U.S. Department of Defense Disability Compensation Under a Fitness-for-Duty Evaluation Approach.

The joint U.S. Department of Defense (DoD) - Department of Veterans Affairs (VA) Integrated Disability Evaluation System is the process by which DoD determines fitness for duty and separation or retirement of service members because of disability. Service members who are evaluated for disability undergo a comprehensive medical examination to document all medical conditions and receive a disability rating for every condition documented during the exam. DoD and the VA use these ratings to determine the amount of disability compensation service members receive if they are determined to be unfit to continue serving and consequently medically discharged. Proposals for reforming the DoD compensation system have been considered in the past, but a rigorous evaluation of what those alternatives might look like and how they would affect service member benefits and costs to DoD has not been conducted. In this article, the authors describe their evaluation of four hypothetical alternative disability compensation approaches that would support a simpler disability evaluation process: compensating based on the current objectives of the DoD system (and using current benefit formulas), compensating on the basis of a military career, compensating on the basis of unfitting conditions, or compensating similar to U.S. allies. Each alternative reduces reliance on disability ratings for determining DoD disability compensation and focuses primarily on a single decision about whether a service member is fit to perform his or her duties. The authors evaluate the potential effects of each alternative on service member compensation, processing times, end strength, lost skills and experience, and readiness.

Readiness of Soldiers and Adult Family Members Who Receive Behavioral Health Care: Identifying Promising Outcome Metrics.

Behavioral health (BH) conditions-such as posttraumatic stress disorder, depression, and anxiety-are the second most common medical reasons for nondeployability in the U.S. Army. The authors of this report aimed to identify promising metrics to assess readiness among soldiers and adult family members who receive BH care. These metrics would expand the Army's outcome monitoring, which currently includes symptom improvement metrics, for patients who received BH care. The authors developed rigorous criteria to evaluate candidate readiness metrics, conducted interviews with stakeholders (Army subject-matter experts and BH providers), reviewed existing sources of data that could support the development of a readiness metric, and conducted a literature review to identify instruments that have been used to measure readiness-related domains in both military and civilian populations. The authors found that no existing data source or patient self-report instrument met criteria for implementation of a readiness metric for soldiers, but one instrument, the Walter Reed Functional Impairment Scale (WRFIS), is promising. No existing data source or patient self-report instrument met criteria for Army-wide implementation of a readiness metric for adult family members. Stakeholders reported that psychiatric symptoms, diagnosis, treatment, and impaired functioning are important indicators of lack of readiness among soldiers and adult family members. BH providers reported variability in assessing readiness and applying profiles, but behavioral experts provided suggestions for improving readiness assessment. The authors recommend that the Army conduct a pilot evaluation of a soldier readiness metric based on the WRFIS and increase standardization in applying profiles by continuing provider training.

Evolution of Department of Defense Disability Evaluation and Management of Posttraumatic Stress Disorder and Traumatic Brain Injury: Overview of Policy Changes, 2001-2018.

For almost two decades, the United States has been engaged in continuous combat operations in Iraq, Afghanistan, and other theaters. Some service members have sustained injuries or developed medical conditions as a consequence of military service that affect their ability to perform their military duties. The process by which the U.S. Department of Defense (DoD) evaluates service members and determines whether they should be medically discharged has changed considerably since 2001. In particular, beginning in 2007, major changes to the Disability Evaluation System (DES) were implemented in response to concern about inefficiencies and confusion resulting from the practice of having DoD and the U.S. Department of Veterans Affairs (VA) conduct separate evaluations according to different criteria, thus producing different disability determinations. In 2008, DoD launched a pilot program to streamline the disability evaluation process, with VA conducting medical exams to be used by both DoD and VA. This system, the Integrated Disability Evaluation System (IDES), was formally adopted military-wide in 2011. Changes to DES also reflected changes in understanding of traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD), the signature injuries of the Iraq and Afghanistan wars. The authors review changes to disability evaluation policy and changes in the diagnosis and treatment of PTSD and TBI since 2001.

Trends in Department of Defense Disability Evaluation System Ratings and Awards for Posttraumatic Stress Disorder and Traumatic Brain Injury, 2002-2017.

Since 2001, more than 3 million service members have deployed in support of multiple combat operations in Afghanistan, Iraq, and other theaters. Many have been diagnosed with the ""signature wounds"" of these conflicts: posttraumatic stress disorder (PTSD) and/or traumatic brain injury (TBI). During the intervening years, the process by which service members are evaluated for disability has evolved significantly, including a complete overhaul of the Disability Evaluation System (DES) beginning in 2007. Meanwhile, the Department of Defense (DoD) and the services made policy changes and initiated other efforts to improve screening for PTSD and TBI, encourage service members to seek treatment, improve quality of care, and reduce the stigma associated with treatment for these conditions. To explore these changes, as well as their potential effects on the numbers and characteristics of service members who are evaluated through DES, the authors identify and assess trends in DES outcomes for PTSD and TBI between 2002 and 2017.

Understanding Treatment of Mild Traumatic Brain Injury in the Military Health System.

Traumatic brain injury (TBI) is considered a signature injury of modern warfare, though TBIs can also result from training accidents, falls, sports, and motor vehicle accidents. Among service members diagnosed with a TBI, the majority of cases are mild TBIs (mTBIs), also known as concussions. Many of these service members receive care through the Military Health System, but the amount, type, and quality of care they receive has been largely unknown. A RAND study, the first to examine the mTBI care of a census of patients in the Military Health System, assessed the number and characteristics (including deployment history and history of TBI) of nondeployed, active-duty service members who received an mTBI diagnosis in 2012, the locations of their diagnoses and next health care visits, the types of care they received in the six months following their mTBI diagnosis, co-occurring conditions, and the duration of their treatment. While the majority of service members with mTBI recover quickly, the study further examined a subset of service members with mTBI who received care for longer than three months following their diagnosis. Diagnosing and treating mTBI can be especially challenging because of variations in symptoms and other factors. The research revealed inconsistencies in the diagnostic coding, as well as areas for improvement in coordinating care across providers and care settings. The results and recommendations provide a foundation to guide future clinical studies to improve the quality of care and subsequent outcomes for service members diagnosed with mTBI.

Current and Projected Characteristics and Unique Health Care Needs of the Patient Population Served by the Department of Veterans Affairs.

The Veterans Access, Choice, and Accountability Act of 2014 addressed the need for access to timely, high-quality health care for veterans. Section 201 of the legislation called for an independent assessment of various aspects of veterans' health care. The RAND Corporation was tasked with an assessment of the current and projected demographics and health care needs of patients served by the Department of Veterans Affairs (VA). The number of U.S. veterans will continue to decline over the next decade, and the demographic mix and geographic locations of these veterans will change. While the number of veterans using VA health care has increased over time, demand will level off in the coming years. Veterans have more favorable economic circumstances than non-veterans, but they are also older and more likely to be diagnosed with many health conditions. Not all veterans are eligible for or use VA health care. Whether and to what extent an eligible veteran uses VA health care depends on a number of factors, including access to other sources of health care. Veterans who rely on VA health care are older and less healthy than veterans who do not, and the prevalence of costly conditions in this population is projected to increase. Potential changes to VA policy and the context for VA health care, including effects of the Affordable Care Act, could affect demand. Analysis of a range of data sources provided insight into how the veteran population is likely to change in the next decade.

Quality of Care for PTSD and Depression in the Military Health System: Phase I Report.

The U.S. Department of Defense (DoD) strives to maintain a physically and psychologically healthy, mission-ready force, and the care provided by the Military Health System (MHS) is critical to meeting this goal. Given the rates of posttraumatic stress disorder (PTSD) and depression among U.S. service members, attention has been directed to ensuring the quality and availability of programs and services targeting these and other psychological health (PH) conditions. Understanding the current quality of care for PTSD and depression is an important step toward improving care across the MHS. To help determine whether service members with PTSD or depression are receiving evidence-based care and whether there are disparities in care quality by branch of service, geographic region, and service member characteristics (e.g., gender, age, pay grade, race/ethnicity, deployment history), DoD's Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE) asked the RAND Corporation to conduct a review of the administrative data of service members diagnosed with PTSD or depression and to recommend areas on which the MHS could focus its efforts to continuously improve the quality of care provided to all service members. This study characterizes care for service members seen by MHS for diagnoses of PTSD and/or depression and finds that while the MHS performs well in ensuring outpatient follow-up following psychiatric hospitalization, providing sufficient psychotherapy and medication management needs to be improved. Further, quality of care for PTSD and depression varied by service branch, TRICARE region, and service member characteristics, suggesting the need to ensure that all service members receive high-quality care.

Health and Economic Outcomes in the Alumni of the Wounded Warrior Project: 2010-2012.

The Wounded Warrior Project (WWP) has developed programs to help care for injured service members and veterans. In order to assess the mental, physical, and economic health of its member population, as well as to gain an understanding of WWP participation, WWP is engaged in a five-year survey effort. The RAND Corporation was asked to analyze the first three survey waves in order to take a more in-depth look at survey responses to explore whether outcomes differ across various subsets of WWP's database of members and, where possible, compare the experiences and outcomes of alumni with those of other ill and injured populations. This study describes specifically how WWP alumni who responded to the surveys are faring in domains related to mental health and resiliency, physical health, and employment and finances. The study finds that WWP goals are being met across a wide range of outcomes of interest but that individuals who have never been married, who are male, who are employed, and who are in higher ranks enjoy better mental health outcomes. On the other hand, women and those in junior ranks report more favorably on their physical health. Finally, married respondents and officers are more likely to have higher levels of education, be employed, and own homes. These outcomes enable WWP to target its programming and messaging to the alumni in need of support in these areas.

Health and Economic Outcomes Among the Alumni of the Wounded Warrior Project: 2013.

The Wounded Warrior Project (WWP) offers support and raises public awareness of service members who have experienced physical or mental health conditions associated with their service on or after September 11, 2001. In this study, the authors use WWP's 2013 survey of its members (alumni) to understand the physical, mental, and economic challenges that Wounded Warriors face. The researchers find that at least half of alumni reported dealing with mental health conditions such as depression and posttraumatic stress disorder, and many of these alumni reported difficulties or delays in seeking mental health care, or not doing so at all. Alcohol misuse also poses a problem. A large proportion of alumni are overweight or obese, conditions that negatively affect their daily lives, exercise routines, and overall health. Almost half of alumni are not working, and there is low participation in veteran-specific employment and education programs. This information can be used to better understand the needs of WWP alumni and the ways that WWP can serve and support this constituency.

Improving Joint Expeditionary Medical Planning Tools Based on a Patient Flow Approach.

The U.S. military's current concept of operations for expeditionary medical care emphasizes quickly moving patients to a series of successively more sophisticated medical facilities that provide the patients with the care necessary to treat their injury or condition. Balancing the deployment of treatment and evacuation resources is therefore necessary to ensure that the right mix of resources is available in a timely fashion. The authors propose a planning concept that, by promoting patient flow rate as the common unit of measurement, will help integrate medical planning across treatment and evacuation functions, across the increasing levels of care, and across the different military services. The primary medical planning tool approved for use by combatant commands for developing their operational plans-the Joint Medical Analysis Tool (JMAT)-already operates in a manner consistent with this concept. However, modifications and enhancements to JMAT are necessary to ensure that the concept can be fully implemented.

Health and Economic Outcomes in the Alumni of the Wounded Warrior Project.

Since 2002, the not-for-profit Wounded Warrior Project (WWP) has sought to offer support for and raise public awareness of those injured during service on or after September 11, 2001. WWP gives members (alumni) access to programs that ensure that wounded warriors are well-adjusted in mind, spirit, and body and that they are economically empowered. Here the authors report a detailed analysis of how individuals with different marital statuses, genders, pay grades, and employment statuses were meeting these goals and how outcomes of its alumni compared with the outcomes of other veteran and nonveteran U.S. POPULATIONS: The organization's decisionmakers can use the information from this report to determine the degree to which strategic objectives are met for each subgroup and to set new goals and the means by which the organization and its alumni and may reach those goals.