At the Breaking Point

By Carrie Vaughan for HealthLeaders News , May 2, 2007
For the past couple of weeks, the House Veterans' Affairs Health Subcommittee has been holding hearings on the problems surrounding veterans' access to healthcare--especially in rural areas. Many rural communities are already designated mental health shortage areas and have limited access to primary and specialty care. The multitude of returning veterans from Afghanistan and Iraq in need of specialized physical and mental healthcare has placed still more strain on the system. The National Rural Health Association estimates that 44 percent of returning veterans are from rural America, due in part to the higher use of National Guard and reserve troops, experts say.

Veterans in rural areas are facing two key problems: geographic inaccessibility and timely access to care. The problem is not limited to Department of Veterans Affairs' healthcare facilities; providing care to veterans is an issue facing many private sector providers as some veterans are choosing to obtain their care locally rather than traveling long distances to VA facilities.

"It is a perfect storm of challenges," says Mary Wakefield, PhD, director of the Upper Midwest Rural Research Center. First, she says, the existing healthcare infrastructure cannot meet current needs. Second, the geographic distance to VA facilities can be challenging for many veterans; in some cases, the nearest VA facility might be 300 miles away. Lastly, mental health services still carry a negative stigma in many rural areas, she says.

In addition, many rural mental health providers are primary-care physicians, nurse practitioners or social workers who may not be equipped to treat post traumatic stress disorders or traumatic brain injuries, says Wakefield. "Do these providers have the expertise needed to treat these individuals, and what are we doing to make additional knowledge and skill sets available to those providers?"

The House panel has been sorting through several bills aiming to address these issues, including HR 92 sponsored by Rep. Ginny Brown Waite, R-FL, that would require VA hospitals and clinics to contract with private providers if veterans are unable to get access to primary care within 30 days. Another measure, HR 538 sponsored by Rep. Solomon Ortiz, D-TX, would establish an inpatient VA facility to provide care to more than 100,000 veterans in southern Texas who currently travel long distances to receive care. And Rep. Michael Michaud, D-ME, proposed initiatives that would establish mobile health clinics in rural areas to improve access and centers of excellence to conduct research on improving rural access to care.

How big is the problem?
Before any of these measures are implemented, one key question must be answered, experts say: How many veterans are actually affected by these problems? "We are hearing it anecdotally a lot," says Wakefield, "but we need to find out how big the issue is." Adrian Atizado, the assistant national legislative director for Disabled American Veterans, agrees. "We need to figure out how much we are talking about here. Not only how many veterans, but how much it is going to cost. Because if we just dive into situations like these bills are suggesting, then we might find ourselves in a very precarious situation," he says.

Atizado is also concerned about procuring care in the private sector. "It takes away the secretary's ability to control the situation--to control the program that he is responsible for." The DAV is apprehensive about shifting patient resources away from the existing VA healthcare system and the impact that could have on the quality of care, Atizado says. The concern is that without adequate patient volumes for providers to hone their skills, quality will suffer.

Not everyone shares Atizado’s concerns, however. Andy Behrman, president and chief executive officer of the Florida Association of Community Health Centers and chair of the NRHA Rural Health Policy Board, testified that linking VA services to existing rural health providers, such as critical-access hospitals, rural health clinics and federally qualified health centers, would improve access and quality of care for rural veterans. He also recommended increasing the number of Veterans Centers, Outreach Health Centers and Community Based Outpatient Centers, as well as boosting the number of Veterans Hospital Administration traumatic brain injury case managers in rural areas.

Plan of attack
One issue on which most everyone agrees is the importance of telehealth services, which can increase access points of care for veterans. Some parts of the U.S. already have the information technology infrastructure in place to create such access. For instance, Montana has had telemental health services for years, and “all of our hospitals are wired in North Dakota,” says Wakefield. “It is just not realistic to think that if [veterans] need treatment every week, they are going to travel 100 miles.”

In addition, telemental health services might be a good way to sidestep the negative stigma associated with mental healthcare in rural areas, says Wakefield. "In a small community, everyone may know that that red pickup is yours outside the physician’s office, but maybe you are going there for a sore throat," she says. Instead you can enter an exam room with real-time audio and video capabilities that connects you to a VA psychologist, she explains, adding that the VA is currently looking at expanding its telehealth services.

Timeline for action
So when can veterans expect to see better and more timely access to care? “We cannot move fast enough on this issue,” says Wakefield. “Maybe it takes a moon shot--a significant amount of resources thrown at the problem.”

No one wants to see veterans go without the healthcare that they need, says Atizado. “If they really want this, it can happen a lot sooner than the average time it takes a bill in Congress to pass. But Congress moves slow for a reason--to make sure the solution is the best solution we can come up with right now.”

Atizado just hopes that the solution doesn’t divert resources away from older veterans. “We are talking about new money. Don’t take away money from existing programs. Otherwise, you are taking resources away from one veteran and giving it to another.”

Carrie Vaughan is editor of HealthLeaders Media Community and Rural Hospital Weekly. She can be reached at




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