Question: How do orthopedics, geography, and psychiatry mix with national
Answer: When care for military veterans in rural areas gets complicated by
distance and red tape.
Bill Dugan, L.C.S.W., is a veteran of the Vietnam War and counsels other
vets for Ozarks Behavioral Healthcare under a contract with the Department of
Veterans Affairs (VA) in south-central Missouri. He cites that confluence of
complicating factors to explain cases he works with every day.
For example, a screw holding together the broken leg of one of Dugan's
clients snapped, leaving the man in pain. There were no orthopedic services at
the VA hospital in Poplar Bluff, itself 100 miles away over"
wretched" roads, and the VA wanted the man to drive 200 miles to
its hospital in St. Louis to repair the bone.
Only when Dugan reported that the man was "suicidal" with pain
was he allowed to admit him to a local hospital for treatment.
Dugan's client is just one of many veterans living far from cities who must
overcome extra barriers to physical or psychiatric care.
Although only 20 percent of Americans live in rural areas, 41 percent of
the patients getting their care through the VA live in sparsely populated
Rural veterans have worse access to primary, long-term, substance abuse,
mental health, dental, and public health services, said Rep. Michael Michaud
(D-Maine), chair of the House Subcommittee on Health of the Committee on
Veterans' Affairs, at a hearing last month.
Now Congress is turning its attention to ways to improve access to care for
these veterans. It passed legislation last year creating the Office of Rural
Health. The VA is now organizing and staffing that office, said a VA
Rural veterans tend to be older and have poorer health practices than their
metropolitan or suburban counterparts, according to VA research.
"All psychiatric disorders except anxiety disorders not related to
posttraumatic stress disorder were more prevalent in urban settings,"
according to an article in the June 2006 Psychiatric Services."
Although less likely than their urban counterparts to have mental
disorders, rural veterans with mental illness experienced a greater disease
burden and were likely to incur greater health care costs. Improving access to
mental health care for veterans in rural settings may narrow quality-of-life
disparities among rural and urban veterans."
The subcommittee sought some perspective on rural health from Marcia Brand,
Ph.D., associate administrator for rural health policy in the Health Resources
and Services Administration (HRSA), a part of the Department of Health and
Human Services. HRSA also sponsors the National Health Service Corps, which
tries to fill gaps in service in rural and other underserved areas (see
"Practicing in Rural America Often a Juggling Act").
People in rural areas face more than one barrier to accessing health
services, said Brand. Distance from clinics or hospitals is only the start.
Often, medical infrastructure simply is not available within reasonable
distances, with mental health and dental services lagging the farthest
(Michaud noted that veterans in the northernmost part of his state required
a four-day round trip to get to and from the Boston VA Medical Center.)
Often when they do reach medical services outside the VA, rural vets are
not asked as part of their medical history if they were ever in the armed
Any failures to inquire about veteran status are probably not due to law or
regulation, explained Brand in a later interview. These data were not"
collected by federally qualified health centers, so these health
centers would not be able to tell you how many veterans they serve."
Nor would small rural hospitals, which probably vary in how they gather
such information, know which patients are vets, she said. Other sources have
recommended such queries as a means of ascertaining exposure to violence,
explosions, infectious diseases, and other risk factors. Knowledge of military
service in a medical history can alert clinicians to increased probability of
depression, anxiety, or post-traumatic stress disorder.
"I believe asking about military service would [provide] important
information for a clinician to have for diagnosis and treatment, as well as
for screening and prevention," she said, but gathering such data may not
"The HRSA hopes to increase the co-location of primary and mental
health services to make access easier and less stigmatizing for
patients," said Brand, echoing some of the thinking within the VA.
In previous sessions, Congress has encouraged use of federally qualified
community health centers as sites where veterans could seek treatment paid for
by their VA benefits. Such arrangements have worked successfully in Wisconsin,
Missouri, and Utah, but no formal national policy has emerged to cement this
relationship, said Andy Behrman, the National Rural Health Association's rural
health policy board chair.
Paying for locally available services makes sense to many.
"If patients need an X-ray or physical therapy, why should they have
to drive a couple of hundred miles?" asked Dugan, in a separate
interview. "They should contract out the service to providers in the
local community and pay the same as Medicare."
Getting the VA to pay for veterans' care at non-VA health facilities raises
red flags for some veterans' groups, however. They fear that paying community
or private professionals to treat veterans may undermine the entire VA health
"Any such collaboration should be used judiciously so that the VA
doesn't become just an insurance agency," said Adrian Atizado, assistant
national legislative director for the Disabled American Veterans. Use of
purchased care has to meet accepted standards for medical quality and
continuity of care, and must protect the VA's core services, he said.
Contracted care also had a tendency to eat up more resources as time
passed, especially in rural areas, where payments were keyed to
higher-than-normal Medicare and Medicaid reimbursement rates, he said.
The VA now operates 650 community-based outpatient centers (CBOCs) around
the country and has said that another 250 are needed. Of those 250, 156 sites
were identified as "critical" for meeting the vets' needs.
However, only 12 of those clinics have been built, while 18 units not deemed
critical were opened, Michaud said, raising questions about whether the VA was
prepared to serve veterans in rural areas.
VA regulations say that at least 70 percent of enrolled veterans should be
within 30 minutes' driving time from urban or rural primary care centers and
within 60 minutes of highly rural sites, although not all parts of the country
meet that standard, said Gerald Cross, M.D., the VA's acting principal deputy
undersecretary for health. The VA made decisions about where to locate clinics
on a case-by-case basis, he said.
The VA is expanding its mental health service at all CBOCs by adding staff,
using local contract services, and employing telehealth technologies.
An expanded telepsychiatry program will soon be available to improve access
to mental health services in rural areas and also permit specialized clinical
services, when indicated, according to Adam Darkins, M.D., M.P.H., chief
consultant in the VA's Office of Care Coordination.
"Rural and Urban Disparities in Health-Related Quality of Life
Among Veterans With Psychiatric Disorders" is posted at<www.psychservices.psychiatryonline.org/cgi/content/full/57/6/851>.▪