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.

Schedule for Rating Disabilities; Gynecological Conditions and Disorders of the Breast. Final rule.

This document amends the Department of Veterans Affairs (VA) Schedule for Rating Disabilities (VASRD) by revising the portion of the rating schedule that addresses gynecological conditions and disorders of the breast. The effect of this action is to ensure that this portion of the rating schedule uses current medical terminology and to provide detailed and updated criteria for evaluation of gynecological conditions and disorders of the breast.

Schedule for Rating Disabilities: the Organs of Special Sense and Schedule of Ratings--Eye. Final rule.

The Department of Veterans Affairs (VA) is revising the portion of the VA Schedule for Rating Disabilities (VASRD or rating schedule) that addresses the organs of special sense and schedule of ratings--eye. The final rule incorporates medical advances that have occurred since the last review, updates current medical terminology, and provides clearer evaluation criteria.

Impact of presumed service-connected diagnosis on the Department of Veterans Affairs healthcare utilization patterns of Vietnam-Theater Veterans: A cross-sectional study.

During the Vietnam War, the US military sprayed almost 20 million gallons of Agent Orange (AO), an herbicide contaminated with dioxin, over Vietnam. Approximately, 2.7 million US military personnel may have been exposed to AO during their deployment. Ordinarily, veterans who can demonstrate a nexus between a diagnosed condition and military service are eligible for Department of Veterans Affairs (VA) service-connected disability compensation. Vietnam Veterans have had difficulty, however, establishing a nexus between AO exposure and certain medical conditions that developed many years after the war. In response, VA has designated certain conditions as "presumed service connected" for Vietnam Veterans who were present and possibly exposed. Veterans with any of these designated conditions do not have to document AO exposure, making it easier for them to access the VA disability system. The extent to which VA healthcare utilization patterns reflect easier access afforded those with diagnosed presumptive conditions remains unknown. In this cross-sectional study, we hypothesized that Vietnam Veterans with diagnosed presumptive conditions would be heavier users of the VA healthcare system than those without these conditions. In our analysis of 85,699 Vietnam Veterans, we used binary and cumulative logit multivariable regression to assess associations between diagnosed presumptive conditions and VA healthcare utilization in 2013. We found that diagnosed presumptive conditions were associated with higher odds of 5+ VHA primary care visits (OR = 2.01, 95% CI: 1.93-2.07), 5+ specialty care visits (OR = 2.11, 95% CI: 2.04-2.18), emergency department use (OR = 1.22, 95% CI: 1.11-1.34), and hospitalization (OR = 1.23, 95% CI: 1.17-1.29). Consistent with legislative intent, presumptive policies appear to facilitate greater VA system utilization for Vietnam Veterans who may have been exposed to AO.

Extension of the Presumptive Period for Compensation for Gulf War Veterans. Final rule.

The Department of Veterans Affairs (VA) is issuing this final rule to affirm its adjudication regulations regarding compensation for disabilities resulting from undiagnosed illnesses suffered by veterans who served in the Persian Gulf War. This amendment is necessary to extend the period during which disabilities associated with undiagnosed illnesses and medically unexplained chronic multi-symptom illnesses must become manifest in order for a Veteran to be eligible for compensation. The intended effect of this amendment is to provide consistency in VA adjudication policy, preserve certain rights afforded to Persian Gulf War (GW) veterans, and ensure fairness for current and future GW veterans.

Schedule for Rating Disabilities; the Endocrine System. Final rule.

This document amends the Department of Veterans Affairs (VA) Schedule for Rating Disabilities (VASRD) by revising the portion of the Schedule that addresses endocrine conditions and disorders of the endocrine system. The effect of this action is to ensure that the VASRD uses current medical terminology and to provide detailed and updated criteria for evaluation of endocrine disorders.

Schedule for Rating Disabilities; Dental and Oral Conditions. Final rule.

This document amends the Department of Veterans Affairs (VA) Schedule for Rating Disabilities by revising the portion of the schedule that addresses dental and oral conditions. The effect of this action is to ensure that the rating schedule uses current medical terminology and to provide detailed and updated criteria for evaluation of dental and oral conditions for disability rating purposes.

Diseases Associated With Exposure to Contaminants in the Water Supply at Camp Lejeune. Final rule.

The Department of Veterans Affairs (VA) amends its adjudication regulations regarding presumptive service connection, adding certain diseases associated with contaminants present in the base water supply at U.S. Marine Corps Base Camp Lejeune (Camp Lejeune), North Carolina, from August 1, 1953, to December 31, 1987. This final rule establishes that veterans, former reservists, and former National Guard members, who served at Camp Lejeune for no less than 30 days (consecutive or nonconsecutive) during this period, and who have been diagnosed with any of eight associated diseases, are presumed to have incurred or aggravated the disease in service for purposes of entitlement to VA benefits. In addition, this final rule establishes a presumption that these individuals were disabled during the relevant period of service for purposes of establishing active military service for benefits purposes. Under this presumption, affected former reservists and National Guard members have veteran status for purposes of entitlement to some VA benefits. This amendment implements a decision by the Secretary of Veterans Affairs that service connection on a presumptive basis is warranted for claimants who served at Camp Lejeune during the relevant period and for the requisite amount of time and later develop certain diseases.

Peace and Reconciliation.

Susan Schnall speaks about the lingering effects of Agent Orange-and what remains to be done about them.

Standard claims and appeals forms. Final rule.

The Department of Veterans Affairs (VA) amends its adjudication regulations and the appeals regulations and rules of practice of the Board of Veterans' Appeals (Board) to require that all claims governed by VA's adjudication regulations be filed on standard forms prescribed by the Secretary, regardless of the type of claim or posture in which the claim arises. This rulemaking also eliminates the constructive receipt of VA reports of hospitalization or examination and other medical records as informal claims for increase or to reopen while retaining the retroactive effective date assignment for awards for claims for increase which are filed on a standard form within 1 year of such hospitalization, examination, or treatment. This final rule also implements the concept of an intent to file a claim for benefits, which operates similarly to the current informal claim process, but requires that the submission establishing a claimant's effective date of benefits must be received in one of three specified formats. Finally, these amendments will provide that VA will accept an expression of dissatisfaction or disagreement with an adjudicative determination by the agency of original jurisdiction(AOJ) as a Notice of Disagreement (NOD) only if it is submitted on a standardized form provided by VA for the purpose of appealing the decision, in cases where such a form is provided. Although a standardized NOD form will only initially be provided in connection with decisions on compensation claims, VA may require a standard NOD form for any type of claim for VA benefits if, in the future, it develops and provides a standardized NOD form for a particular benefit. The purpose of these amendments is to improve the quality and timeliness of the processing of veterans' claims for benefits by standardizing the claims and appeals processes through the use of forms.

Science versus policy in establishing equitable Agent Orange disability compensation policy.

This article makes the case that current Agent Orange compensation policy for Vietnam War veterans is based neither wholly upon scientific findings about Agent Orange health effects nor on pure public health policy considerations. Rather, it is the logical culmination of decades of experience among policy makers and public health scientists trying to establish clear-cut, equitable, and scientifically defensible compensation policy in the face of limited relevant science and poor or nonexistent exposure data-all within the broader context of Veterans Affairs disability compensation policies, and a deep-seated commitment to support the men and women who served their country during the Vietnam War. Finally, attempts to update current policy will benefit from an understanding of this background.

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.

Stressor determinations for posttraumatic stress disorder. Final rule.

The Department of Veterans Affairs (VA) is amending its adjudication regulations governing service connection for posttraumatic stress disorder (PTSD) by liberalizing in some cases the evidentiary standard for establishing the required in-service stressor. This amendment eliminates the requirement for corroborating that the claimed in-service stressor occurred if a stressor claimed by a veteran is related to the veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of PTSD and that the veteran's symptoms are related to the claimed stressor, provided that the claimed stressor is consistent with the places, types, and circumstances of the veteran's service. This amendment takes into consideration the current scientific research studies relating PTSD to exposure to hostile military and terrorist actions. The amendment acknowledges the inherently stressful nature of the places, types, and circumstances of service in which fear of hostile military or terrorist activities is ongoing. With this amendment, the evidentiary standard of establishing an in-service stressor will be reduced in these cases. The amendment will facilitate the timely processing of PTSD claims by simplifying the development and research procedures that apply to these claims.

"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.

Presumption of service connection for osteoporosis for former prisoners of war. Final rule.

The Department of Veterans Affairs (VA) is amending its adjudication regulations to establish a presumption of service connection for osteoporosis for former Prisoners of War (POWs) who were detained or interned for at least 30 days and whose osteoporosis is at least 10 percent disabling. The amendment implements a decision by the Secretary to establish such a presumption based on scientific studies. VA is additionally amending its adjudication regulations to establish a presumption of service connection for osteoporosis for POWs who were detained or interned for any period of time, have a diagnosis of posttraumatic stress disorder (PTSD), and whose osteoporosis is at least 10 percent disabling. This amendment reflects statutory provisions of the Veterans' Benefits Improvement Act of 2008.

Presumptive service connection for disease associated with exposure to certain herbicide agents: AL amyloidosis. Final rule.

This document amends the Department of Veterans Affairs (VA) adjudication regulations concerning presumptive service connection for a certain disease based on the most recent National Academy of Sciences (NAS) Institute of Medicine committee report, "Veterans and Agent Orange: Update 2006" (Update 2006). This amendment is necessary to implement a decision of the Secretary of Veterans Affairs that there is a positive association between exposure to herbicides used in the Republic of Vietnam during the Vietnam era and the subsequent development of AL amyloidosis. The intended effect of this amendment is to establish presumptive service connection for AL amyloidosis based on herbicide exposure.

Presumption of service connection for amyotrophic lateral sclerosis. Final rule.

This document adopts as a final rule the interim final rule amending the Department of Veterans Affairs (VA) adjudication regulations to establish a presumption of service connection for amyotrophic lateral sclerosis (ALS) for any veteran who develops the disease at any time after separation from service. This amendment implements the decision by the Secretary of Veterans Affairs to establish such a presumption based on a November 2006 report by the National Academy of Sciences Institute of Medicine on the association between active service and ALS.

Board of Veterans' Appeals: expedited claims adjudication initiative--pilot program. Final rule.

The Department of Veterans Affairs (VA) is launching an initiative for accelerated claims and appeals processing at four VA facilities, based on voluntary participation by eligible claimants. The purpose of this initiative is to determine whether VA can expedite the processing of claims and appeals by obtaining claimants' waivers of certain statutory and regulatory response periods, and by utilizing the Board of Veterans' Appeals' (Board or BVA) statutory authority to pre-screen cases. VA's responsibility to fully develop and decide cases in a fair, accurate, and non-adversarial manner remains unchanged under this initiative. If this initiative is successful at the four trial sites, the data obtained may provide a basis for expanding some, or all, of the program nationwide, and ultimately help accelerate the processing of all claims and appeals. The parameters of the initiative are set forth in these regulations.

Extension of the presumptive period for compensation for Gulf War veterans. Final rule.

This document affirms an amendment to the Department of Veterans Affairs (VA) adjudication regulation regarding compensation for disabilities resulting from undiagnosed illnesses suffered by veterans who served in the Persian Gulf War. This amendment is necessary to extend the presumptive period for qualifying chronic disabilities resulting from undiagnosed illnesses that must become manifest to a compensable degree in order that entitlement for compensation be established. The intended effect of this amendment is to provide consistency in VA adjudication policy and preserve certain rights afforded to Persian Gulf War veterans and ensure fairness for current and future Persian Gulf War veterans.