Letter to President, Congressional Leaders

Family Physicians 'Stand Ready to Assist' Nation's Veterans

June 11, 2014 01:43 pm Michael Laff

(Editor's Note: Shortly after this story posted, the U.S. Senate passed -- by a 93-3 margin -- bipartisan legislation aimed at resolving the health care system crisis now plaguing the Department of Veterans Affairs.)

Struggling with the side effects of his medication, a veteran in Arizona recently visited family physician Andrew Carroll, M.D., for treatment of his progressive dementia. The patient told Carroll that the medication was exacerbating his dementia and causing incontinence.

The Department of Veterans Affairs has been struggling to meet the demand for health care among military veterans.

Repeated calls to the local Department of Veterans Affairs (VA) office had provided no help. Quite the opposite, in fact: VA staff informed the patient that the neurology visit he had scheduled for June was being cancelled and his August appointment would be delayed.

Fortunately, the patient is covered by Medicare, so Carroll was able to provide a referral to a civilian neurologist.

Still, such stories illustrate the frustration that is far too common among veterans and their caregivers, as dozens of news reports about a backlog of patients waiting for appointments at VA hospitals have surfaced in recent weeks. Policymakers are searching for solutions to increase primary care access for veterans who wait long periods before seeing a physician.

Carroll, who has a lot on his plate as medical director of Renaissance Medical Group in Chandler; clinical assistant professor in the Department of Family, Preventive and Community Medicine at the University of Arizona College of Medicine in Phoenix; and president of the Arizona AFP, still manages to treat a number of veterans in his practice. In a recent interview with AAFP News, he offered some off-the-cuff advice to the VA on how to address the current crisis.

Story highlights
  • One family physician recounts his experiences caring for veterans unable to obtain services from Department of Veterans Affairs (VA) facilities.
  • The AAFP recently sent a letter to the White House saying the VA needs to allow civilian physicians the ability to care for veterans who cannot get an appointment at a VA hospital.
  • Federal legislators are moving to address the problem -- at least in the short term.

"The bottleneck at the VA is the lack of primary care physicians," Carroll explained. "It's not their fault; there's just not enough of them," he added.

"If they increased the number of primary care physicians at the VA, they could solve the problem tomorrow," Carroll observed, although he acknowledged that bureaucratic red tape likely would preclude the agency from moving that quickly.

Carroll gave a concrete example of that bureaucracy. If he, as a civilian physician, were to write a prescription for a veteran to take to the VA, he said, it could take months for the prescription to be filled by the VA pharmacy. That's because no VA pharmacy will recognize a prescription unless it is written by a physician within the agency. So, the patient would have to wait for a VA physician to sign off on it.

The alternative? The patient has to pay out-of-pocket for the medication at a community pharmacy.

Short-term Solutions for Acute Needs

Charged with running the nation's largest health care system, the VA serves 9 million enrolled veterans via 150 medical centers and 800 outpatient clinics. Primary care visits in the system have risen by 50 percent in the past three years, according to a recent article(www.nytimes.com) in The New York Times. The number of new nurses and other staff members increased at the same rate, but the number of full-time primary care physicians rose by only 9 percent.

In response to the VA debacle, the AAFP sent a letter to the White House and congressional leaders on June 3 that suggested policy options to help reduce the long waiting periods veterans encounter when trying to access health services through the VA system.

"We should not permit any additional delays in providing maximum opportunity for veterans seeking an appointment with a primary care physician," said AAFP Board Chair Jeff Cain, M.D., of Denver, in the letter. "According to the VA and most media reports, the most significant challenges appear to be in accessing primary care services within the VA system."

The AAFP outlined five proposals that could address the immediate primary care physician shortage:

  • Allow family physicians working outside the agency to treat eligible veterans.
  • Permit prescriptions written by civilian family physicians to be filled at VA pharmacies.
  • Allow civilian family physicians to order diagnostic tests at VA facilities.
  • Permit FPs outside the system to make referrals to subspecialists and other health care professionals working in VA facilities.
  • Enable civilian FPs to provide care for eligible veterans in accordance with the protections provided by the Federal Tort Claims Act.

In his letter, Cain acknowledged that some of the proposed actions would require significant policy revisions. Even so, he added, "While it may not be appropriate to make these changes on a national scale or permanent basis, we do support their implementation in those areas of the country facing the most significant challenges."

More Than One Problem

The current media spotlight is focused on disabled veterans who are trying to meet with a physician, but that is not the only problem currently facing the VA health care system. Becoming eligible to receive care at a VA hospital is the first hurdle for many veterans.

"There are two backlogs," said Terrence Schulte, C.A.E., a veteran and chapter executive of both the AAFP's Uniformed Services chapter and the Virginia AFP. "There is a long line to get approval just to go to the VA."

Individuals who were recently discharged and who suffer from a disability are required to fill out a detailed application and be examined by a physician who can attest to their injury or disability. But because of the physician shortage at the VA, many servicemen and -women wait long periods before they are even declared eligible to visit the agency's hospitals, according to Schulte.

Last year, in fact, Schulte sent a request to family physicians in Virginia, asking them to consult with veterans who were seeking a medical determination on their health status. The VA will honor a medical evaluation performed by a civilian physician.

Fortunately, help may be on the way: As news reports of prolonged and, in some cases, fatal delays among veterans seeking care through the VA system continue to dominate headlines across the country, federal lawmakers are moving to address the crisis.

This week, the House passed a bill sponsored by Rep. Jeff Miller, R-Fla., that allows the VA to contract with hospital facilities outside the agency to provide care for veterans. Veterans who have been waiting more than 30 days for care can visit a facility outside of the VA. The legislation also allows veterans who live more than 40 miles from the nearest VA hospital to receive care at a facility that is not affiliated with the VA. The legislation passed with overwhelming support from both parties.

On the Senate side, Sens. Bernard Sanders, I-Vt., and John McCain, R-Ariz., recently introduced legislation that would also permit veterans to be treated by physicians outside the agency. In addition, the Senate measure would allow the VA to lease 26 new facilities, and it allocates $500 million to hire more physicians and nurses at VA hospitals.

The House bill does not include funding for hiring or the provision to lease facilities.

Yet even if legislation is enacted, any major effort to recruit additional health care professionals would require six to 12 months, according to Carroll, and would be of little help to veterans who need care immediately.