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Potential changes to How the VA rates mental disorders, sleep apnea, tinnitus, etc.

Please note: These are just proposed changes for public comment and the actual changes that get implemented may not look like this. In addition, we don’t know when these will be effective but there will likely be some time before they are. The VA will need to implement new DBQ forms. At least in some instances they’ll need to train C&P examiners to use the system since the changes are pretty dramatic. Likewise, there will need to be training for raters. In addition, anyone who had C&P exams with DBQ forms under the old system will likely not be able to get rated under the new system since the information needed to be rated simply won’t be available in the medical record (and many of the proposals below pretty much guarantee that a C&P exam will be needed on every case).

The VA has proposed substantial changes to how they rate some disabilities. Here is a nice summary article: VA to Overhaul Disability Evaluations for Mental Health, Other Conditions: VA to Overhaul Disability Evaluations for Mental Health, Other Conditions (yahoo.com)

For example, there is a dramatic overhaul proposed for psych conditions; you can view that here:

Federal Register :: Schedule for Rating Disabilities: Mental Disorders

There are also dramatic changes proposed for sleep apnea (which sadly may have the unintended consequence of incentivizing noncompliance with a treatment that can be hard to adjust to and comply with at first, i.e. PAP therapy such as a CPAP). You can view that here:

Federal Register :: Schedule for Rating Disabilities-Ear, Nose, Throat, and Audiology Disabilities; Special Provisions Regarding Evaluation of Respiratory Conditions; Schedule for Rating Disabilities-Respiratory System

Here is an excerpt related to sleep apnea:

VA also proposes to modernize the rating criteria for DC 6847, “Sleep Apnea Syndromes (Obstructive, Central, Mixed)” and retitle that DC as “Sleep Apnea Syndromes (Obstructive, Central, or Mixed)”. The discipline of sleep medicine has greatly evolved since VA published the existing criteria. The American Academy of Sleep Medicine (AASM), founded since then, conducted in-depth, peer-reviewed research in conjunction with its partners to develop scientifically-refined criteria regarding the definition, measurement, and treatment of sleep apnea. Sleep apnea may be defined as complaints of unintentional sleep episodes and/or awakenings and/or snoring associated with an apnea-hypopnea index (AHI) equal to or greater than 5 per hour or, alternatively, an asymptomatic patient with an AHI greater than 15 per hour. See Richard B. Berry, Fundamentals of Sleep Medicine 238 (2012). Additional findings supporting a diagnosis of sleep apnea include oxygen desaturation greater than 4 percent and/or a reduction in airflow below 70 percent. Such measurements can evaluate the effectiveness of treatment intervention or lifestyle modifications such as weight loss.
VA proposes to extensively revise the rating criteria for sleep apnea to primarily provide compensation that is more compatible with earning impairment than the current criteria. The current criteria evaluate based upon treatment rather than actual impairment. VA currently assigns higher ratings to individuals when their physicians prescribe more intensive therapies, such as continuous airway pressure (CPAP) machines, without regard to whether individuals first tried more conservative therapies, such as weight loss or oral appliances, or what actual impairment continues following use of CPAP machines. As discussed below, VA’s proposed criteria will focus on the result rather than the type of treatment. Hence, individuals whose treatments are equally effective will receive equal disability ratings, regardless of the treatments. Individuals for whom treatment similarly fails (or is only partially effective) will also receive similar ratings. These proposed changes for sleep apnea comply with 38 U.S.C. 1155 that the VASRD ratings reflect average losses in earning capacity.

Specifically, VA proposes to assign a 0 percent evaluation when sleep apnea syndrome is asymptomatic, with or without treatment. VA would assign a 10 percent evaluation when treatment yields “incomplete relief.” VA would assign ratings above 10 percent ( e.g., 50 and 100 percent) only when treatment is either ineffective or the veteran is unable to use the prescribed treatment due to comorbid conditions. VA would assign a 100 percent evaluation only if there is also end-organ damage. VA proposes to include an informational note that defines and gives examples of qualifying comorbid conditions, i.e., conditions that, in the opinion of a qualified medical provider, directly impede or prevent the use of, or implementation of, a recognized form of treatment intervention normally shown to be effective.

6847 Sleep apnea syndromes (obstructive, central, or mixed):
Treatment ineffective (as determined by sleep study) or unable to use treatment due to comorbid conditions; and with end-organ damage …………………………………………………………………………………………………………………………………………………………. 100
Treatment ineffective (as determined by sleep study) or unable to use treatment due to comorbid conditions; and without end-organ damage …………………………………………………………………………………………………………………………………………………………. 50
Incomplete relief (as determined by sleep study) with treatment ………………………………………………………………………………………. 10
Asymptomatic with or without treatment ………………………………………………………………………………………………………………………… 0
Note: Qualifying comorbidities are conditions that, in the opinion of a qualified medical provider, directly impede or prevent the habitual use of a recognized form of treatment shown by sleep study to be effective in the affected veteran’s case (e.g., contact dermatitis where the mask or interface touches the face or nares, Parkinson’s disease, missing limbs, facial dis-figurement, or skull fracture).

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Personally, I’m not a fan of the VA’s proposed changes to how sleep apnea is rated. For one, the notation “as determined by sleep study” isn’t realistic given that it isn’t routine practice for Veterans to keep getting sleep studies over and over again to see how their CPAP is working, and the data from their CPAP itself rarely if ever actually makes it in to a medical record (and wouldn’t reasonably be considered a sleep study anyway). The data the VA would want wouldn’t be available to the Veteran and therefore there’d be an undue burden on them. Regardless, sleep studies in this context would often not yield the data that is most relevant to the continued impairment seen despite CPAP use. For example, the AHI which is a measure obtained in a sleep study and is often used as a shorthand for severity of sleep apnea, is not an ideal predictor of actual functional impairment. Sleep studies also have no measures of the many actual lingering functional impairments tied to sleep apnea such as cognitive impairment (but I don’t see where the VA is indicating that they are willing to pay for a neuropsychological evaluation for every single Veteran having continued lingering symptoms despite their CPAP use).

Ironically, while the VA is concerned about saving the pennies they are spending on VA disability claims related to sleep apnea, the proposal is pound-foolish. While CPAP use/ breathing assistance device use is not a fool-proof proxy for impairment and loss of earnings potential, there are few other evidence-based contenders to replace it. More importantly, the unique position of CPAP use in the disability rating has created a positive public health phenomenon where Veterans are now educating each other about sleep apnea and supporting each other’s pursuit of the gold standard treatment of PAP therapy. This has an incredibly powerful and positive public health impact and preventing all the negative consequences of untreated sleep apnea in Veterans will save the VA money in the long-term despite the money spent on sleep apnea disability claims. CPAP use has been proven to be cost-effective for healthcare systems. However, CPAP is also notoriously hard to adjust to and a huge percentage of individuals prescribed a CPAP do not continue with CPAP use because of that. We also know that individuals with PTSD in particular have difficulties adjusting to the CPAP due to their symptoms. The VA’s new proposal would have a profoundly negative impact on Veterans and reverse the course of progress that has been made in identifying Veterans with untreated sleep apnea and increasing their adherence to PAP therapy. The VA’s proposal would actually incentivize Veterans to give up on an important treatment that is very difficult to adjust to, leading them to have an increased likelihood of countless other difficulties due to that untreated sleep apnea. This proposal would have a very negative impact on the overall health of Veterans and quite literally kill them more quickly by contributing to their early deaths from the consequences of untreated sleep apnea. The public health benefit of using CPAP/breathing assistance device use as a proxy for impairment and potential income loss (including preventing the early deaths of our Veterans) far outweigh any concerns related to the cost of paying those sleep apnea claims.

These are my first impressions and I’ll work on a more nuanced public response with research citations before the deadline. However, I did just add some more relevant studies I thought of in the sleep apnea secondary to PTSD page on this website (look under Additional citations related to impairment- especially in regards to CPAP use and cognitive impairment (the citations are in the text and I’ll add links at some point). You can find some quick summaries of that research here: http://nexusletters.com/sleep-apnea-secondary-to-ptsd/