Gulf War Illness: Improvements Needed for VA to Better Understand, Process, and Communicate Decisions on Claims
Highlights
What GAO Found
The Department of Veterans Affairs (VA) completed processing about 11,400 Gulf War Illness (GWI) claims in fiscal year 2015, which was more than double the 4,800 claims processed in fiscal year 2010. GWI is a collective term for certain medical conditions among veterans who have served in Southwest Asia since 1990. Symptoms of GWI can include joint pain, gastrointestinal problems, fatigue, and neurological problems. On average, GWI claims have twice as many medical issues per claim as other disability claims, and take 4 months longer to complete. During fiscal years 2010 through 2015, the most recent data available at the time of our review, approval rates for GWI claims were about three times lower than for all other claimed disabilities. Several factors may contribute to lower approval rates, including that—according to VA—GWI claims are not always well understood by VA staff and veterans sometimes file for benefits without medical records to adequately support their claim.
VA's ability to accurately process GWI claims is hampered by inadequate training, and its decision letters for denied claims do not communicate key information to veterans. VA claims rating staff often rely on VA medical examiners to assess a veteran's disability before a decision can be made on a claim. VA medical examiners told GAO that conducting Gulf War general medical exams is challenging because of the range of symptoms that could qualify as GWI. VA has developed elective GWI training for its medical examiners, but only 10 percent of examiners had taken the training as of February 2017. Federal internal control standards call for adequate training for staff so they can correctly carry out an agency's procedures. Medical examiners who do not take this GWI-specific training may not be able to provide information to VA staff to correctly decide whether to grant a veteran's claim. Once a determination is made, VA regulations also require clear explanations to veterans regarding claim decisions. GAO found that decision letters for GWI claims do not always include key information on why the claim was denied.
VA considers research when adding to the list of conditions it associates with Gulf War service, but it does not have a plan to develop a uniformly used case definition of GWI. In 2010, VA added nine infectious diseases to the list of GWI-related conditions. VA advisory groups noted, however, that researchers face obstacles in conducting GWI research, including the lack of a single case definition of the illness for research and treatment purposes. In its 2015 Gulf War Research Strategic Plan, VA included an objective to develop a single case definition, but an official told GAO that VA had no action plan in place to achieve it. Without a plan to achieve a single case definition, research on and treatment for GWI may continue to progress slowly.
Why GAO Did This Study
VA estimates that 44 percent of veterans who served in the Persian Gulf War in 1990-91 have medical issues commonly referred to as Gulf War Illness and that those who have been deployed to Southwest Asia since then may suffer from similar medical issues. These medical issues may entitle a veteran to VA benefits. Recently, questions have been raised about whether VA is processing GWI claims correctly. GAO was asked to review VA's handling of these claims.
This report examines (1) recent trends in GWI disability claims, (2) challenges associated with accurately processing and clearly communicating decisions on GWI claims, and (3) how VA uses GWI research to inform the disability compensation program. GAO reviewed relevant federal laws, regulations, and guidance; analyzed VA data on GWI-related claim decisions from fiscal years 2010–2015 (the most recent data available); visited 4 of 58 regional offices, choosing those with high GWI caseloads; and interviewed headquarters and regional VA staff and key stakeholders. GAO also reviewed a non-generalizable sample of 44 claim files to provide illustrative examples of how VA evaluated and communicated decisions on GWI claims.
Recommendations
GAO recommends that VA require GWI training for medical examiners, improve its decision letters, and develop a plan to establish a single GWI case definition. VA agreed with GAO's recommendations.
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Department of Veterans Affairs | To help ensure VHA medical examiners are prepared to conduct the Gulf War general medical exam, the Secretary of Veterans Affairs should direct the Under Secretary for Health to require medical examiners to complete training, such as the 90-minute Gulf War Illness web-based course, before conducting these exams. |
VA agreed with this recommendation and, in July 2017, VHA made its 90-minute Gulf War Illness web-based training course mandatory for its medical examiners who conduct disability compensation exams for Gulf War Illness. As of November 3, 2017, all VHA certified medical examiners had completed this course. This should better prepare these medical examiners to conduct the Gulf War general medical exams.
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| Department of Veterans Affairs | To provide more complete information to veterans whose Gulf War Illness claims are denied, the Secretary of Veterans Affairs should direct the Under Secretary for Benefits to update guidance to require that decision letters indicate whether Gulf War Illness medical issues were evaluated under both a presumptive and direct service connection method. |
In August 2017, VA revised its guidance to require that decision letters sent to veterans indicate whether Gulf War Illness medical issues were evaluated under both a presumptive and direct service connection method. In addition, VA made changes to system-generated language used in the narrative portion of the rating decision to clearly indicate that a claim was evaluated under both methods of service connection. These changes should result in more complete information being provided to veterans whose Gulf War Illness claims are denied.
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| Department of Veterans Affairs | To increase the likelihood of making progress toward developing a single case definition of Gulf War Illness, the Secretary of Veterans Affairs should direct the Under Secretary for Health to prepare and document a plan to develop a single case definition of Gulf War Illness. This plan should include near- and long-term specific actions, such as analyzing and leveraging information in existing datasets and identifying any areas for future research to help VA achieve this goal. |
VA agreed with this recommendation and worked with subject matter experts from VHA, VBA, and the Department of Defense to create a 7-step plan to develop a single case definition of Gulf War Illness. This plan-including both near- and long-term actions-was developed in November 2017 and approved by VA's Principal Deputy Undersecretary for Health in May of 2018. VA has since completed the first two steps of this plan, with the 3rd step underway. Once a potential case definition is derived, VA will seek input from academic and other experts to validate this definition. This plan should position VA to reach its long-standing goal of establishing a single case definition and ultimately, better meet the healthcare needs of Gulf War veterans.
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