May 28, 2008

By First Class Mail and Fax (202-565-8667)

George J. Opfer
Inspector General
Department of Veterans Affairs
810 Vermont Avenue, N.W.
Washington, D.C. 20420

Dear Mr. Opfer:

Citizens for Responsibility and Ethics in Washington (“CREW”) and VoteVets.org

request that you open an investigation into the process and manner by which the Department of
Veterans Affairs (“VA”) makes a diagnosis of post traumatic stress disorder (“PTSD”) in
veterans. We are aware that Senator Barack Obama has already requested that VA Secretary
Peake open an investigation into this matter based on an email we recently disclosed revealing
that in at least one medical facility for veterans in Texas, a mental health professional on the VA
staff told staff members to refrain from diagnosing PTSD and consider instead the alternative
and less costly diagnosis of adjustment disorder.1 Based on confidential tips we have received
since this revelation, it appears that this is a far more widespread and systemic problem, not
limited to Texas, that has significantly and adversely affected a large number of service members
and veterans.

As you know, in an email dated March 20, 2008, VA employee Norma Perez, who has
been identified publicly as an individual “who helps lead the post-traumatic stress disorder
program” at a medical facility for veterans,2 advised VA mental health staff at the VA’s Center
in Temple, Texas as follows:

Given that we are having more and more compensation seeking

veterans, I’d like to suggest that you refrain from giving a diag-
nosis of PTSD straight out. Consider a diagnosis of Adjustment
Disorder, R/O PTSD.

Additionally, we really don’t or have time to do the extensive

testing that should be done to determine PTSD.

1
A redacted copy of that email is attached as Exhibit 1.
2
See Christopher Lee, Official Urged Fewer Diagnoses of PTSD, The Washington Post,
May 16, 2008 (attached as Exhibit 2).
George J. Opfer
May 28, 2008
Page Two

Also, there have been some incidence where the veteran has
a C & P, is not given a diagnosis of PTSD, then the veteran
comes here and we give the diagnosis, and the veteran appeals
his case based on our assessment.

See Exhibit 2. On the basis of this email, Senator Obama requested that the VA investigate,
among other things, whether health officials at other VA facilities have been given similar
directives in diagnosing PTSD.

Since Senator Obama requested an investigation, CREW and VoteVets.org have received
new information from VA employees and veterans illuminating further the nature of the problem
and directly calling into question VA Secretary James B. Peake’s claim that Ms. Perez’s email
does not reflect VA policy.3 Specifically, VA employees have advised us that the diagnostic
outcome counseled in Ms. Perez’s email happens all the time and that VA employees are
routinely ordered to change PTSD diagnoses on compensation exams. One VA employee
suggested that the behavioral health departments in Eastern Pennsylvania in particular should be
investigated for these practices. This same individual reported that VA employees are bullied
and threatened if they do not change PTSD diagnoses.

Another former VA employee who processed benefit claims for seven years explained
that the practice memorialized in Ms. Perez’s email is only a small part of what is going on at the
VA. According to this source, the problem began when the VA implemented an Incentive
Award Program to reduce the backlog of claims. This program gives bonuses to employees who
process the most claims and to hospitals that process the most claims and distribute lower levels
in compensation to veterans. Another VA employee has confirmed the pernicious effect that this
incentive program has had; veterans receive lower levels of compensation based primarily on
cost-cutting incentives, rather than the most appropriate medical diagnoses. Although your
office investigated some of these practices and the widespread tampering of veteran medical
records in 2004, the problems continue and appear to be even more widespread.

In 2004, your office also issued a report on the state-by-state discrepancies in the average
compensation given to veterans, finding a direct correlation between the number of veterans
diagnosed with 100% PTSD and the states that had paid the highest amount of compensation. In
response to this report, the VA undersecretary of benefits promised to increase consistency
between states in their diagnosis of PTSD. Unfortunately, it now appears that consistency was
accomplished to the detriment of veterans. Rather than increase education on the symptoms and
treatment of PTSD, the VA instead put into its guidebook the recommendation that PTSD
diagnoses be downgraded to adjustment disorder diagnoses. We have obtained a copy of
portions of the VA examination manual that, for costly disorders such as PTSD and major

3
Lee, The Washington Post, May 16, 2008.
George J. Opfer
May 28, 2008
Page Three

depression, encourage the diagnosis of an alternative, so-called “matching disorder” that is much
less costly to compensate. This process, like the process outlined in the Perez email, allows
hospitals and examiners to cut costs by compensating veterans for disorders that are easier and
less costly to diagnose and treat.

Along these same lines, the 2005 Gulf War Handbook, VHA Handbook 1303.2, in its
diagnostic coding section gives the same diagnostic code for adjustment disorder and PTSD.
The clear suggestion is that VA examiners can use the terms interchangeably when coding a
diagnosis, even though a diagnosis of adjustment disorder drastically reduces the amount of
compensation a veteran will receive.

A source has also advised us that the VA has protected its faulty reward system through
the installation of a computer system, the Vista-Capri, that allows officials to downgrade
diagnoses by changing the results of medical examinations. Our understanding is that Vista-
Capri allows co-signers of medical documents and examinations to make copies of the medical
files, edit the copies and submit the edited versions for processing by getting a qualified
individual -- who was not the original signer or present during the examination -- to sign the
altered documents. In this way an initial diagnosis of PTSD can easily be changed to the less
costly diagnosis of adjustment disorder, even though there is no additional medical evidence to
support the downgraded diagnosis.4

The VA’s own website makes clear the agency’s goal of introducing economic
evaluations into health care decisions, particularly PTSD. For example, an on-line abstract of a
journal article, A Guide to Economic Evaluation: Methods for Cost-Effectiveness Analysis of
Person-Level Data, describes the article as follows:

The authors . . . begin by establishing why health care decision

should be guided by economics . . . To illustrate how to conduct
and evaluate a cost-effectiveness analysis, a hypothetical study
about the treatment of posttraumatic stress disorder with
psychotherapy versus pharmacotherapy is considered. The
authors conclude with recommendations for increasing the
strength and relevance of economic evaluations.

4
These and related practices are currently the subject of at least one lawsuit, Veterans for
Common Sense v. Peake, Civil No. 07-3758 (N.D. Ca.). That lawsuit also alleges that there is a
practice of inducing service members who suffer from PTSD to accept discharges for personality
disorders, which then results in their being denied benefits or medical treatment by the VA on
the basis that they have pre-existing conditions.
George J. Opfer
May 28, 2008
Page Four

http://www.herc.research.va.gov/publications/journal_article_details.asp?AccessionNumber=171
95977.

Our two organizations have also heard from a number of veterans who provide first-hand
evidence of what happens when the VA substitutes an adjustment disorder diagnosis for a PTSD
diagnosis. For example, one veteran described how when he was first admitted to the
Albuquerque VA Medical Center for depression he was advised that an admitting diagnosis of
adjustment disorder instead of PTSD would preserve his career in the military and not be seen as
a “black mark.” He is now receiving care as an inpatient at a PTSD treatment program in
Tucson, Arizona.

Another Iraq war veteran explained that he was able to receive the proper diagnosis and
treatment for his PTSD only after his primary care physician fought his initial VA diagnosis of
adjustment disorder. We also heard from a Vietnam veteran suffering from PTSD who had
worked within the VA system. He described how VA health professionals are trained to suspect
veterans of falsifying their symptoms, and that the resulting failure to properly diagnose and treat
veterans has sometimes resulted in veteran suicides. These are just some of the painful reports
we have received that highlight how behind each statistic there is a very human and painful
story.

While cost-saving is a laudable goal, savings should not come at the direct expense of the
veterans and service members who have served their country so heroically. The VA’s self-
described mission is to provide “excellence in patient care, veterans’ benefits and customer
satisfaction . . . to help veterans get the services they have earned.”
http://www.va.gov/about_va/ Deliberatively misdiagnosing returning veterans to cut costs is
fundamentally at odds with this mission.

Accordingly, we request that you investigate how widespread the practice is of using
alternative and lower-cost diagnoses in lieu of PTSD to cut costs. We also request that you
investigate the extent to which VA employees have been threatened with retaliation for not
supporting a less costly diagnosis such as adjustment disorder.
George J. Opfer
May 28, 2008
Page Five

Thank you for your prompt attention to this serious issue. Those who risk their lives
serving our country deserve the best and most appropriate medicate care we can fer.

Melanie Sloan
Executive Director
Citizens for Responsibility and
Ethics in Washington

. £eiy:/
nSoltz I~
Chairman
VoteVets.org

cc: Senator Daniel K. Akaka

Chair, Senate Committee on Veterans' Affairs

Senator Barack Obama

Member, Senate Committee on Veterans' Affairs

Representative Bob Pilner

Chair, House Committee on Veterans' Affairs

Enclosures