PTSD Disability Examination Reports: A Comparison of Veterans Health Administration and Contract Examiners
Background: An enormous increase in disability claims for posttraumatic stress disorder (PTSD) has occurred over the past decade. To meet the demand for examinations required to determine diagnosis, causation, and impairment, the US Department of Veterans Affairs Veterans Health Administration (VHA) has increasingly relied on contract examiners. Despite anecdotal reports of poor-quality examinations by contractors, no systematic study comparing VA and contract examinations has been reported.
Methods: Data from 113 initial PTSD examination reports were coded and rated on variables related to content and quality. Administrative disability decisions rendered by VHA were identified and coded independently.
Results: Contract examinations reported more symptoms and a greater degree of impairment, resulting in higher VHA disability ratings compared with VHA examiner reports. Contractor examinations were rated as having poorer quality than were VHA examinations on 2 of 3 metrics and included several examination reports that contained no relevant history or discussion required to support opinions about diagnosis or impairment.
Conclusions: The findings provide the first systematic evidence of greater symptom/impairment reporting and poorer overall quality in contract examinations for PTSD disability claims compared with those conducted by VHA examiners, with resulting differential outcomes in VHA disability ratings. The findings have implications for the quality, integrity, and reliability of the VHA PTSD disability claims process and support the need for program oversight, examiner training, and quality assurance.
Although contract examiners did not diagnose PTSD significantly more frequently than VHA examiners (71% vs 57%, respectively), the overall frequency of PTSD diagnosis across both groups (65%) was substantially higher than previous figures that have, on average, estimated the lifetime prevalence of PTSD in trauma-exposed veterans to be about 31%.15 A re-analysis of the same National Vietnam Veterans Readjustment Survey data, but applying more conservative diagnostic criteria, reduced the lifetime prevalence to just under 19%, with point prevalence estimates even lower.15,16
In a study of concordance rates between service connection for PTSD and both current and lifetime diagnosis by independent, structured assessment, Marx and colleagues found that a “significant minority” of veterans who were already receiving service-connected disability for PTSD did not meet lifetime and/or current diagnostic criteria.17 Although it is possible that the group of veterans who were applying for disability benefits in our study had a higher rate of PTSD, it also is possible if not likely that the PTSD examination process overall yields inflated rates of diagnosis and levels of impairment. This speaks to the concern raised by Marx and colleagues who found that veterans with service connection for PTSD who received related benefits “may not have the disorder.”17
Limitations
A methodological limitation of the present study was that, due to structural differences in the DBQ forms used for VHA and contract examinations, the reports could not be de-identified as to examiner type and thus raters could not be masked/blinded. To mitigate bias, a predetermined, piloted, and refined coding and rating plan for report quality metrics was adhered to strictly, and interrater reliabilities were acceptable. Future study is suggested in which all report content is standardized for coding using the same format, which at present would require a complete rewriting of the entire report; this problem could be resolved by having the VBA adopt a more coherent system in which all reports, regardless of examiner type, use a single, standardized template. Further study using larger data sets and expanding to other VA regions also is needed.
Conclusions
The present study suggests that poor examination and report quality—by contract examiners and to a lesser degree VHA examiners—are not uncommon. The findings confirm and extend previous anecdotal reports of deficiencies in PTSD examinations performed by contract examiners and provide empirical support for concerns raised of global deficiencies in the VBA oversight of the MDE program. Such deficiencies have significant implications for the quality and integrity of the VA disability determination process for veterans claiming PTSD related to military service.
The current findings support and strengthen the call for development and management of a structured and enforced training and quality assurance/improvement program for VA PTSD disability examinations. Such training and oversight will be critical to improve the quality and integrity of these examinations, reduce error and waste in VBA’s Compensation and Pension process, and in doing so optimize VA financial resources to best serve veterans’ benefits and health care needs.
