Institute of Medicine Report:
Improving the Presumptive Disability Decision-making Process for Veterans
Jonathan M. Samet, M.D., M.S.
Chairman, Committee on Evaluation of the Presumptive Disability Decision-Making Process for Veterans
Board on Military and Veterans Affairs
Institute of Medicine
The National Academies
Professor and Chairman
Department of Epidemiology
Johns Hopkins Bloomberg School of Public Health
Subcommittee on Disability Assistance and Memorial Affairs
Committee on Veterans’ Affairs
U.S. House of Representatives
February 26, 2008
Good afternoon Congressman Hall and members of the Subcommittee on Disability Assistance and Memorial Affairs of the House Committee on Veterans’ Affairs. I am pleased to speak with you today about the Institute of Medicine report, Improving the Presumptive Disability Decision-making Process for Veterans. I am Jonathan Samet, the Chair of the committee. I represent my colleagues on the Committee, a multidisciplinary group of 16 people that covered the broad range of expertise needed to take on this important, but very challenging topic. The Subcommittee has access to the report and a copy of the Executive Summary is attached to my testimony.
Our Committee was charged with describing the current process for how presumptive decisions are made for veterans who have health conditions arising from military service and with proposing a scientific framework for making such presumptive decisions in the future. Presumptions are made in order to reach decisions in the face of unavailable or incomplete information. They address the gaps in evidence that introduce uncertainty in decision-making. Presumptions have been made with regard to exposure and causation. In trying to assess whether a particular health problem in veterans can be linked to their exposures in the military, a presumption might be needed because of missing information on exposures of the veterans to the agent of concern or because of uncertainty as to whether the exposure increases risk for the health condition. A presumption might also be made with regard to the link between an exposure and risk for a disease, while the evidence is still uncertain or accumulating as to whether the exposure causes the disease.
Presumptions have long been made; in fact, the first were established in 1921. More recently, a number of presumptions have been made with regard to the consequences of Agent Orange exposure during service in Vietnam and most recently they have been made around the health risks sustained by military personnel in the Persian Gulf War.
To address its charge, the Committee met with the full range of involved stakeholders: past and present staffers from Congress, the Veterans Administration (VA), the Institute of Medicine, veteran’s service organizations, and individual veterans. The Department of Defense (DoD) gave the Committee information about its current activities and its plans to track exposures and health conditions of personnel. The Committee attempted to formally capture how the current approach works and completed a series of case studies to identify “lessons learned” that would be useful in proposing a new approach. The Committee also considered how information is obtained on the health of veterans and how exposures during military service can be linked to any health consequences via scientific investigation. It gave substantial attention to how information can best be synthesized to determine if an exposure is associated with a risk to health and whether the association is causal.
The present approach to presumptive disability decision-making largely flows from the Agent Orange Act of 1991, which started a model for decision-making that is still in place. In that law, Congress asked the VA to contract with an independent organization, —the Institute of Medicine—to review the scientific evidence for Agent Orange. Subsequently, the Institute of Medicine has produced reports on Agent Orange, evaluating whether there is evidence that Agent Orange is associated with various health outcomes. The Institute of Medicine provides its reports to the VA, which then acts through its own internal decision-making process to determine if a presumption is to be made.
The case studies conducted by the Committee probed deeply into this process. The case studies pointed to a number of difficulties that need to be addressed in any future approach:
- Lack of information on exposures received by military personnel and inadequate surveillance of veterans for service-related illnesses.
- Gaps in information because of secrecy.
- Varying approaches to synthesizing evidence on the health consequences of military service.
- In the instance of Agent Orange, classification of evidence for association but not for causation.
- A failure to quantify the effect of the exposure during military service, particularly for diseases with other risk factors and causes.
- A general lack of transparency of the presumptive disability decision-making process.
The Committee discussed in great depth the optimum approach to establishing a scientific foundation for presumptive disability decision-making, including the methods used to determine if exposure to some factor increases risk for disease. This assessment and the findings of the case studies led to recommendations to improve the process:
- As the case studies demonstrated, Congress could provide a clearer and more consistent charge on how much evidence is needed to make a presumption. There should be clarity as to whether the finding of an association in one or more studies is sufficient or the evidence should support causation.
- Due to lack of clarity and consistency in congressional language and VA’s charges to the committees, IOM committees have taken somewhat varying approaches since 1991 in reviewing the scientific evidence, and in forming their opinions on the possibility that exposures during military service contributed to causing a health condition. Future committees could improve their review and classification of scientific evidence if they were given clear and consistent charges and followed uniform evaluation procedures.
- The internal processes by which the VA makes it presumptive decisions following receipt of an IOM report have been unclear. VA should adopt transparent and consistent approaches for making these decisions.
- Adequate exposure data and health condition information for military personnel (both individuals and groups) usually have not been available from DoD in the past. Such information is one of the most critical pieces of evidence for improving the determination of links between exposures and health conditions. Approaches are needed to assure that such information is systematically collected in an ongoing fashion.
All of these improvements are feasible over the longer term and are needed to ensure that the presumptive disability decision-making process for veterans is based on the best possible scientific evidence. Decisions about disability compensation and related benefits (e.g., medical care) for veterans should be based on the best possible documentation and evidence of their military exposures as well as on the best possible information. A fresh approach could do much to improve the current process. The Committee’s recommended approach (see Figure GS-1 below) has several parts:
- an open process for nominating exposures and health conditions for review; involving all stakeholders in this process is critical;
- a revised process for evaluating scientific information on whether a given exposure causes a health condition in veterans; this includes a new set of categories to assess the strength of the evidence for causation, and an estimate of the numbers of exposed veterans whose health condition can be attributed to their military exposure;
- a consistent and transparent decision-making process by VA;
- a system for tracking the exposures of military personnel (including chemical, biological, infectious, physical and psychological stressors), and for monitoring the health conditions of all military personnel while in service and after separation; and
- an organizational structure to support this process.
To support the Committee’s recommendations, we suggest the creation of two panels. One is an Advisory Committee (advisory to VA), that would assemble, consider and give priority to the exposures and health conditions proposed for possible presumptive evaluation. Nominations for presumptions could come from veterans and other stakeholders as well as from health tracking, surveillance and research. The second panel would be a Science Review Board, an independent body, which would evaluate the strength of the evidence (based on causation) which links a health condition to a military exposure and then estimates the fraction of exposed veterans whose health condition could be attributed to their military exposure. The Science Review Board’s report and recommendations would go to the VA for its consideration. The VA would use explicit criteria to render a decision by the VA Secretary with regard to whether a presumption would be established. In addition, the Science Review Board would monitor information on the health of veterans as it accumulates over time in the DoD and VA tracking systems, and nominate new exposures or health conditions for evaluation as appropriate.
This Committee recommends that the following principles be adopted in establishing this new approach:
- Stakeholder inclusiveness
- Evidence-based decisions
- Transparent process
- Causation, not just association, as the target for decision making.
The last principle needs further discussion, as it departs from the current approach. In proposing causation as the target, the Committee had concern that the approach of relying on association, particularly if based on findings of one study, could lead to “false-positive” presumptions. The Committee calls for a broad interpretation of evidence to judge whether a factor causes a disease in order to assure that relevant findings from laboratory studies are adequately considered. The Committee also recommends that benefits be considered when there is at least a 50% likelihood of a causal relationship, and does not call for full certainty on the part of the Science Review Board.
The Committee suggests that its framework be considered as the model to guide the evolution of the current approach. While some aspects of the approach may appear challenging or infeasible at present, feasibility would be improved by the provision of appropriate resources to all of the participants in the presumptive disability decision-making process for veterans and future methodological developments. Veterans deserve to have these improvements accomplished as soon as possible.
The Committee recognized that action by Congress will be needed to implement its proposed approach. Legislation to create the two panels is needed and Congress should also act to assure that needed resources are available to create and sustain exposure and health tracking for service personnel and veterans. Many of the changes proposed by the Committee could be implemented now, even as steps are taken to move the DoD and VA towards implementing the model recommended. Veterans deserve to have an improved system as soon as possible.
Thank you for the opportunity to testify. I would be happy to address any questions the Subcommittee might have.
FIGURE GS-1 (IOM 2007) Proposed Framework for Future Presumptive Disability Decision-Making Process for Veterans.
a Includes research for classified or secret activities, exposures, etc.
b Includes veterans, Veterans Service Organizations, federal agencies, scientists, general public, etc.
c This committee screens stakeholders’ proposals and research in support of evaluating evidence for presumptions and makes recommendations to the VA Secretary when full evidence review or additional research is appropriate.
d The board conducts a two-step evidence review process (see report text for further further detail).
e Final presumptive disability compensation decisions are made by the Secretary, Department of Veterans Affairs, unless legislated by Congress.
Jonathan M. Samet, M.D., M.S. is a professor and the Chair of the Department of Epidemiology of The Johns Hopkins University’s Bloomberg School of Public Health. Dr. Samet also has joint Johns Hopkins’ appointments in the Department of Medicine and the Oncology Center, and serves as the Director of the Institute for Global Tobacco Control and as the Co-Director for the Risk Sciences and Public Policy Institute. Before coming to Johns Hopkins, he was Professor and Chief of the Pulmonary and Critical Care Division in the Department of Medicine of the University of New Mexico School of Medicine. His research has emphasized the assessment of health effects of environmental pollutants using epidemiological approaches. His work addressing indoor and outdoor air pollution and occupational exposures, including asbestos and radon, has made use of risk assessment methods as a tool for translation of scientific findings into policy. Dr. Samet received his M.D. from the University of Rochester’s School of Medicine and Dentistry and his M.S. from the Harvard School of Public Health. He interned at the University of Kentucky Medical Center and then served in the U.S Army as an anesthesiologist at Gorgas Hospital (Balboa Heights, Canal Zone) from 1971–1973. Following his military service, Dr. Samet completed his internal medicine residency in Medicine at the University of New Mexico and then a research and clinical fellowship at Harvard Medical School’s Channing Laboratory. He is board certified in internal medicine and the subspecialty of pulmonary medicine. Dr. Samet was elected to the Institute of Medicine in 1997 (Section 9) and has served as a member and Chair of numerous committees for The National Academies. He currently chairs the Board on Environmental Studies and Toxicology. In addition, he is a member of the Committee on Science, Technology and Law.