WASHINGTON—Recent problems with initiatives implemented by the Veterans Benefits Administration point to much larger, systemic issues in how the agency rolls out new programs, according to the VA Office of the Inspector General.

Appearing before the House VA Subcommittee on Disability Assistance and Memorial Affairs last month, OIG officials testified that VBA’s emphasis on efficiency has come at the cost of their ability to review and process claims effectively.

Lawmakers expressed frustration at what they consider a pattern of reactionary behavior at VA—rolling out a new program; learning about problems afterward; then rushing to fix them.

“If the IG didn’t flag these programs, I don’t know how the VBA would have ever identified the problem and taken corrective action,” declared Subcommittee Chair Rep. Mike Bost (R-IL). “I think one reason that VBA’s new initiatives fail or have problems is because VBA is so anxious to find a silver bullet that painlessly solves all the problems. VBA repeatedly rolls out new initiatives without testing them or considering the downstream impact, how it would impact VA, or how it would serve the veteran.”

OIG cited four recent reports they believe are emblematic of the problem. One released late last year found that VBA staff requested unwarranted medical reexaminations in 111 of 300 cases reviewed. The report found that a lack of internal controls and inadequate quality assurance reviews were among the root causes of the problem.

Another report, released in August 2018, found VBA may have mistakenly denied PTSD claims related to military sexual trauma due to lack of specialized reviewer training and the absence of any additional level of review. Inaccurate claims decisions were also the focus of a third review—this one looking at claims of service-connected ALS. The OIG found that in 100 sample cases, VBA staff made 71 errors involving 45 veterans’ ALS claims.

A fourth report looked at VBA’s intent to file submission initiative. The initiative allows a veteran to preserve an early effective date, even if they don’t yet have all the information to file the formal claim. The OIG estimated that, of the 1 million ITF submissions received by VA between March 2015 and September 2017, as many as 137,000 cases may have had incorrect dates assigned—errors made by VBA’s electronic claims processing system. While VBA assured legislators that this issue has been resolved, with the rate of incorrect claims down to 4%, the fact that the errors occurred because VBA was unprepared when the initiative went live is why VBA included it in its summary of VBA’s larger issues.

“Root causes of the problems we found include deficient internal controls, inadequate program leadership and monitoring, lack of IT system functionality and the unintended impacts of VBA’s National Work Queue implementation,” VA Inspector General Michael Missal told lawmakers. The NWQ is designed to distribute claims daily to each VA regional office based on factors such as workload capacity, claims processing priorities and special missions (claims that require special handling). When the NWQ went live in 2016, many specialized claims, including MST-related claims, were assigned to processors that did not have the proper expertise or experience.

While Missal testified that he believes policy changes and programs such as the NWQ are well-intentioned, problems occur due to VBA leadership making decisions without considering possible unintended consequences. “They’re sacrificing accuracy for timeliness,” Missal said. “VBA is rolling out national initiatives after small and short pilot programs [and they’re] implementing programs that do not have fully developed IT systems and robust internal controls.”

Missal also cited communication issues within VBA as a continuing problem. “There are instances where one side is aware of an issue, but the other side doesn’t get the same information,” he said.

VBA officials agreed with the inspector general’s unflinching critique and promised better performance in the future with VA Undersecretary for Benefits Paul Lawrence admitting that VBA has a history of implementing too many programs too quickly.

“Previously, we issued unilateral decisions and did not engage our stakeholders early enough,” Lawrence said. “VBA is now focused on continuous improvement [and] fostering a culture of collaboration.”

Asked how VBA intended to make these changes, Lawrence said he hoped to change the culture by modeling better practices at the leadership level. “Decisions were made very quickly with not the right expertise in the room,” he said. “We want to slow things down. We want more people in the room to make sure we have the right voices.”