Military Sexual Trauma: Improvements Made, but VA Can Do More to Track and Improve the Consistency of Disability Claim Decisions
Highlights
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.
Recommendations
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.
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Department of Veterans Affairs | 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. |
The Veterans Benefits Administration (VBA) developed a new online refresher course on processing Military Sexual Trauma-related claims and made it available to staff starting on August 15, 2014. The course includes the following four modules: (1) Introduction, (2) Rules and Regulations, (3) Development, and (4) Rating. As of October 1, 2014, the course is mandatory for all adjudicators, including veterans service representatives, rating veterans service representatives, and decision review officers.
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| Department of Veterans Affairs | 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. |
In October 2014, VBA completed a quality review of denied MST-related PTSD claims for regional offices with increased denial rates, and plans to conduct additional studies of MST-related claims on a biannual basis. Specifically, for 22 regional offices with increased denial rates between FY 2012 and FY 2013, VBA examined a random sample of 491 claims denied in FY 2013 and made recommendations to address common errors. The sampling method used for the 2014 review is not exactly the same as those used in previous MST-related reviews, so VA cannot track national or regional accuracy performance over time. Nevertheless, VA's biannual review will allow it to monitor national and regional trends in denial rates, including in relation to PTSD not related to MST, and subsequently target problem areas for additional analysis and improvement. In addition, VBA plans to continue assessing reviewers' knowledge of MST-related claims through consistency questionnaires, revising the questions over time to improve them. While the continued revisions will not allow for cross-year comparisons, the results of the questionnaires have the potential to identify problem areas and target improvement efforts. VBA's actions to institute regularly biannual and consistency reviews address this recommendation.
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| Department of Veterans Affairs | 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. |
VA has further analyzed data about MST-related claims decisions, and plans to continue doing so on a bi-annual basis. In the fall of 2014, VA used statistical testing to identify the likelihood that various factors affected MST-related claims decisions between fiscal years 2009 and 2013. The factors considered in the analysis included the veteran's gender; whether the veteran received a medical examination; and the length of time between when a veteran left the military and when he or she filed an MST-related claim. VA plans to analyze MST-related claims decisions bi-annually and use the results to inform training. While these actions are sufficient to address GAO's recommendation, VBA's reports would have benefited from additional information about the specific variables used, the standard errors of reported estimates, and other elements of sound statistical analysis and reporting. We encourage VBA to refine how it reports on its analytical approach in future reviews.
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| Department of Veterans Affairs | 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. |
VA has taken several steps to systematically collect additional data on MST-related claims - and plans to take more steps in the future - that will likely help VA monitor the consistency of MST-related decisions. At the same time, we identified additional steps VA could include in its future efforts that might enhance its ability to track consistency. Specifically, in Fall 2014, the agency created a checklist for all MST-related claims that were denied without the veteran receiving a medical examination. This checklist will help ensure consistency for claims not involving a medical examination because it documents steps taken to identify evidence about the MST event, and requires a supervisor's signature to verify the accuracy and completeness of the checklist. VA said that it plans to use the information obtained through this checklist for future analysis and training. Moving forward, VA could also consider developing a checklist for MST-related claims that received an examination that would allow VA to more readily identify the most common types of evidence used to support claimed MST events and any variation between the types of evidence offered for approved versus denied claims. In a separate effort, VA analyzed the reasons why a sample of MST-related claims were denied after the veteran received a medical examination, and reported that the second most common reason for denial - insufficient evidence of the claimed MST event - may result from inaccurate or insufficient adjudication. Based on these results, VA plans to assess whether adjudicators followed proper procedures. In designing such follow-up analysis, VA could also consider whether the medical examiners followed proper procedures for evaluating evidence of the claimed MST event. This is especially important given GAO's findings that medical examiners may vary in how they evaluate such evidence and VA's related plans to improve examiners' training.
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| Department of Veterans Affairs | 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. |
In July 2014, VBA sent letters to 2,600 veterans who had "personal assault" claims denied between 2008 and 2010, inviting them to resubmit MST-related claims. Although veterans with MST-related claims are only a subset of these "personal assault" claimants, VA's data systems from that time period did not capture information that would allow VBA to further target the population who received letters. A key VBA official also met with Veterans Service Organizations twice in August 2014 to inform them of the recent letters and explain the re-evaluation process. In addition, VBA reported working closely with the Veterans Health Administration to ensure that relevant staff were aware of the re-evaluation initiative and could explain it to veterans seeking MST-related health care.
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| Department of Veterans Affairs | 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. |
VHA developed and implemented training for medical personnel who conduct disability examinations related to military sexual trauma (MST). VHA verified that all relevant personnel participated in the training by: (1) disseminating training attendance records to Veterans Integrated Service Network (VISN) officials and contracting organizations and (2) requiring the officials to certify that all personnel who conduct disability examinations completed the training, including contractors and fee basis employees.
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