Results
Comparison of VHA and contract examinations revealed no significant differences between groups on relevant sociodemographic and other measures (Table). Missing data were not obtained from other records or sources, and for this study, reflect only what is recorded in the examination reports except for age, which was calculated using veteran’s date of birth and the date of examination.
To examine differences between VHA and contract examinations, the groups were first compared on a set of predetermined objectively coded variables taken directly from the DBQ. The frequency of PTSD diagnoses by VHA (57%) and contract (71%) examiners was not significantly different nor were rates of non-PTSD diagnoses by VHA (51%) and contract (73%) examiners. There also was no difference in the mean number of PTSD symptoms endorsed across PTSD diagnostic criteria B, C, D, and E (maximum of 20) recorded by VHA (9.4) and contract (10.9) examiners.
Contract examiners recorded a significantly greater mean number of “other symptoms” on a checklist of 31 possible symptoms as compared to VHA examiners: 7.3 vs 5.8, respectively (t[104] = 2.27, P < .05). An initial analysis of overall social/vocational impairment ratings coded by examiners did not reveal significant differences between examiner groups. However, when the 2 most severe impairment categories were combined to create a pooled “severe” category, 31% of contract examiners rated veterans as severely impaired compared with only 12% of VHA examiners (χ2 = 5.79, 1 df, P < .05) (Figure 1).
VHA and contract examinations were compared on 3 measures of report quality. Significant differences were found for both level of detail (χ2 = 16.44, 2 df, P < .01) and synthesis (χ2 = 6.68, 2 df, P < .05). Contract examinations were more likely to be rated as poor and less likely to be rated good, with a similar proportion of fair ratings for the 2 examination types (Figures 2 and 3). There was no significant difference in the proportion of VHA and contract examinations providing clear statement of opinion regarding causation (ie, whether or not the diagnosed condition was service related), with the majority rendering an adequate opinion in both examiner groups (VHA, 78%; contract, 79%).
Qualitative review revealed examples of markedly deficient examinations among contract examinations, including several reports that contained no review of records, no report of relevant background, and no mention or assessment of social and vocational function needed to inform opinions about diagnosis and impairment.
Finally, the VBA database was used to compare the resulting disability award decisions made by VBA based on the examination reports in question. Examination by contractors resulted in significantly higher mean service-connected disability ratings for examinees compared with VHA examiners (46.8 vs 33.5, respectively; t[108] = 2.3, P < .05).
Discussion
The present study provides the first reported systematic comparison of VA disability examinations for PTSD completed by examiners employed by the VHA and those hired as contract examiners through the MDE program. Although the frequency of PTSD diagnoses by contract examiners was higher than that of VHA examiners (71% vs 57%, respectively), the difference was not statistically significant. However, contract examiners recorded significantly more symptoms for examinees and rated them as severely impaired more frequently than did their VHA counterparts. In keeping with rating guidelines used by the VBA, these differences in examination content resulted in higher disability ratings for veterans seen by contract examiners.
Along with these elevated reports in symptom and severity ratings, contract examiners were less likely to provide adequate detail in the narrative sections of their reports and less frequently provided a satisfactory explanation and synthesis of relevant history and findings in support of their conclusions. Although not reflected in the statistical analysis, case-by-case review revealed some startlingly inadequate examination reports by contract examiners, several of which contained no review of records, no report or discussion of relevant background, and no discussion or analysis of social and vocational function to inform and support their opinion about level of impairment. None of the VHA examination reports reviewed lacked information to that degree.
Such deficiencies in detail and synthesis run counter to accepted guidelines for the adequate assessment of psychological injury in general and in VA disability claims specifically.11,12 For example, Watson and colleagues proposed that a minimum of 3 hours was required to conduct an initial PTSD examination, with more complex cases possibly taking longer.11 There is no information available about how long contract examiners take to complete their examinations and how that compares with the time taken by VA examiners. The VBA failure to monitor whether or not examiners follow accepted guidelines for PTSD examination has not previously been evaluated. Historically, a large number of clinicians, researchers, and policy critics have raised concerns about the potential for exaggeration or malingering among VA PTSD disability claimants and have urged the need to adequately assess for unreliable reporting and presentation.13,14 However, the possibility of systematic examiner deficiency and/or bias increasing the frequency of false or inflated claims being approved has received little empirical attention.
