Expert Commentary

The U.S. Veterans Affairs Department and challenges to providing care for service members: Research roundup

2014 roundup of recent research on the difficulties that retired troops face when using V.A. services and the challenges to reforming the organization and improving its efficiency.

US veteran on Memorial day

In September 2015, a third-party report prepared for the U.S. Department of Veterans Affairs was released detailing a “leadership crisis” within the health care delivery system that serves over 9.1 million veterans. This report was mandated by the Veterans Access, Choice, and Accountability Act of 2014, which was passed by Congress amidst accusations that these healthcare facilities were underserving its patients. In some cases, delayed care was blamed for the death of veterans, some of whom were put on “secret lists” meant to falsify the documented patient wait times at V.A. facilities.

The report came on the heels of a tumultuous year and a half for the V.A. In May 2014, the department’s Inspector General launched an investigation after managers of a V.A. hospital in Phoenix, AZ were accused of concealing months-long wait times; the probe eventually widened to include 26 medical facilities. Dr. Robert Petzel, the V.A. Undersecretary for Health quickly resigned, followed by Secretary Eric Shinseki. Two-months later, Robert McDonald was appointed to the position with a mandate to address long-standing problems at the agency. He soon faced criticism that he wasn’t moving fast enough. In July 2015, McDonald appeared at a hearing of the House Veteran Affairs Committee, in which he asked for funds to close the $2.5 billion gap for his department’s 2015 budget. During the hearing, McDonald was questioned by representatives on why these concerns were not brought up sooner and on his department’s lack of accountability.

The intense pressure on V.A. facilities is the consequence of a number of interlinked factors. Thanks to improved medical care, more service members survive battle — currently, 16 are wounded for every one killed, compared to 2.6 soldiers wounded for every one killed in Vietnam. When soldiers do come home, their injuries can be more profound and the care required more involved. Thousands suffer from post-traumatic stress disorder (PTSD), many have lost one or more limbs, and even injuries that seem to leave no external sign can have a severe impact, including traumatic brain injury (TBI). Meanwhile, many of the V.A.’s technical patient management systems are out of date, leading to considerable duplication, delays and errors.

The proposed budget for the V.A. — which enrolls 9.1 million veterans of the estimated 21.9 million living U.S. veterans — in fiscal year 2015 is $158.6 billion, according to a May 2014 Congressional Research Service (CRS) report, which also notes that in 2015 the V.A. “anticipates treating more than 757,000 Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND) veterans.” Between fiscal years 2011 and 2014, the number of V.A. enrollees increased 6.3%.

The Department of Defense estimates that more than 50,000 service members have been wounded in action during the Global War on Terror conflicts, but that figure does not fully capture mental health needs or still-emerging disabilities. A 2013 CRS report provides a detailed look at all casualty statistics and spells out the extent of the mental health injuries. A 2014 survey by the Washington Post and Kaiser Family Foundation of Iraq and Afghanistan veterans found deep dissatisfaction with current levels of government care. The Iraq and Afghanistan Veterans of America (IAVA) issued a 2014 report exploring the troubles with the V.A. claims backlog and detailing the experiences of service members.

A 2013 report from the Harvard Kennedy School estimates that spent or accrued costs for post-9/11 veterans’ medical and disability care are already $134.3 billion, and may run as high as $970.4 billion by 2053. For more, see Brown University’s “Costs of War” project which states as one of its goals “to identify less costly and more effective ways to prevent further terror attacks.”

As The New Republic noted in a May 21 2014 article, the V.A.’s problems are anything but new: A 2001 report from the Government Accounting Office warned that wait times were often excessive even then. In 2007 the Army general in charge of the Walter Reed medical center was fired after the Washington Post revealed poor living conditions and excessive red tape at the facility. A presidential commission recommended “fundamental changes” to the V.A. system, but change has been slow to come. In 2013, a whistleblower revealed chronic understaffing and life-threatening medical mistakes at a Mississippi V.A. hospital and in July of that year, the Department of Veterans Affairs released a “strategic plan” to eliminate the claims backlog.

Below is a roundup of other background research on the Veterans Affairs Department and the challenges it faces in providing care to former soldiers, now and in the future. For journalists covering veterans issues, the American Journal of Public Health publishes a wide range of studies, including new research on suicide risks, gender disparities and the challenges of providing care to homeless veterans.



“Access to the U.S. Department of Veterans Affairs Health System: Self-reported Barriers to Care Among Returnees of Operations Enduring Freedom and Iraqi Freedom”
Elnitsky, Christine A.; et al. BMC Health Services Research, December 2013, 13:498. doi: 10.1186/1472-6963-13-498.

Abstract: “The U.S. Department of Veterans Affairs (VA) implemented the Polytrauma System of Care to meet the health care needs of military and veterans with multiple injuries returning from combat operations in Afghanistan and Iraq…. We studied combat veterans (n = 359) from two polytrauma rehabilitation centers using structured clinical interviews and qualitative open-ended questions, augmented with data collected from electronic health records. Our outcomes included several measures of exclusive utilization of VA care with our primary exposure as reported access barriers to care. Results: Nearly two thirds of the veterans reported one or more barriers to their exclusive use of VA healthcare services. These barriers predicted differences in exclusive use of VA healthcare services. Experiencing any barriers doubled the returnees’ odds of not using VA exclusively, the geographic distance to VA barrier resulted in a seven-fold increase in the returnees’ odds of not using VA, and reporting a wait time barrier doubled the returnee’s odds of not using VA. There were no striking differences in access barriers for veterans with polytrauma compared to other returning veterans, suggesting the barriers may be uniform barriers that predict differences in using the VA exclusively for health care.”


“Health Care Spending and Efficiency in the U.S. Department of Veterans Affairs”
Auerbach, David I.; Weeks, William B.; Brantley, Ian. RAND Corporation, 2013.

Abstract: “In its 2013 budget request, the Obama administration sought $140 billion for the U.S. Department of Veterans Affairs (VA), 54% of which would provide mandatory benefits, such as direct compensation and pensions, and 40% of which is discretionary spending, earmarked for medical benefits under the Veterans Health Administration (VHA). Unlike Medicare, which provides financing for care when its beneficiaries use providers throughout the U.S. health care system, the VHA is a government-run, parallel system that is primarily intended for care provision of veterans. The VHA hires its own doctors and has its own hospital network infrastructure. Although the VHA provides quality services to veterans, it does not preclude veterans from utilizing other forms of care outside of the VHA network — in fact, the majority of veterans’ care is received external to the VHA because of location and other system limitations. Veterans typically use other private and public health insurance coverage (for example, Medicare, Medicaid) for external care, and many use both systems in a given year (dual use). Overlapping system use creates the potential for duplicative, uncoordinated, and inefficient use. The authors find some suggestive evidence of such inefficient use, particularly in the area of inpatient care. Coordination management and quality of care received by veterans across both VHA and private sector systems can be optimized (for example, in the area of mental illness, which benefits from an integrated approach across multiple providers and sectors), capitalizing on the best that each system has to offer, without increasing costs.”


“Recovering Servicemembers and Veterans: Sustained Leadership Attention and Systematic Oversight Needed to Resolve Persistent Problems Affecting Care and Benefits”
Government Accountability Office, November 2012, GAO-13-5.

Findings: “Deficiencies exposed at Walter Reed Army Medical Center in 2007 served as a catalyst compelling the Departments of Defense (DOD) and Veterans Affairs (VA) to address a host of problems for wounded, ill, and injured servicemembers and veterans as they navigate through the recovery care continuum. This continuum extends from acute medical treatment and stabilization, through rehabilitation to reintegration, either back to active duty or to the civilian community as a veteran. In spite of 5 years of departmental efforts, recovering servicemembers and veterans are still facing problems with this process and may not be getting the services they need. Key departmental efforts included the creation or modification of various care coordination and case management programs, including the military services’ wounded warrior programs. However, these programs are not always accessible to those who need them due to the inconsistent methods, such as referrals, used to identify potentially eligible servicemembers, as well as inconsistent eligibility criteria across the military services’ wounded warrior programs. The departments also jointly established an integrated disability evaluation system to expedite the delivery of benefits to servicemembers. However, processing times for disability determinations under the new system have increased since 2007, resulting in lengthy wait times that limit servicemembers’ ability to plan for their future. Finally, despite years of incremental efforts, DOD and VA have yet to develop sufficient capabilities for electronically sharing complete health records, which potentially delays servicemembers’ receipt of coordinated care and benefits as they transition from DOD’s to VA’s health care system.”


“Department of Veterans Affairs: Strategic Plan to Eliminate the Compensation Claims Backlog”
Department of Veterans Affairs, January 2013

Introduction: “The VBA completed a record-breaking 1 million claims per year in fiscal years 2010, 2011, and 2012. Yet the number of claims received continues to exceed the number processed. In 2010 VBA received 1.2M claims. In 2011, VBA received another 1.3M claims, including claims from veterans made eligible for benefits as a result of the Secretary’s decision to add three new presumptive conditions for Veterans exposed to Agent Orange. In 2012, VBA received 1.08M claims. Over the last three years, the claims backlog has grown from 180 thousand to 594 thousand claims…. But too many veterans have to wait too long to get the benefits they have earned and deserve. These delays are unacceptable. This report outlines VA’s robust plan to tackle this problem and build a paperless, digital disability claims system — a lasting solution that will transform how we operate and ensure we achieve the Secretary’s goal of eliminating the claims backlog and improving decision accuracy to 98 percent in 2015.”


“Departments of Defense and Veterans Affairs: Status of the Integrated Electronic Health Record (iEHR)”
Panangala, Sidath Viranga; Jansen, Don J. Congressional Research Service, 2013.

Introduction: “In December 2010, the Deputy Secretaries of [the Department of Defense and the Veterans Administration] directed the development of an integrated Electronic Health Record (iEHR) , which would provide both Departments an opportunity to reduce costs and improve interoperability and connectivity. On March 17, 2011, the Secretaries of DOD and VA reached an agreement to work cooperatively on the development of a common electronic health record and to transition to the new iEHR by 2017. On February 5, 2013, the Secretary of Defense and the Secretary of Veterans Affairs announced that instead of building a single integrated electronic health record (iEHR), both DOD and VA will concentrate on integrating VA and DOD health data by focusing on interoperability and using existing technological solutions. This announcement was a departure from the previous commitments that both Departments had made to design and build a new single iEHR, rather than upgrading their current electronic health records and trying to develop interoperability solutions…. It is unclear at this time what the long-term implications of the most recent change in the program strategy will be.”


“Uninsured Veterans and Family Members: Who Are They and Where Do They Live?”
Haley, Jennifer; Kenney, Genevieve M. Urban Institute, May 2012.

Findings: Approximately 1 in 10 — 1.3 million — of the country’s 12.5 million nonelderly veterans did not have health insurance coverage or access to Veterans Affairs (VA) health care as of 2010. When family members of veterans are included, the uninsured total rises to 2.3 million. An additional 900,000 veterans use VA health care but have no other coverage. Nearly 50% of uninsured veterans have incomes at or below 138% of the Federal Poverty Line ($30,429 for a family of four in 2010). Under the Affordable Care Act (ACA), these would qualify for coverage as of January 2014. Another 40.1% of veterans and 49% of their families have incomes that qualify for new subsidies through health insurance exchanges with the ACA. The uninsured rate is 12.3% in states with the least progress on exchange implementation, compared with 9.6% to 9.8% for veterans in states with most progress to health insurance exchange implementation.


“Improving Trends in Gender Disparities in the Department of Veterans Affairs: 2008–2013”

Whitehead, Alison M.; et al. American Journal of Public Health, September 2014, Vol. 104, No. S4, S529-S531, doi: 10.2105/AJPH.2014.302141.

Abstract: “Increasing numbers of women veterans using Department of Veterans Affairs (VA) services has contributed to the need for equitable, high-quality care for women. The VA has evaluated performance measure data by gender since 2006. In 2008, the VA launched a 5-year women’s health redesign, and, in 2011, gender disparity improvement was included on leadership performance plans. We examined data from VA Office of Analytics and Business Intelligence quarterly gender reports for trends in gender disparities in gender-neutral performance measures from 2008 to 2013. Through reporting of data by gender, leadership involvement, electronic reminders, and population management dashboards, VA has seen a decreasing trend in gender inequities on most Health Effectiveness Data and Information Set performance measures.”


“Racial Disparities in Cancer Care in the Veterans Affairs Health Care System and the Role of Site of Care”
Samuel, Cleo A.; et al. American Journal of Public Health, September 2014, Vol. 104, No. S4, S562-S571. doi: 10.2105/AJPH.2014.302079

Abstract: “We assessed cancer care disparities within the Veterans Affairs (VA) health care system and whether between-hospital differences explained disparities…. Compared with Whites, Blacks had lower rates of early-stage colon cancer diagnosis; curative surgery for stage I, II, or III rectal cancer; 3-year survival for colon cancer; curative surgery for early-stage lung cancer; 3-dimensional conformal or intensity-modulated radiation; and potent antiemetics for highly emetogenic chemotherapy…. Conclusions: Disparities in VA cancer care were observed for 7 of 20 measures and were primarily attributable to within-hospital differences.”


“Retaining Homeless Veterans in Outpatient Care: A Pilot Study of Mobile Phone Text Message Appointment Reminders”
McInnes, D. Keith; et al. American Journal of Public Health, September 2014, Vol. 104, No. S4, S588-S594. doi: 10.2105/AJPH.2014.302061.

Abstract: “We examined the feasibility of using mobile phone text messaging with homeless veterans to increase their engagement in care and reduce appointment no-shows… Results: Participants were satisfied with the text-messaging intervention, had very few technical difficulties, and were interested in continuing. Patient-cancelled visits and no-shows trended downward from 53 to 37 and from 31 to 25, respectively. Participants also experienced a statistically significant reduction in emergency department visits, from 15 to 5 and a borderline significant reduction in hospitalizations, from 3 to 0. Conclusions: Text message reminders are a feasible means of reaching homeless veterans, and users consider it acceptable and useful. Implementation may reduce missed visits and emergency department use, and thus produce substantial cost savings.”


Keywords: veterans affairs, health care, PTSD, TBI, cost-effectiveness, military budgets and defense, research roundup

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