary for Benefits to expand existing training and guidance to adjudicators responsible for MST-related claims by, for example, providing mandatory refresher courses or regularly distributing examples of relevant errors identified from quality assurance reviews.

    Agency Affected: Department of Veterans Affairs

    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

    Recommendation: The Acting Secretary of Veterans Affairs should direct the Under Secretary for Benefits to develop a plan for conducting more comprehensive quality reviews of MST-related claims that allows the agency to identify problem areas, target improvement efforts, and track performance over time.

    Agency Affected: Department of Veterans Affairs

    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

    Recommendation: The Acting Secretary of Veterans Affairs should direct the Under Secretary for Benefits to further analyze existing data on MST-related claim decisions by, for example, determining approval rates by regional office and veteran gender.

    Agency Affected: Department of Veterans Affairs

    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

    Recommendation: The Acting Secretary of Veterans Affairs should direct the Under Secretary for Benefits to explore ways to systematically collect additional data on MST-related claims that might allow the agency to better track consistency. Such data could include reasons for denials, whether claim evaluations included a medical exam, and how often related medical exam reports are returned to VHA for clarification or deemed insufficient.

    Agency Affected: Department of Veterans Affairs

    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

    Recommendation: The Acting Secretary of Veterans Affairs should direct the Under Secretary for Benefits to expand outreach to veterans who are eligible to resubmit their previously denied PTSD claims related to MST. The agency should conduct this outreach in partnership with the Veterans Health Administration or external organizations, such as veteran service organizations.

    Agency Affected: Department of Veterans Affairs

    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

    Recommendation: The Acting Secretary of Veterans Affairs should further direct the Under Secretary for Health to ensure that planned training on conducting MST- related exams is provided to all medical examiners who perform them, including contractors.

    Agency Affected: Department of Veterans Affairs

    Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

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