VA has mismatch between where hospitals, veterans are

Anthony Hardie, a disabled Army veteran who served in the first Iraq War, suffers from Gulf War syndrome. He lives an hour's drive away from the closest Department of Veterans Affairs medical center in Bay Pines, Fla.

So when he gets lung “flare-ups” several times a year, he uses his private health insurance and goes to a private urgent-care center close to his home in Bradenton. “Forty-five minutes later, I'm walking out with a prescription,” Hardie said.

The VA is facing a torrent of criticism about long waitlists, off-the-books recordkeeping, doctor shortages, and some patient-safety problems. But one issue that hasn't gotten as much attention is the mismatch of VA facilities to where most veterans live. Of the approximately 20.8 million veterans living in the U.S., 9.6 million live in 14 Sun Belt states. Yet only about a third of the VA's 152 hospitals are in those states.

Most VA hospitals are in Northern and Midwestern states where more veterans used to live. Hardie previously lived in Madison, Wis., and received his care at nearby William S. Middleton Memorial Veterans Hospital. But in 2013, he moved to Florida, a state with 1.5 million veterans served by six hospitals. In contrast, South Dakota, which has only 76,000 veterans, boasts three VA medical centers.

“It reflects the relative political balance of power 50 years ago,” said Phillip Longman, a senior research fellow at the New America Foundation who has studied the VA system.

This is a problem that the VA has confronted before. A 1999 Government Accountability Office report found that the VA was wasting lots of money maintaining underused facilities. What followed under then-VA Secretary Anthony Principi was one of the largest-ever reorganizations of the VA system, involving closing three hospitals and partially closing eight more, building three new hospitals and opening 156 new outpatient clinics mostly in rural areas.

It's a process Principi, now a private consultant, would like to see repeated. “You should have a process in place that does an assessment of all your facilities around the country, whether it be a closure, addition or realignment,” he said. “Circumstances and resources change.”

One big change is the influx of veterans from the wars in Iraq and Afghanistan. Between 2001 and 2014, six integrated hospital systems in Sun Belt states—out of 23 VA integrated systems in all—provided treatment to more than half of the veterans from these wars, the VA reported.

At the same time, the VA also is dealing with an overall decrease in the number of veterans. From 2000 to 2013, the total veteran population fell 17%, primarily due to the passing of veterans from World War II, Korea and Vietnam. The VA's “most acute long-term problem is the vanishing of veterans,” Longman said. “I've been to VA hospitals all over the country. Most places you go, it's eerie how few patients there are.”

The VA Palo Alto (Calif.) Health Care System, built in 1960, illustrates the problem. The system includes 808 beds, but according to the latest American Hospital Association data for fiscal 2012, the average number of inpatients receiving care each day in the system was 397. During 2012, 5,674 patients were accepted for inpatient service. That's low compared with other hospitals of comparable size.

The Palo Alto system includes inpatient facilities and outpatient clinics in a region that runs 90 miles south to Monterey and 130 miles east to Sonora. Those clinics have telehealth capabilities that allow veterans to see a doctor without having to travel 100 miles to a medical center. That telehealth capacity is important because most veterans can't afford to live in the very expensive Palo Alto area close to the medical center. Census data for 2008-12 estimated that just 2,675 veterans were living in Palo Alto.

Around the country, many veterans live in rural counties away from the larger VA facilities, VA data show. But VA hospitals traditionally have been in larger, urban settings so they could be affiliated with academic medical centers such as the Stanford University School of Medicine, which shares its physicians with the Palo Alto VA system.

“For elderly veterans who are totally disabled and no longer working, perhaps they can take an entire day to get to (their) VA medical appointments,” Hardie said. “But it's an incredible challenge for veterans who are working and veterans who are students.”

To improve access, in July 2012 the VA announced plans for 13 new community-based outpatient clinics to open gradually through 2015. In April 2013, the GAO reported that the VA was managing the construction of 50 major medical-facility projects ranging from $10 million to hundreds of millions of dollars, including an $800 million replacement hospital near Denver.

A bipartisan Senate deal announced June 5 also authorizes the VA to lease 26 new facilities in 18 states.

One partial solution is to put more focus on telehealth, mobile health and home monitoring, as the Palo Alto system has begun to do, said Dr. Kenneth Kizer, who served as VA undersecretary for health from 1994-99 and is now director of the Institute for Population Health Improvement at UC Davis Health System, Sacramento, Calif. By his estimate, at least 30% of primary-care visits could be shifted from face-to-face to remote services.

“It's not a matter of providing less care, but providing smarter and more patient-centered care,” he said.

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