ANCILLARY BENEFITS AND QUALITY OF LIFE
Lonnie Bristow, M.D.
Committee on Medical Evaluation of Veterans for Disability Compensation
Board on Military and Veterans Health
Institute of Medicine
The National Academies
Subcommittee on Disability Assistance & Memorial Affairs
Committee on Veterans’ Affairs
U.S. House of Representatives
July 23, 2009
Good morning, Chairman Hall, Ranking Member Lamborn, and members of the Committee. My name is Lonnie Bristow. I am a physician and a Navy veteran. I am a member of the Institute of Medicine and have served as the president of the American Medical Association. I am pleased to appear before you again to testify about improving the disability benefits system of the Department of Veterans Affairs (VA).
I had the great pleasure and honor of chairing the Institute of Medicine (IOM) Committee on Medical Evaluation of Veterans for Disability Compensation, which was established at the request of the Veterans’ Disability Benefits Commission and funded by the Department of Veterans Affairs. The IOM was established in 1970 under the charter of the National Academy of Sciences to provide independent, objective advice to the nation on improving health.
The Committee I chaired, which reported in 2007, was asked to evaluate the VA Schedule for Rating Disabilities and related matters, including the medical criteria for ancillary benefits. My task today is to present to you the Committee’s recommendations on improving ancillary benefits, which are in Chapter 6 of our report, A 21st Century System for Evaluating Veterans for Disability Benefits. I will also comment on our recommendation concerning quality of life, which is in Chapter 4 of the report.
Medical Criteria for Ancillary Benefits
The Veterans’ Disability Benefits Commission asked the Committee to focus on the appropriateness of medical criteria for five specific ancillary benefits available to veterans being compensated for service-connected disabilities. These were:
- Vocational rehabilitation and employment (VR&E) services,
- Automobile assistance and adaptive equipment,
- Specially adapted housing grants,
- Special housing adaptation grants, and
- Clothing allowances.
The Committee was asked to consider, from a medical viewpoint, the appropriateness of the specific conditions that a veteran is required to have in order to receive these ancillary benefits. For example, assistance in purchasing a specially adapted automobile or other vehicle requires
- loss, or permanent loss of use, of one or both feet; or
- loss, or permanent loss of use, of one or both hands; or
- permanent impairment of vision in both eyes with a central visual acuity of 20/20 or less in the better eye with corrective glasses, or central visual acuity of more that 20/200 if there is a field defect in which the peripheral field has contracted to such an extent that the widest diameter of visual field has an angular distance no greater than 20 degrees in the better eye.
To qualify for assistance in purchasing a specially modified home, a veteran must have a permanent and total service-connected condition or conditions due to
- the loss or loss of use of both lower extremities, such as to preclude locomotion without the aid of braces, crutches, canes, or a wheelchair; or
- the loss or loss of use of both upper extremities, such as to preclude use of the arms at or above the elbows; or
- blindness in both eyes, having only light perception, plus loss or loss of use of one lower extremity, or
- the loss or loss of use of one lower extremity together with residuals of organic disease or injury, or the loss or loss of use of one upper extremity, which affects the functions of balance or propulsion as to preclude locomotion without the aid of braces, crutches, canes, or a wheelchair.
These medical eligibility criteria are very specific and require a very high degree of impairment. They are so specific that they may not include veterans with somewhat different impairments that hinder mobility, such as multiple sclerosis.
Assessing Ancillary Benefit Criteria
When the Committee reviewed ancillary benefits, we found that they were
- created piecemeal over time.
- not designed as part of a comprehensive program.
- not systematically updated and, in some cases, not indexed for inflation.
- not based on an empirical analysis of veterans’ actual needs or loss of quality of life.
- not evaluated for their effectiveness in meeting veterans’ needs or loss of quality of life (except for VR&E).
In 2004, a VA-appointed task force on VR&E recommended that VA coordinate its health, VR&E, and compensation programs to achieve a broader, more integrated approach to assisting veterans move from military to civilian life. The task force suggested a more individualized approach including
- continuing and systematic medical examinations of veterans for better informed career and employment decisions;
- early, routine functional capacity assessments by vocational experts for both disability compensation and rehabilitation decisions; and
- a change from a sequential series of required steps to a more individualized sequence taking into consideration the veteran’s education, vocational rehabilitation, and compensation needs.
The Committee agreed with these recommendations—and the veteran-centered concept of service delivery underlying them—and added some recommendations of its own.
IOM Recommendations for Improving Ancillary Benefits
The Committee offered four recommendations for improving ancillary benefits.
- The lack of data on the need for or effectiveness of ancillary benefits made it impossible for the Committee to assess the appropriateness of the medical criteria requirements. The eligibility requirements were not based on research relating needs to rating level or type of impairment, so it is possible that the benefits could be changed to serve veterans better or to address other needs. Accordingly, we recommended that “VA should sponsor research on ancillary benefits and obtain input from veterans about their needs. Such research could include conducting intervention trials to determine the effectiveness of ancillary services in terms of increased functional capacity and enhanced health-related quality of life.”
- In addition to obtaining data on the mitigating effects of each type of benefit on functional limitations, work disability, and quality of life, a better approach to assessing the needs of individual veterans is needed. The Committee concluded that “An assessment of health-care and rehabilitation needs should be performed in conjunction with the assessment of compensation needs, so that the veteran will benefit from all services VA provides to help veterans with disabilities succeed in civilian life…The assessment should also include the need for education, vocational rehabilitation, and other VA ancillary services and benefits, which, together, could enhance a veteran’s ability to succeed in civilian life.” Specifically, we recommended that “VA and the Department of Defense should conduct a comprehensive multidisciplinary medical, psychosocial, and vocational evaluation of each veteran applying for disability compensation at the time of service separation.”
- There is no medical basis for the current 12-year limit on eligibility for vocational rehabilitation services, although there may be administrative convenience or fiscal control reasons. Some employment and training needs may not adhere to a 12-year deadline. For example, emerging assistive and workplace technologies (e.g., computing) may provide training or retraining opportunities for veterans with disabilities through continuing education of various kinds. New types of work may also emerge for which veterans with disabilities could be trained. Advancements in medical knowledge and breakthroughs in medical technology also do not abide by a 12-year limit. The Committee recommended that “The concept underlying the extant 12-year limitation for vocational rehabilitation for service-connected veterans should be reviewed and, when appropriate, revised on the basis of current employment data, functional requirements, and individual vocational rehabilitation and medical needs.”
- Finally, the Committee was concerned about low rate of participation in the VR&E program. For example, in FY 2005, about 40,000 veterans applied for VR&E services and were accepted. But 160,000 veterans began receiving benefits for service-connected disabilities that year, and the pool of those potentially eligible from prior years is much larger. Also, in recent years, between a quarter and a third of the participants had not completed the program. We concluded that VA should explore ways to increase participation in this program, and we recommended that “VA should develop and test incentive models that would promote vocational rehabilitation and return to gainful employment among veterans for whom this is a realistic goal.”
IOM Recommendation on Compensating for Loss of Quality of Life
The Committee did not view the ancillary benefits that it was asked to review as a form of compensation for loss of quality of life. We considered them as services to improve functional mobility and employability.
Rather than consider if and to what degree that benefits such as adapted housing and automobiles, or Special Monthly Compensation, help to compensate for loss of quality of life, the Committee recommended that quality of life be measured directly. Then, if it is found that veterans experience an average loss of quality of life for a given disability that exceeds the average loss of earning capacity as measured by the Rating Schedule, we recommended that VA compensate for the additional loss.
We noted that VA already uses a quality of life measurement tool, the SF-36, in research on clinical outcomes. We cited a quality-of-life methodology used on injured workers in Ontario, Canada, that found that impairment ratings systematically underpredicted the loss of quality of life that workers associated with certain disabilities. We said some additional work would have to be done by VA to adapt the SF-36 or Canadian or possibly some other quality of life tool for veterans’ compensation purposes. If such a tool could be developed, and we believe that it could be, VA could use it to determine average quality of life of veterans with different disabilities, relative to nondisabled veterans. If it turns out that veterans experience a serious loss of quality of life for a condition that is not highly rated by the Rating Schedule, then VA should compensate for the disparity.
In summary, the main points of our report A 21st Century System for Evaluating Veterans for Disability Benefits concerning ancillary benefits and quality of life are:
- VA should more systematically research the needs of disabled veterans and the effectiveness of its ancillary benefit programs in meeting these needs and make needed revisions in these programs based on this research.
- VA should assess the individual needs of disabled veterans at time of separation from military service and coordinate the delivery of the services identified in the assessment.
- VA should develop a tool to measure the quality of life of disabled veterans, determine the extent to which the Rating Schedule already accounts for loss of quality of life, and—for disabling conditions in which average loss of quality of life is worse than the Rating Schedule indicates—compensate for the difference.
An archived webcast of the hearing can be found on the House Veterans' Affairs Committee's Web site.