Findings
Our case review found that regardless of whether a contractor or VA physician completed the C&P disability medical examination, the rating outcome was essentially the same. Also, raters we surveyed reported that contractor and VA physician medical examinations were generally of the same quality. However, we noted that consistency in the way medical examinations are completed still needs management attention, and the C&P exam templates recently developed by the CPEP are not being used by many VHA medical facilities. Additionally, the CPEP management needs to improve communication with rating staff at the VAROs regarding the new template and seek their comments on any improvements needed.
The assignment of a disability rating to a veteran requires the collection and assessment of data from various sources. The veteran’s current medical status is determined through the performance of a physical examination. When a veteran is ill and presents to a hospital, the goal of the physical examination is to determine the cause and extent of the illness. If a veteran is examined for the purpose of determining the extent of his medical disability for compensation purposes, a focused physical examination is performed. Although similar, these two examinations have different goals and require different data to reach their conclusions.
VA physicians perform most disability medical examinations. VBA has a contract with
QTC Medical Group, Inc.9 as an additional source for these examinations. After a
veteran requests a disability determination, a VARO rater arranges for the veteran to have the required examination. The veteran may be scheduled for an examination with a provider at a VA hospital or a QTC physician.
Physicians contracted to QTC are not uniformly distributed throughout the county.10 The
documentation and quality assurance procedures for QTC examinations are different than the procedures used by VA. The RVSR is therefore presented medical examination data in a similar format. VA pays QTC about $61 million for these services. The QTC average cost per examination is approximately $590.
Little Difference Between QTC and VA Physician Medical Examinations. To
determine whether disability examination reports prepared by VA and QTC physicians affected the variance in ratings, we reviewed examination reports for initial PTSD examinations and joint examinations involving at least one knee.
9 As a result of Public Law 104-275, VBA initiated a contract with QTC Medical Group, Inc. to conduct a pilot to
examine the impact of disability examinations performed by non-VA physicians.
10 Under the QTC pilot, regional offices in Atlanta, Boston, Los Angeles, Roanoke, Salt Lake City, San Diego,
Wichita, and Winston Salem utilized QTC resources. In addition to the test sites, the regional offices in Seattle,
For those veterans whose initial PTSD examination was performed by a VA physician, the average rating was 31.3 with a confidence interval of 5.52. The average rating for those veterans whose initial PTSD examination was performed by a QTC physician was 37.7 with a confidence interval of plus or minus 4.93. At the .05 level of statistical significance, these results are similar. The joint examination review yielded a similar result. The VA physician examinations resulted in an average rating of 22.2 with a confidence interval of 4.63, which was not significantly different from the QTC physician group average rating of 23.4 with a confidence interval of 5.02. The physical examination samples we selected suggest that the rating result does not depend upon the source of the physical examination when comparing VA physicians and QTC physicians. This result is consistent with the finding in the Evaluation of Contract Examination Pilot Test of December 1999 where data suggested that the quality of QTC and VHA
examinations is relatively constant across the examination categories.11
Our survey of raters yielded similar findings. Forty-eight percent of the 1,349 survey respondents evaluated the quality of examinations by VA physicians as good or very good; 19 percent evaluated them as poor or very poor. Forty-nine percent evaluated the quality of examinations by QTC physicians as good or very good; 16 percent evaluated them as poor or very poor.
The C&P Service maintains 57 types of disability examination request worksheets that guide clinicians to collect and report information needed to decide veterans’ disability claims. Each type of worksheet addresses a particular body system or category of disability. In the past, the worksheets have been provided to clinicians for reference during the conduct of examinations and dictation of findings.
Examination Report Templates Need To Be Mandated and Communicated to
Medical Facilities and Regional Offices. CPEP, a joint VBA/VHA entity, is
collaborating with the VHA Health Systems Design and Development office to develop an automated examination report template for each of the 57 disability examination request worksheets. The primary objective of automating the report templates is to eliminate errors of omission by means of “structured data entry.” This means that the automated template prompts the examiner to address each information element that is relevant for rating the specific condition being examined, and bypasses elements that does not pertain to that specific condition.
According to CPEP management, as of March 2005, 55 of the 57 automated examination report templates had been installed at all VHA examination facilities, but their use has not been mandated. These 55 templates are currently available for production purposes system-wide (that is they can be used in preparing any C&P examination report involving one or more of those 55 worksheets). CPEP management informed us that two templates
11 SRA International submission to Congress as required in Section 504 of Public Law 104-275, “Evaluation of Contract Examination Pilot Test” pg 61.
not yet in production system-wide are currently in beta testing and scheduled for system-
wide release in April 2005.12 A software update, also scheduled for release in April, will
allow a clinician to add templates during an examination when findings indicate a need for information from another worksheet.
While VA, through the development and implementation of CPEP report templates, is making an effort to standardize C&P medical examinations, use of the templates is not yet required of VHA facilities. VBA rating personnel have seen only a limited number of examination reports submitted in the template format. We spoke with personnel at seven VAROs and were informed that use of the templates at VHA facilities is not yet common. VSC personnel at five of the seven VAROs indicated that they either have not seen any examination reports completed in the template format or they have only seen a limited number completed by one medical center in their area. Use of the templates was more frequent at medical centers serving the other two VAROs. Rating personnel at two VAROs who have seen the results of C&P examinations presented in the template format stated that they believed the examination reports need to be improved and that it was difficult to locate the information needed for rating purposes. According to VBA management, they are engaged in an effort to review and approve the report templates.
Conclusion
We concluded that there is little difference between the quality of contractor produced C&P examinations and VA examinations and their impact on the degrees of disability that are eventually awarded to the veterans. Actions need to be taken to ensure examination report templates provide complete and accurate evidence needed to evaluate disability claims.
“Beta testing” means that the software for those worksheets has been installed and is being used for C&P examinations at a limited number of exam facilities. These beta test facilities volunteered to use the software and provide feedback about their experience with it so that any necessary adjustments can be made before deploying it system-wide for production purposes.