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Harsh quote alert: PTSD & contract exams

A critical piece was recently published related to the VA PTSD disability process and I don’t agree with much of the tone. The authors write as if they were almost against awarding disability for PTSD in general and believe that validity scales on the MMPI alone can determine whether a Veteran is malingering (they can’t). The article reads like the opposite of the VA’s motto of “to care for him who shall have borne the battle and for his widow, and his orphan.” As sexist as this Abraham Lincoln quote might read in the context of our current times, it certainly reflects that we should do what we need to do to help those with PTSD.

However, the article is interesting as it does take contract exams to task though noting “there are several possible explanations for the observed deficiencies in contract exams, including lack of supervision, more limited access to VA treatment records, and inadequate training and experience. An additional explanation is that, unlike exams by salaried VA staff, contractors are paid a flat fee for each exam which is a small fraction of the typical fees paid for forensic psychological evaluation in the community. Thus, there is a financial incentive to complete exams quickly, which would preclude careful record review, psychological testing, and detailed report preparation.”

Interestingly, while suggesting that the “flat fee” which is a “small fraction of the typical fees paid for forensic psychological evaluation in the community…” is a problem, the authors did not propose solutions to this such as increasing the fees paid for the exams in order to attract better educated and more experienced forensic experts to the work or address issues with the contract exams being a volume business where examiners have to churn out a number of exams in order to keep the lights on due to what they are being paid.

The author go on to suggest that “anecdotally, it is not uncommon for veterans seen by contractors needing to be reexamined, at times with requests for second and even third opinions to resolve “conflicting medical evidence” after a contract examiner rendered an opinion that contradicted those in the veteran’s records or in previous C&P exams. Inefficiencies resulting from poor exams increase the workload for both examiners and VBA personnel and increase the costs for VA C&P operations overall.”

It is amusing that the authors simply prescribe more “education” of raters in a vague and nebulous way as if the raters aren’t already bombarded with such attempts and have to focus on all the other body systems as well. It is likely the authors mostly wanted to complain but in the end had few specific and actionable suggestions related to this. Vague calls for “education” alone are rarely going to be sufficient, particularly when raters have so much they need to be educated on even outside the realm of psychology. The authors note “although raters are not expected to become experts in psychology, they are tasked with making critical determinations about cases in which complex issues of psychological causation and apportionment are central, subject matter in which they likely have little or no knowledge or training.” The authors focus on examination quality and note “to our knowledge, there are no mental health experts working at VBA or in close consultation to VBA in day-to-day operations. Quality assurance review by expert examiners working in conjunction with VBA would be a simple and efficient means of identifying deficient examinations and implementing examiner remediation plans.” The authors missed the opportunity to propose that, like the Social Security Administration does for Social Security disability claims, actual experts such as psychologists and physicians should be reviewing the case and offering their opinions on the rating– actual experts can review the exams and all of the other records in the file and offer their own opinions on the claim for every single claim (opinions which could be drafted by the raters but signed off on by an expert professional). This is exactly how a Social Security claim gets processed. If a consultative exam is needed one gets ordered (like a C&P), however a different, expert file reviewer reviews all of the evidence and offers an expert opinion on the rating. Adjudicators often draft the rating but they are reviewed and signed off on by an expert. This would go beyond quality assurance and put the experts right where the decisions were being made.

It is sad that the article had to focus so much on the cost of disability payments for PTSD, rather than the cost that PTSD takes out on our Veterans’ lives. If there were a guiding mission statement for any revision to the PTSD compensation process, it should not sound anything like the tone of Meisler & Gianoli’s article, it should sound much more like Abraham Lincoln’s desire to care for him (and her as well) who has borne the battle. In that case we should be willing to even spend more to ensure that we are in fact doing what we should to care for those who have borne the battle with quality decisions, and to do what is right by them– even though we may never be able to make them whole again.

The Article: Meisler, A. W., & Gianoli, M. O. (2022). The Department of Veterans Affairs disability examination program for PTSD: Critical analysis and strategies for remediation. Psychology, Public Policy, and Law. Advance online publication