Author Terri Tanielian

WASHINGTON — As the debate about increasing access for veterans to community-based provider heats up, a serious problem has emerged: Few providers outside the VA health system appear to be prepared to meet the unique challenges of the veteran population.

In New York state, for example, only 2% of providers have the preparation to provide prompt, quality care to veterans, according to a recent RAND Corporation study. The shortage is especially acute among mental health professionals.1
A lack of community care coordinators at the VA, exacerbated by continued funding difficulties, is likely to make preparing additional providers and expanding the network even more challenging. Then-VA Secretary David Shulkin testified in March that the Veterans Choice program could run out of money in late May. The program has lurched from temporary funding extension to financial crisis repeatedly since its inception in 2014 and has nearly run out of money three times in the past year.

In April, TriWest Healthcare Alliance, which arranges community care for veterans through the Choice program, told Congress that the continued funding issues threaten veteran access and physician participation. Without a resolution soon, “veterans will be denied access to the community provider network we have constructed to support VA, providers likely will experience substantial claims payment delays, and TriWest will be forced to reduce as much as 25 percent of our workforce just to survive, if that’s even possible,” wrote TriWest’s President and CEO David McIntyre Jr.

Even if Congress addresses the funding issues, veterans already face barriers to quality care which will likely grow, if the number seeking services in their communities rises, even in areas with an abundance of healthcare providers.
The RAND researchers found that 92% of providers initially appear to be well positioned to accept new patients, including veterans, in a survey of 746 physicians, nurse practitioners, physician assistants, mental health therapists and physical and occupational therapists.

Rates dropped quickly, however, when the researchers “asked a series of questions designed to understand aspects of the availability of care in their settings, their perceived preparedness to manage patients with a range of conditions (those known to be common among veterans), the frequency with which they implemented screenings, the types of accommodations for individuals with disabilities made in their office settings and their familiarity with military and veteran culture,” said lead author Terri Tanielian, MA, a senior behavioral scientist at RAND.

The questions reflected issues previously identified in medical literature as critical to providing high-quality care to veterans. They also asked about providers’ use of clinical practice guidelines and their perceptions of the VA and the VA Community Care program. The researchers considered providers ready to serve veterans if they met all seven criteria, a hurdle met by only 2.3% of respondents.

“As you layer on these dimensions of preparedness, the proportion of providers who meet our criteria declines,” Tanielian told U.S. Medicine. Half of providers said they could see a new patient within two weeks. Just 19% asked patients about their military experience or veteran status, although nearly 80% said they treat veterans, servicemembers or military families. Only 13% had participated in any formal training on veteran culture, even though the VA offers extensive resources for providers to learn about military and veteran culture and healthcare conditions common among former servicemembers, she said.

Not asking about military history or understanding veteran culture might cause providers to “miss important opportunities to develop a therapeutic alliance with their veteran patients, and [they] may not ask appropriate screening questions about their health-related concerns and conditions,” Tanielian said.

Overlooking Problems

That could lead clinicians to overlook problems common among veterans but less frequently seen among individuals who have never served in the armed forces, such as traumatic brain injury, post-traumatic stress disorder, chronic multisymptom illness (formerly called Gulf War Syndrome), occupational exposures such as Agent Orange or burn pits and spinal injuries. The oversight could result in worsening conditions and poorer health outcomes, she noted.

Only 5% of providers surveyed participate in Veterans Choice or other VA community care programs. Two-thirds of providers were unaware of the programs, and 1 in 8 expressed concerns about the reimbursement rates and paperwork associated with working with the VA.

RAND worked with the New York State Health Foundation to evaluate the ability of that state’s healthcare providers to deliver high-quality care to veterans. “We know from earlier RAND research that about half of New York’s veterans prefer to get care in their own communities, rather than at the VA,” said David Sandman, president and CEO of the New York State Health Foundation. More than 800,000 veterans call the Empire State home.

“These findings reveal significant gaps and variations in the readiness of community-based healthcare providers to provide high-quality care to veterans,” Tanielian pointed out. “It appears that more work needs to be done to prepare the civilian healthcare workforce to care for the unique needs of veterans.”

Veterans may seek community-based care for a multitude of reasons. The Veterans Choice program will pay for veterans to seek outside care, if the nearest VA medical facility cannot see them within 30 days of the next clinically indicated date or lacks the needed service or if the veteran must travel more than 40 miles from home to see a primary care physician and in some other instances. Last year, 36% of VA appointments were made through the Veterans Choice program, the VA reported.

Other veterans might prefer to seek non-VA care to avoid having treatment documented in their record that could limit their ability to serve in the reserves or return to military service. Many veterans have insurance coverage through Medicare or employers and use the networks associated with those payers. Previous studies have shown that, on average, veterans who are eligible for VA healthcare only receive 30% of their care at the VA.

1Tanielian T, Farmer CM, Burns RM, Duffy EL, Setodji CM. Ready or Not? Assessing the Capacity of New York State Health Care Providers to Meet the Needs of Veterans. Mar 1, 2018. RAND Corporation.