A proposed Veterans Administration (VA) rule would increase the involvement of speech-language pathologists and audiologists in evaluating the disabling effects of traumatic brain injuries (TBIs), a process that determines the level of disability compensation for an affected veteran. Veteran-patients could request that providers advocate for them to support a VA claim, and an audiologist's or SLP's medical records could become evidence in such claims.
On Jan. 3, the VA published the proposed rule, which would revise the method for rating the lingering effects of TBIs, known as residuals. This rule would rename Diagnostic Code (DC) 8045 in the VA Schedule for Rating Disabilities as "residuals of traumatic brain injury" rather than the current "brain disease to trauma." The proposed revision of DC 8045 would allow higher disability ratings—and thus higher levels of compensation—for TBI residuals than those now permissible.
Residuals can manifest as a wide range of impairments that affect communication, hearing, sensory perception, and motor function (including those that affect swallowing and eating), along with subjective symptoms that adversely affect quality of life. The proposed change comes as cases of TBI in veterans increase in number and draw increased attention. Commonly used weapons in Iraq and Afghanistan (such as rocket-propelled grenades and improvised explosive devices) and penetrating shrapnel cause concussive force capable of severe closed head injuries.
Under the new rule, TBI residuals such as documented hearing impairment, neurological disorders, and diagnosed mental disorders will be rated under DCs specific to those disorders. VA requires that a state-licensed audiologist conduct auditory testing, the results of which are used for ratings. Hearing impairment is rated with a matrix to calculate the combined disabling effect from the affected ears. Cognitive impairments and subjective clusters of symptoms will be rated under DC 8045, if separable from signs and symptoms of other, rated TBI disorders. For other types of impairments, the VA proposes to rate TBI residuals under either objectively demonstrable cognitive impairments or subjective "symptoms cluster."
VA split cognitive impairment into categories ("facets"), one of which broadly aggregates speech-language and writing disorders. Each facet has criteria related to different severity levels; the overall severity ratings are based on the average of the top three severity levels. "Symptoms cluster" includes mainly subjective symptoms indicative of speech, language, and auditory impairments. These include symptoms such as "dizziness or vertigo," "cognitive impairment, difficulty concentrating," "tinnitus or hypersensitivity to sound," and "difficulty hearing in noisy situations or with competing sounds in the absence of objective hearing loss."
Rating Cognitive Impairment
ASHA provided recommendations about the lack of linguistic precision in the proposed regulation and in various technical aspects of the proposed TBI rating method. ASHA disagrees with VA's structural framework to evaluate cognitive impairment, especially the criteria for speech and language disorders, which are grouped into the broader category of speech, spoken language, and written language impairment.
ASHA's position is that rating criteria for those disorders should be in separate categories, stratified by components. More specific criteria would allow a more precise, uniform rating approach and would reduce numbers of appeals. ASHA suggested that VA use standard assessment tools for speech and language disorders—specifically ASHA's functional communication measures, used in the national outcomes measurement system data collection system—to more accurately evaluate speech and language disorders by scaled levels with precisely graded criteria.
ASHA also recommends that VA:
- Allow the normal 60-day comment period instead of the proposed 30 days.
- Add higher potential ratings for the subjective "symptoms cluster" so that veterans with the most severe disabilities would be eligible for additional compensation. VA proposed to cap the rating for this TBI "symptoms cluster" at 40%, a level that would preclude eligibility for a total rating based on unemployability, regardless of actual disability level.
- Initiate reviews of all TBI cases after the effective date of the final rule, instead of requiring the veteran to affirmatively make a claim for a rating under the new rule. VA initiation of re-ratings would also prevent veterans from losing compensation if they are entitled to more under the new criteria but do not know or could not apply for it.
- Ensure that veterans re-rated under the new DC 8045 criteria will not have their ratings reduced because of the criteria change, at least for a reasonable time period.
- Specifically direct ratings officials to consider any other rating regulations under which a veteran with service-connected TBI residuals may be entitled to increased benefits, such as "extra-schedular" ratings (ratings that go beyond the standard schedule); special monthly compensation ratings; total disability ratings based on unemployability or unemployability and age; and ratings for aid and attendance or for being housebound.
- Rate overall cognitive impairment based on the number of impairment categories (facets) and their severity levels, rather than VA's plan to average the veteran's top three facet levels and disregard the impact of other facets of impairment.
Impact on Professionals
VA's approach to rating TBI residuals may affect ASHA members in several ways. Some audiologists and SLPs will evaluate and treat active military personnel and veterans with TBI residuals. Military and civilian SLPs and audiologists will increasingly be called upon to evaluate TBI-related impairments, as their incidence increases. The veteran-patient may request that the provider advocate for him or her to support a VA claim.
It is essential that the medical documentation used by an SLP or audiologist to make TBI rating decisions is clear, detailed, and objective. Preferably, it will address the VA's rating criteria for easy comparison. VA gives the most evidentiary weight to treating providers' opinions and records.
Veterans with severe disabilities often make claims for Social Security Administration (SSA) disability benefits, in addition to their VA claims. An audiologist's or SLP's medical records may become evidence in VA and/or SSA disability claims, even if neither is in progress when the veteran sees that provider.
To resolve difficult cases, VA may request advisory medical opinions from medical experts who are not VA employees, and SLPs and audiologists may be asked to provide unbiased, independent medical opinions (IMOs) to help resolve claims. VA arranges to obtain IMOs from medical schools, universities, clinics, or medical institutions. An official of the institution selects the expert(s) to render an opinion. Similarly, SSA uses independent medical examiners.
VA's compensation system may affect the veteran-patient's therapeutic relationship with a provider in subtle ways. VA increases compensation when a disability worsens and reduces compensation when it improves. Increased-rating claims can be filed any time. VA does not require or award more compensation for treatment compliance or other steps toward improvement.
Conversely, there are no disincentives for non-compliance or failure to affirmatively act to improve function. In essence, incentives are not in line with the goal of functional improvement. Due to the pressure of financial incentives to resist improvement, some patients may exhibit an otherwise inexplicable reluctance to comply with a treatment plan, surgery, or other professional recommendations. SLPs and audiologists may benefit such patients by communicating sensitively to elicit and overcome potential compliance barriers.