Vets in Rural Areas Face Multiple Barriers to Care

Question: How do orthopedics, geography, and psychiatry mix with national politics?

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 regions.

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 spokesperson.

Urban vs. Rural Differences Cited

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 Original article: “Practicing in Rural America Often a Juggling Act”).

Multiple Hurdles Face Rural Vets

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 behind.

(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 forces.

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 be routine.

“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.

More Local Sites Needed

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 system.

“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>.▪

Psychiatr Serv 2006 57 851