November
7, 2018
Jordanna
Mallach came home from Afghanistan with a rasping cough that she could not
explain. She called it her Army asthma.
She had
chalked it up to the strain of the deployment when it first started, when she
would wake up gasping for breath as if something was squeezing the air from her
lungs. But it didn't end with the deployment. Her civilian doctors were just as
puzzled and powerless as she was. “They just didn't know what questions to
ask,” she says now.
Her
experience underscores what RAND researchers found when they surveyed
hundreds of private-sector health care providers. Most lacked the specialized
knowledge and training to treat veterans like Mallach. Few even asked their
patients whether they had ever served in the military.
That
raises a fundamental question as the U.S. Department of Veterans Affairs shifts
billions of dollars for veteran care to outside providers: Are those providers
even ready?
Access
Is an Issue, but So Is Quality
Mallach
faced a problem familiar to many veterans when she came home from her 2010
deployment with the Army National Guard struggling to catch her breath. Nearly
one-third of all U.S. veterans live 40 miles or more from the nearest VA
medical center; in her case, living in rural upstate New York, it was more like
100. When her breathing problems got bad, she opted for the nearest urgent care
clinic instead.
In
recent years, the VA has tried to make it easier for veterans like her to get
health care from private-sector providers closer to home. It plans to spend
more than $14 billion on such outside care in the coming year alone. “We are
committed to moving care into the community where it makes sense for the
veteran,” then–Secretary of Veterans Affairs David Shulkin promised last year.
Just 2
percent of New York health care providers met every standard to ensure timely,
high-quality care for veterans.
Yet
nobody had taken a close look at whether those outside providers were fully
prepared to treat veterans, a small but medically complex population with
higher rates of post-traumatic stress, toxic exposures, cancer, and diabetes.
With more veterans preferring to seek care in the community, the nonprofit New
York State Health Foundation decided that question needed some answers. It
brought in RAND to investigate.
Researchers
surveyed more than 700 private health care providers across the state, from New
York City to the small farming towns of western New York. They were physicians
and mental-health counselors, nurse practitioners and physical therapists.
Almost none had served in the military themselves.
Fewer
than a third knew enough about military culture to talk with veterans on their
own terms. Fewer than half screened their patients for conditions common among
veterans, like sleep problems or suicide risk.
Most
were unfamiliar with deployment-related health stressors (63 percent),
unprepared to address the unique health needs of women veterans (78 percent),
and unsure how to refer a patient to the VA (73 percent). Fewer than one in
five even asked their patients if they had ever served.
In all,
the researchers estimated that just 2 percent met every standard to ensure
timely, high-quality care for veterans.
New
York Health Care Providers' Readiness to Ensure Quality Care for Veterans
Accepting new patients
92%
and prepared to treat conditions common among
veterans
59%
and uses clinical practice guidelines
42%
and screens for conditions common among veterans
25%
and accommodates patients with disabilities
17%
and familiar with military culture 5%
and
screens patients for military/veteran affiliation 2%
Doctors
Need to Know What to Look for
“There's
this belief sometimes that the private sector has all the solutions and that by
providing veterans with more choice and greater access to community-based
providers, somehow their needs will be met,” said Terri Tanielian, a senior behavioral scientist
at RAND who led the study and has focused for more than a decade on how to
improve veteran care. But, she added, “You can't make a diagnosis if you don't
ask the questions.”
Mallach's
doctors were asking the questions, but they missed the clue. They knew she had
just come home from Afghanistan; they thought she might have developed a blood
clot in her lungs during the long flight home. It was a pulmonologist at the VA
who took one look at her file and asked, Were you near the burn pit on your
base?
The
burn pit. She had jogged past the noxious tower of burned plastic and
smoldering garbage almost every day during her morning laps around the base.
Service members exposed to burn pits on overseas bases have sometimes
complained of asthma-like symptoms and other breathing problems. The VA doctor
gave Mallach a steroid inhaler. She was breathing freely within a few days.
“The
civilian doctors were trying to treat something they just didn't know about,”
Mallach says now. “They were running a whole series of tests based on me having
a blood clot. I just don't think they had the awareness. None of the civilian
doctors recognized it for what it was.”
What
We've Learned from New York State
RAND's study looked only at New York
providers. But there's no reason to think its conclusions would be much
different in other states. New York has the fifth-largest population of
veterans in the country, so if anything, its providers might be more familiar
with veteran health needs than providers elsewhere.
The VA
has some leverage to make improvements. It could require more training and
testing on veteran care before it signs any community care contract with a
private-sector provider, researchers wrote. It also could better monitor the
providers it works with, to make sure they meet the same standards it sets for
itself. The state, too, could drive home the importance of veteran care by
adding questions about screening and treating veterans to its licensing exam.
It will
take “significant efforts” to better prepare private-sector providers to
deliver high-quality, culturally competent care to veterans, RAND's study
concluded.
“The
military goes to war, but I don't feel like we've gone to war as a country,
where everyone feels like we all need to serve in some capacity,” said Derek
Coy, a former Marine who served in Iraq and is now the veterans' health officer
for the New York State Health Foundation. “I think more people would get on
board if we put it out there like that. They'd see serving veterans as serving
their country, as a form of service, which benefits everyone.”
Previous
RAND research has shown that around half of
all New York veterans would choose to get care from community providers if they
could. That adds up to potentially hundreds of thousands of patients in need of
high-quality, specialized care, in one state alone.
Jordanna
Mallach is one of them. She still sees her pulmonologist at the VA twice a
year, just for checkups; but she stays closer to home for most other health
needs. When a dump truck slammed into the back of her car a few years ago, her
community doctors and therapists had all the training they needed to get her
back on her feet.
— Doug
Irving
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