from Colonel Dan AMA on veterans healthcare article

The battle at home: Struggling for VA health care access
Veterans are encountering administrative barriers, waiting lists and staffing shortages when they try to use the VA's health system.
By David Glendinning, AMNews staff. Dec. 3, 2007.

http://www.ama-assn.org/amednews/2007/12/03/gvsa1203.htm


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For some veterans, the fight didn't stop on the streets of Iraq or in the mountains of Afghanistan. Despite the promise that world-class medical care would be there for them when they arrived home, some are running into a bureaucratic battlefield and a stressed system struggling to give aid.

Recent congressional and public attention has focused on access problems at the Dept. of Veterans Affairs, which provides medical care to servicemen and women once they have left active duty in a time of war or an official period of hostility. Although investigators note that improvements are under way, they say the VA has a long way to go.

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Nearly 700,000 active-duty personnel and reservists who served in Operation Iraqi Freedom and Afghanistan's Operation Enduring Freedom have been eligible for VA health care since 2002. More than 200,000 have sought it out so far, the Congressional Budget Office reported in October. While this represents only a small fraction of the nearly 8 million veterans from all conflicts who are enrolled, the impact of veterans from today's wars on the system is great.

Thanks to recent advances in battlefield medicine, more servicemen and women are surviving severe injuries, CBO said. But they require more costly medical care when they return. The rapid influx of new enrollees has helped strain a system that already was under pressure from caring for the veterans of yesterday's wars. In 1995, fewer than 3 million veterans received VA health services. That number had increased to 5 million last year.

Many of the resulting access problems start at the very beginning of the enrollment process, said Donna E. Shalala, PhD, president of the University of Miami and former Dept. of Health and Human Services secretary. She co-chaired a presidential commission on care for America's "wounded warriors" that convened earlier this year after news reports exposed substandard conditions and a mass of red tape at Walter Reed Army Medical Center in Washington, D.C.

Although the Dept. of Defense and VA need to work together to foster a patient-centered continuum of care for each veteran, the commission found evidence that returning personnel were not experiencing a smooth transition from military health care to the veterans system, Dr. Shalala said.

There are nearly 8 million veterans in the VA system.
Without designated care coordinators to plan the best treatment path for new patients, an untold number ended up lost.

In addition, injured combatants must go through two antiquated disability assessments -- one by the military and one by the VA -- to determine what treatment options are available. This means that many are forced to jump through bureaucratic hoops that might not even get them to the right place, Dr. Shalala said.

"For veterans' families to give up everything just to coordinate this care themselves is fundamentally unfair," she said. "The process is too old-fashioned. It has nothing to do with modern medicine, and we ought to be embarrassed."

The Bush administration scrambled to correct several problems identified in the commission's July report. The Defense Dept. and VA in October agreed on an initial plan to place at least 10 care coordinators at four military medical sites that often serve as the first stop for wounded veterans. The Army also announced in October the formation of "warrior transition units" consisting of primary care physicians, nurse case managers and mental health professionals that would serve a similar purpose.

But Dr. Shalala said progress is still slower than she would like, and some of the commission's recommendations would require tough congressional action. The proposal to consolidate and modernize the disability review process, for instance, quickly became mired in partisan bickering.

Delays and headaches
For veterans who make it through the VA's bureaucratic gauntlet, the care they need might not be immediately accessible or available.

The department has more than 150 hospitals and nearly 900 outpatient clinics. While the number of facilities has increased in recent years, it is not nearly enough to provide VA services everywhere in the country. Many patients in rural or remote areas must travel hundreds of miles to reach the nearest department facility -- an impossible prospect for many.

The VA has more than 150 hospitals and nearly 900 outpatient clinics.
Jeffrey Scavron, MD, a former Navy doctor who practices at a community health center in Springfield, Mass., has seen this problem firsthand. Veterans in his area can get basic services at the Northampton VA Medical Center in nearby Leeds, Mass., but often must travel to Boston or Connecticut if they need to see certain types of specialists through the system. Some simply cannot make the trip and go without the care rather than pay for it, he said.

When veterans decide to stick with the VA, the system does not always respond quickly. Advocacy groups have complained to lawmakers that some enrollees seeking appointments, non-emergency surgeries or other medical care have been placed on waiting lists when facilities have been unable to meet demand.

In recent years, Spokane (Wash.) VA Medical Center implemented waiting lists when lean federal budgets forced it to cut back on services, said Joseph M. Manley, the center's former director. At one point, more than 3,000 veterans were waiting for more than a year just to receive their initial medical appointments.

The VA strives to see all patients within 30 days of when they call for an appointment. Out of the roughly 39 million appointments processed in a year, about 4 million exceed the 30-day threshold, said Michael J. Kussman, MD, the VA's health under secretary. While this leaves room for improvement, the department is proud of its nearly 90% record, especially because these appointments are not for urgent or emergent medical situations, he said. "I'm not aware of people being hurt in any way by some of the delays."

The VA's record is disputed by the department's inspector general, who in September released an audit that found the VA analysis likely understated wait times.

Not enough doctors to go around
Some facilities have little choice but to make patients wait for treatments or to refer them elsewhere because they do not have enough medical personnel. The department has struggled, along with many private health systems, to provide quick access to such in-demand subspecialists as dermatologists, ophthalmologists and otolaryngologists, Dr. Kussman said. Mental health professionals also are at a premium, the VA reports.

Some experts on the ground say the situation can be particularly difficult for the department when it attempts to treat veterans who have complex and specialized wounds, such as traumatic brain injuries -- the signature injury of today's wars.

1.8 million veterans were uninsured in 2004, up nearly 300,000 since 2000.
The VA polytrauma rehabilitation center in Palo Alto, Calif., is touted as a flagship for taking care of the most severely wounded veterans but still faces major staffing concerns. The center works hard to attract and retain physicians and others in a very competitive market, but it has fallen short of recruitment goals for physiatrists and other medical professionals, said its director, Elizabeth Joyce Freeman.

Veterans advocacy groups say the way the VA receives federal health funding is largely to blame for many of its shortfalls. Unlike Medicare and Medicaid, which receive mandatory funding every year based on projected costs, the department gets its money from the discretionary budget. This process is much less predictable and more prone to political tinkering.

Although Congress in recent years has kept up a steady stream of funding that has satisfied many advocates, the process has not been without missteps.

The department weathered an embarrassing episode in 2005 when then-Secretary R. James Nicholson went to Congress with a request for $2.6 billion in additional funding because it had vastly underestimated the number of Iraq and Afghanistan veterans who would require care.

The budget unpredictability makes it hard for VA facilities to plan ahead on hiring physicians or buying equipment, said Joseph A. Violante, the Disabled Veterans of America national legislative director.

Veterans can be waitlisted or shut out as a result.

"If the VA was able to get the funding on time and was able to know beforehand what that funding level was going to be, a lot of those access problems would be solved," he said.

The department opposes mandatory funding because the process would not easily adapt to changes in clinical practice or enrollee demographics, said W. Paul Kearns III, VA chief health financial officer.

Finding care outside -- or not at all
For some veterans, accessing VA health care simply will not be the best option because of their circumstances, locations or the specialized care they need. Some, especially those who plan to return to active duty, will continue to receive care from the military. Others will enroll in private insurance or receive coverage through another government program once they re-enter private life.

The department has boosted the amount it spends on private-sector care for veterans who remain enrolled in the VA but need to receive care outside the system. In fiscal year 2007, the department committed $2.2 billion out of its roughly $35 billion health budget to such fee-for-service care, a figure that has doubled since 2000.

For others, accessing VA health care is not an option at all. In 2003, the Bush administration decided to cut off new enrollment for many Priority Group 8 veterans, the department's lowest disability rating. These veterans are deemed to have sustained no service-connected disabilities and have yearly incomes that exceed predetermined limits, about $28,000 for an individual.

All combat veterans who have served in Iraq and Afghanistan are still guaranteed two years of free VA care after they return, and Priority Group 8 combat veterans who enroll during that window can keep receiving the care beyond that timeframe by making set co-payments. But those who fail to enroll in time risk losing access unless they later can prove they actually sustained a disability during their service.

Lawmakers have proposed extending the free combat veteran care from two years to five years, a move the White House supports. The Bush administration, however, opposes any plan to reopen new enrollment to non-combat Priority 8 veterans because the new enrollees would cost tens of billions over the decade and could hurt access and quality for higher priority patients, Dr. Kussman said.

But as long as this and other barriers exist, veterans who can't afford or obtain private coverage will go without needed care, said Steffie Woolhandler, MD, MPH, a Harvard Medical School professor and co-founder of Physicians for a National Health Program, a single-payer advocacy group. An October study she co-authored concluded that 1.8 million veterans from all conflicts were uninsured in 2004, up nearly 300,000 since 2000. Nearly half of them had not seen a physician in more than a year.

Dr. Scavron, the former Navy physician, said the uninsured veterans he sees in his clinic are evidence that the government is not fulfilling its responsibilities

"It's only the government that can take you into military service," he said. "So it seems to me that it's only the government who can take responsibility for the people that they take into service."

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ADDITIONAL INFORMATION:
Strains on the system
A higher percentage of servicemen and women are surviving injuries in today's wars than they did in the past, thanks largely to extensive body armor use, improved battlefield medicine and immediate aerial evacuation of the wounded.

In the Vietnam War, there were 5.2 wounded for every service member who died; in Iraq, that ratio is 7.6 to 1.

More Iraq and Afghanistan veterans are accessing the VA health care system each year, and the price the government pays for each patient increases:

Veterans treated Average annual
cost per patient
2005 101,000 $2,310
2006 155,000 $2,610
2007 209,000 $2,740
2008 263,000 $2,860

Note: Data for 2007 and 2008 is projected.

Source: "Projecting the Costs to Care for Veterans of U.S. Military Operations in Iraq and Afghanistan," Congressional Budget Office, October

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