Consideration of substance use in compensation and pension examinations of veterans filing PTSD claims.

Veterans filing claims that service-induced PTSD impairs them worry that claims examiners may attribute their difficulties to conditions other than PTSD, such as substance use. Substance use commonly co-occurs with PTSD and complicates establishing a PTSD diagnosis because symptoms may be explained by PTSD alone, PTSD-induced substance use, or by a substance use condition independent of PTSD. These alternative explanations of symptoms lead to different conclusions about whether a PTSD diagnosis can be made. How substance use impacts an examiner's diagnosis of PTSD in a Veteran's service-connection claim has not been previously studied. In this study, we tested the hypothesis that mention of risky substance use in the Compensation & Pension (C&P) examination would result in a lower likelihood of service-connection award, presumably because substance use reflected an alternative explanation for symptoms. Data were analyzed from 208 Veterans' C&P examinations, medical records, and confidentially-collected research assessments. In this sample, 165/208 (79%) Veterans' claims were approved for a mental health condition; 70/83 (84%) with risky substance use mentioned and 95/125 (76%) without risky use mentioned (p = .02). Contrary to the a priori hypothesis, Veterans with risky substance use were more likely to get a service-connection award, even after controlling for baseline PTSD severity and other potential confounds. They had almost twice the odds of receiving any mental health award and 2.4 times greater odds of receiving an award for PTSD specifically. These data contradict assertions of bias against Veterans with risky substance use when their claims are reviewed. The data are more consistent with substance use often being judged as a symptom of PTSD. The more liberal granting of awards is consistent with literature concerning comorbid PTSD and substance use, and with claims procedures that make it more likely that substance use will be attributed to trauma exposure than to other causes.

Cost of malingering mild traumatic brain injury-related cognitive deficits during compensation and pension evaluations in the veterans benefits administration.

Given the high rates of exaggeration in those claiming long-term cognitive deficits as a result of mild traumatic brain injury (mTBI), the aim of this study was to evaluate the rates of malingering in those seeking disability through the Veterans Benefits Administration and estimate the financial burden of disability payments for those receiving compensation despite exaggerated mTBI-related cognitive deficits. Retrospective review included 74 veterans seen for Compensation and Pension evaluations for mTBI. Rates of malingering were based on failure of the Medical Symptom Validity Test (MSVT) and/or the Test of Memory Malingering (TOMM) trial 1 ≤ 40. Total estimated compensation was based on the level of disability awarded and the number of individuals found to be malingering cognitive deficits. Overall, 33-52% of the sample was found to be malingering mTBI-related cognitive deficits. The malingering groups were receiving approximately $71,000-$121,000/year ($6,390-$7,063 per year, per veteran on average). Estimated nationwide disability payments for those possibly malingering mTBI-related cognitive deficits would be $136-$235 million/year (projected costs from 2015-2020 = $700 million-$1.2 billion). It is critical that providers and administrative officials identify those exaggerating disability claims attributed to mTBI. The cost of malingering impacts society in general as well as veterans themselves, as it diverts needed funds/resources away from those legitimately impaired by their military service.

VA Disability Compensation and Money Spent on Substance Use Among Homeless Veterans: A Controversial Association.

OBJECTIVE: There has long been concern that public support payments are used to support addictive behaviors. This study examined the amount of money homeless veterans spend on alcohol and drugs and the association between public support income, including VA disability compensation, and expenditures on alcohol and drugs. METHODS: Data were from 1,160 veterans from 19 sites on entry into the Housing and Urban Development-Veterans Affairs Supportive Housing program. Descriptive statistics and nonparametric analyses were conducted. RESULTS: About 33% of veterans reported spending money on alcohol and 22% reported spending money on drugs in the past month. No significant association was found between public support income, VA disability compensation, and money spent on alcohol and drugs. CONCLUSIONS: A substantial proportion of homeless veterans spend some income on alcohol and drugs, but disability income, including VA compensation, does not seem to be related to substance use or money spent on addictive substances.

Using the Army Medical Cost Avoidance Model to prioritize preventive medicine initiatives.

The MCAM's ICD-9 Analysis Tool provides preventive medicine program developers with a powerful tool to demonstrate ROI. Previously disjointed cost components have been brought together in the MCAM to calculate the total medical cost avoided. Users are required to make 4 data entries. In response, the user receives the highly coveted medical cost avoidance that should be realized. The SPHMP example demonstrates how simple it is to use the MCAM to determine the expected ROI.

Compensation and treatment: disability benefits and outcomes of U.S. veterans receiving residential PTSD treatment.

The U.S. Department of Veterans Affairs (VA) provides specialized intensive posttraumatic stress disorder (PTSD) programs to treat trauma-related symptoms in addition to providing service-connected disability to compensate veterans for injury sustained while serving in the military. Given the percentage of veterans who are receiving treatment for PTSD, in addition to seeking compensation for PTSD, a debate has emerged about the impact of compensation on symptom recovery. This study examined the associations among status of compensation, treatment expectations, military cohort, length of stay, and outcomes for 776 veterans who were enrolled in 5 VA residential PTSD programs between the years of 2005 and 2010. Mixed model longitudinal analyses, with age, gender, and baseline symptoms nested within treatment site in the model, found that treatment expectations were modestly predictive of treatment outcomes. Veterans seeking increased compensation reported marginally lower treatment expectations (d = .008), and did not experience poorer outcomes compared to veterans not seeking increased compensation with the effect of baseline symptoms partialled out. Veterans from the era of the Iraq and Afghanistan conflicts reported lower treatment expectations (d = .020) and slightly higher symptoms at intake (d = .021), but had outcomes at discharge equivalent to veterans from other eras with baseline symptoms partialled out. These findings help further inform the debate concerning disability benefits and symptom changes across time.

A qualitative study of U.S. veterans' reasons for seeking Department of Veterans Affairs disability benefits for posttraumatic stress disorder.

Posttraumatic stress disorder (PTSD) is the most prevalent compensable mental disorder within the U.S. Department of Veterans Affairs disability system and the number of veterans with PTSD service-connected disability has increased steadily over the past decade. An understanding of the reasons veterans apply for PTSD disability status may inform interpretation of this increase and policies and interventions to assist veterans with military-related PTSD. The authors conducted an exploratory qualitative study to describe the reasons veterans seek PTSD disability benefits and explored differences between those who served in different military service eras. They gathered data through in-depth interviews with 44 purposefully selected U.S. veterans, and conducted content analysis of transcribed interviews using inductive and deductive analysis with constant comparison. Participants described 5 interrelated categories of reasons for seeking PTSD disability benefits, including 3 internal factors (tangible need, need for problem identification or clarification, beliefs that justify/legitimize PTSD disability status) and 2 external factors (encouragement from trusted others and professional assistance). There were no major differences by service era. Findings may help policy makers, providers, and researchers understand what veterans hope to achieve through PTSD disability and the instrumental role of social networks and government systems in promoting the pursuit of PTSD disability status.

Federal policy and the rise in disability enrollment: evidence for the Veterans Affairs' Disability Compensation Program.

The U.S. Department of Veterans Affairs compensates 13 percent of the nation's military veterans for service­related disabilities through the Disability Compensation (DC) program. In 2001, a legislative change made it easier for Vietnam veterans to receive benefits for diabetes associated with military service. In this paper, we investigate this policy's effect on DC enrollment and expenditures as well as the behavioral response of potential beneficiaries. Our findings demonstrate that the policy increased DC enrollment by 6 percentage points among Vietnam veterans and that an additional 1.7 percent experienced an increase in their DC benefits, which increased annual program expenditures by $2.85 billion in 2007. Using individual-level data from the Veterans Supplement to the Current Population Survey, we find that the induced increase in DC enrollment had little average impact on the labor supply or health status of Vietnam veterans but did reduce labor supply among their spouses.

"Willful misconduct": how the US government prevented tobacco-disabled veterans from obtaining disability pensions.

In this descriptive case study, we analyze the unsuccessful struggle to access disability pensions by veterans sickened by tobacco use begun during service. Drawing on tobacco industry documents and other material, we show how the US government, tobacco industry, and veterans' organizations each took inconsistent positions to protect their interests. Congress and Department of Veterans Affairs leadership, concerned about costs, characterized veterans' smoking as "willful misconduct," thereby contradicting the government's position in a federal lawsuit that tobacco companies addicted smokers. Veterans' groups supported the pensions, despite previously defending smoking as a "right." The tobacco industry wavered, fearing liability. Securing pensions was complicated by the notion that smoking is primarily a personal choice. The US government should compensate veterans fairly and should abolish military practices that encourage tobacco addiction.

The use of epidemiological evidence in the compensation of veterans.

Men and women serving in the U.S. military are exposed to diverse agents that may affect their health, causing injury and disease while they are in the service or after discharge. This case study addresses the compensation of veterans for injury and illnesses arising from exposures received during military service and focuses on the presumptions that are made around compensation of veterans for conditions arising after their service. Presumptions are made because of evidence gaps related to exposure and causation. The current process for evidence review related to causation involves Institute of Medicine (IOM) committees that evaluate evidence relevant to association. The Veterans Administration uses the IOM reports in making presumptions. A new approach was recommended by an IOM committee: a transparent, evidence-based approach that would lead to decisions by means of an explicit process. The Committee set out six principles as a foundation for its framework: stakeholder inclusiveness, evidence-based decisions, transparent process, flexibility, consistency, and the use of causation, not just association, as the basis for decision making. The committee also called for needed tracking of exposure and associated health outcomes during and after military service. This case study covers "lessons learned" around evidence synthesis, causal inferences, and decision-making.

Modeling the Unites States government's economic cost of noise-induced hearing loss for a military population.

OBJECTIVE: The purpose of this paper is to demonstrate the feasibility and utility of developing economic cost models for noise-induced hearing loss (NIHL). First, we outline an economic model of NIHL for a population of US Navy sailors with an "industrial"-type noise exposure. Next, we describe the effect on NIHL-related cost of varying the two central model inputs--the noise-exposure level and the duration of exposure. Such an analysis can help prioritize promising areas, to which limited resources to reduce NIHL-related costs should be devoted. METHODS: NIHL-related costs borne by the US government were computed on a yearly basis using a finite element approach that took into account varying levels of susceptibility to NIHL. Predicted hearing thresholds for the population were computed with ANSI S3.44-1996 and then used as the basis for the calculation of NIHL-related costs. Annual and cumulative costs were tracked. Noise-exposure level and duration were systematically varied to determine their effects on the expected lifetime NIHL-related cost of a specific US Navy sailor population. RESULTS: Our nominal noise-exposure case [93 dB(A) for six years] yielded a total expected lifetime cost of US $13,472 per sailor, with plausible lower and upper bounds of US $2,500 and US $26,000. Starting with the nominal case, a decrease of 50% in exposure level or duration would yield cost savings of approximately 23% and 19%, respectively. We concluded that a reduction in noise level would be more somewhat more cost-effective than the same percentage reduction in years of exposure. CONCLUSION: Our economic cost model can be used to estimate the changes in NIHL-related costs that would result from changes in noise-exposure level and/or duration for a single military population. Although the model is limited at present, suggestions are provided for adapting it to civilian populations.

The army health hazard assessment program's medical cost-avoidance model.

BACKGROUND: The Logistics Management Institute initially developed a medical cost-avoidance model (MCAM) to estimate the costs associated with the failure to eliminate or control health hazards of army materiel systems during 1997. METHODS: Presented is an updated version of the MCAM that uses cost factors for individual health hazard categories. The earlier MCAM calculated army materiel acquisition-life cycle medical costs based on a single cost factor for all hazard categories. RESULTS: The Army's Health Hazard Assessment (HHA) Program, which uses the MCAM while assessing 18 types of health hazards commonly found in materiel undergoing the acquisition process, recognized the need to refine the MCAM to be hazard-type specific. These hazard types have unique cost factors and serve as the basis for the revised model. CONCLUSIONS: The revision will assist the HHA program in targeting health hazards that have the potential to affect soldier health and readiness.

Equity in Veterans Affairs disability claims adjudication in a national sample of veterans.

OBJECTIVES: To address potential equity concerns about the U.S. Department of Veterans Affairs' (VA) process for adjudicating military service-related disability claims. METHODS: Participants were a nationally representative sample of 20,048 veterans completing the 2001 National Survey of Veterans. Sociodemographic, access, and illness correlates of both the award and rate of general disability benefits awarded by the VA were examined using an established theoretical framework. RESULTS: Sociodemographic, access, and illness variables were associated with both the award ("yes/no") and rate of benefits (0-100%) awarded, with combat exposure, unemployment, and physical impairment accounting for the strongest model effects. CONCLUSIONS: Veterans' needs were not overshadowed by factors related to demographic background or access (e.g., race, gender, insurance), reducing concerns about disparities in general VA disability disbursements. These data are timely as disability claims/payments will likely increase dramatically in the near future because of current conflicts in the Middle East.

Impact of public support payments, intensive psychiatric community care, and program fidelity on employment outcomes for people with severe mental illness.

This study explored the relationship of public support payments, intensive psychiatric community care (IPCC), and fidelity of implementation to 1-year employment outcomes for 520 veterans with severe mental illness (SMI) in a clinical trial of IPCC. At study entry, 455 (87.5%) participants received public support. At 1 year, 46 (8.8%) participants met criteria to be classified as workers. A multivariate analysis indicated that baseline public support was significantly associated with a lower likelihood of employment, and baseline work was positively associated with employment at 1 year. IPCC patients were three times more likely to be working than control subjects, and a significant interaction favored well-implemented IPCC programs over others. This study points out not only the inhibiting effect of public support payment on employment but also the value of IPCC and the special importance of fidelity to program models for employment for people with SMI.

Effects of compensation-seeking on treatment outcomes among veterans with posttraumatic stress disorder.

The desire to acquire or increase financial compensation for a psychiatric disability is widely believed to introduce a response bias into patients' reports of their symptoms and their work performance. The hypothesized effects of compensation-seeking in inhibiting improvement from treatment are examined. Data from outpatient (N = 455) and inpatient (N = 553) programs for the treatment of posttraumatic stress disorder and associated disorders in the Department of Veterans Affairs were used to compare outcomes for veterans who were and were not seeking compensation. Outcome was measured as pre/post improvement in symptoms and work performance over the course of 1 year after the initiation of treatment. No compensation-seeking effect was observed among outpatients, but a significant effect was found for some inpatients. The effect for inpatients was manifested essentially by patients in a program type which was designed to have an extremely long length of stay, thus triggering a virtually automatic increase in payments. Like outpatients, inpatients in programs with a moderate length of stay did not manifest a compensation-seeking effect on improvement. Although not permitting a definitive explanation, the preponderance of the evidence favors the overstatement of symptoms rather than either the severity or the chronicity of the disorder as the most likely explanation for the compensation-seeking effect that was observed. For patients treated in standard outpatient and short-stay inpatient programs, compensation does not seem to affect clinical outcomes adversely.

Veterans affairs disability compensation: a case study in countertherapeutic jurisprudence.

This article examines the disability compensation programs and health care system of the Department of Veterans Affairs (VA) from the perspective of therapeutic jurisprudence scholarship. VA psychiatric patients have unambiguous financial incentives to endlessly litigate disability claims, to seek lengthy hospitalization rather than outpatient treatment, and to be ill, disabled, and unemployed. These countertherapeutic incentives reward incapacitation, encourage perceiving one-self as sick, diminish personal responsibility, taint treatment relationships, and lead to disparaging perceptions of VA patients. In addition, such perceptions produce moral dilemmas that arise from mutual distrust and frustration when patients and caregivers have antagonistic goals for the clinical encounter. Changes in disability determination procedures, compensation levels, and patterns of payment for treatment could give VA patients and caregivers a "healthier" health care system that encourages personal responsibility and promotes respectful attitudes toward patients. In the absence of such changes, an awareness of countertherapeutic financial incentives can help clinicians distinguish between psychopathological behavior and the pursuit of a rational income strategy, and can help practitioners recognize that apparently deceitful or litigious behavior represents a reasonable response to the economic contingencies that VA patients face.

Disability income, cocaine use, and repeated hospitalization among schizophrenic cocaine abusers--a government-sponsored revolving door?

BACKGROUND: Many patients with serious mental illness are addicted to drugs and alcohol. This comorbidity creates additional problems for the patients and for the clinicians, health care systems, and social-service agencies that provide services to this population. One problem is that disability income, which many people with serious mental illness receive to pay for basic needs, may facilitate drug abuse. In this study, we assessed the temporal patterns of cocaine use, psychiatric symptoms, and psychiatric hospitalization in a sample of schizophrenic patients receiving disability income. METHODS: We evaluated 105 male patients with schizophrenia and cocaine dependence at the time of their admission to the hospital. They had severe mental illness and a long-term dependence on cocaine, with repeated admissions to psychiatric hospitals; many were homeless. The severity of psychiatric symptoms and urinary concentrations of the cocaine metabolite benzoylecgonine were evaluated weekly for 15 weeks. RESULTS: Cocaine use, psychiatric symptoms, and hospital admissions all peaked during the first week of the month, shortly after the arrival of the disability payment, on the first day. The average patient spent nearly half his total income on illegal drugs. CONCLUSIONS: Among cocaine-abusing schizophrenic persons, the cyclic pattern of drug use strongly suggests that it is influenced by the monthly receipt of disability payments. The consequences of this cycle include the depletion of funds needed for housing and food, exacerbation of psychiatric symptoms, more frequent psychiatric hospitalization, and a high rate of homelessness. The troubling irony is that income intended to compensate for the disabling effects of severe mental illness may have the opposite effect.