VA Health Care For Women: Progress Made in Providing Services to Women Veterans

Published by the Government Accountability Office on 1999-01-29.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

                 United States General Accounting Office

GAO              Report to the Chairman, Subcommittee
                 on Health, Committee on Veterans’
                 Affairs, House of Representatives

January 1999
                 VA HEALTH CARE
                 FOR WOMEN
                 Progress Made in
                 Providing Services to
                 Women Veterans

      United States
GAO   General Accounting Office
      Washington, D.C. 20548

      Health, Education, and
      Human Services Division


      January 29, 1999

      The Honorable Cliff Stearns
      Chairman, Subcommittee on Health
      Committee on Veterans’ Affairs
      House of Representatives

      Dear Mr. Chairman:

      The Department of Veterans Affairs (VA) is required to provide health care
      to men and women who have served in the U.S. military. Because male
      veterans account for 95 percent—24.3 million of the total veteran
      population and VA’s total outpatient workload (29.4 million visits)—it has
      been difficult for women veterans to obtain health care services, especially
      gender-specific care, within VA medical facilities. By 2010, however,
      women are expected to represent over 10 percent—over 2 million of the
      projected 20 million veterans—compared to about 5 percent in 1997.

      In response to past criticisms, VA has taken a number of steps to improve
      its accommodation of the special health care needs of women and plans to
      continue its efforts. For example, last April, we testified on VA’s efforts to
      provide counseling services to women who had been sexually traumatized
      and found that, as a result of VA’s efforts, women veterans were
      increasingly using these services.1

      Concerned about women veterans’ access to other, more general services,
      you asked us to review the current status of the women veterans’ health
      care program. Specifically, you asked us to (1) describe the progress VA
      has made in removing barriers that may prevent women veterans from
      obtaining VA health care services and (2) determine the extent to which VA
      health care services, particularly gender-specific services, are available to
      and used by women veterans.

      To conduct our work, we interviewed officials at VA’s Readjustment
      Counseling Center (Vet Center), medical centers, and Center for Women
      Veterans in the Office of the Secretary; the Veterans Health Administration
      (VHA); and two Veterans Benefits Administration (VBA) regional offices. In
      addition, we reviewed and analyzed VA’s health care plans for women,
      patient utilization data, and prior reports and studies on women veterans’
      health care programs. (For a complete description of our scope and

       See Women Veterans’ Health Care: VA Efforts to Respond to the Challenge of Providing Sexual
      Trauma Counseling (GAO/T-HEHS-98-138, Apr. 23, 1998).

      Page 1                             GAO/HEHS-99-38 Health Care Services for Women Veterans

                   methodology, see app. I). We performed our work between
                   September 1998 and December 1998 in accordance with generally
                   accepted government auditing standards.

                   VA has made considerable progress in removing barriers that prevent
Results in Brief   women veterans from obtaining care. For example, VA has increased
                   outreach to women veterans to inform them of their eligibility for health
                   care services and designated women veterans coordinators to assist
                   women veterans in accessing VA’s health care system. VA has also improved
                   the health care environment in many of its medical facilities, especially
                   with respect to accommodating the privacy needs of women veterans.
                   However, VA recognizes that it has more work to do in these areas and
                   plans to address concerns about the effectiveness of its outreach efforts
                   and privacy barriers that still exist in some facilities. In addition, in
                   response to women veterans’ concerns, VA has begun to assess its capacity
                   to provide inpatient psychiatric care to women veterans.

                   With regard to gender-specific services, VA’s efforts to emphasize women
                   veterans’ health care have contributed to a significant increase in the
                   availability and use of all services over the last 3 years. The range of
                   services differs by facility; services may be provided in clinics designated
                   specifically for women veterans, or they may be provided in the overall
                   medical facility health care system. More importantly, utilization has
                   increased significantly between 1994 and 1997. For example,
                   gender-specific services—pap smears, mammograms, and reproductive
                   health care—grew from over 85,000 to more than 121,000. During the same
                   time period, the number of women veterans treated for all health care
                   services on an outpatient basis increased by about 32 percent or 119,300.

                   Women represent a small but rapidly growing segment of the nation’s
Background         veteran population. In 1982, there were about 740,000 women veterans. By
                   1997, that number had increased by 66 percent to over 1.2 million, or
                   4.8 percent, of the veteran population. Today, women make up nearly
                   14 percent of the active duty force and, with the exception of the Marine
                   Corps, 20 percent of new recruits. By 2010, women are expected to
                   represent over 10 percent of the total veteran population.

                   Like male veterans, female veterans who serve on active duty in the
                   uniformed services for the minimum amount of time specified by law and
                   who were discharged, released, or retired under conditions other than

                   Page 2                     GAO/HEHS-99-38 Health Care Services for Women Veterans

dishonorable are eligible for some VA health care services. Historically,
veterans’ eligibility for health care services depended on factors such as
the presence and extent of service-connected disabilities, income, and
period and conditions of military service.

In 1996, the Congress passed the Veterans Health Care Eligibility Reform
Act (P.L. 104-262), which simplified the eligibility criteria and made all
veterans eligible for comprehensive outpatient care. To manage its health
care services, the act requires VA to establish an enrollment process for
managing demand within available resources. The seven priorities for
enrollment are (1) veterans with service-connected disabilities rated at
50 percent or higher2; (2) veterans with service-connected disabilities
rated at 30 or 40 percent; (3) former prisoners of war, veterans with
service-connected disabilities rated at 10 or 20 percent, and veterans
whose discharge from active military service was for a compensable
disability that was incurred or aggravated in the line of duty or veterans
who with certain exceptions and limitations are receiving disability
compensation; (4) catastrophically disabled veterans and veterans
receiving increased non-service-connected disability pensions because
they are permanently housebound; (5) veterans unable to defray the cost
of medical care; (6) all other veterans in the so-called “core” group,3
including veterans of World War I and veterans with a priority for care
based on presumed environmental exposure; and (7) all other veterans. VA
may create additional subdivisions within each of these enrollment

With the growing women veteran population came the need to provide
health care services equivalent to those provided to men. Over the past 15
years, GAO, VA, and the Advisory Committee on Women Veterans have
assessed VA services available to women veterans. In 1982, GAO reported
that VA lacked adequate general and gender-specific health care services,
effective outreach for women veterans, and facilities that provided women
veterans appropriate levels of privacy in health care delivery settings.4 In
1992, GAO reported that VA had made progress in correcting previously
identified deficiencies, but some privacy deficiencies and concerns about

 VA assigns disability ratings to compensate veterans for physical or mental conditions incurred or
aggravated during military service. These ratings are assigned in increments of 10, ranging from 0 to
100 percent, and are used to determine compensation for service-connected conditions.
 “Core” refers to World War I and Mexican-border veterans, veterans solely seeking care for disorders
associated with exposure to toxins or environmental hazards in service, and compensable 0-percent
service-connected veterans.
  Actions Needed to Ensure That Female Veterans Have Equal Access to VA Benefits (GAO/HRD-82-98,
Sept. 24, 1982).

Page 3                               GAO/HEHS-99-38 Health Care Services for Women Veterans

                      availability and outreach remained.5 In response to concerns about the
                      availability of women veterans’ health care and to improve VA’s delivery of
                      health care to women veterans, the Congress enacted the Women Veterans
                      Health Programs Act of 1992 (P.L. 102-585). This act authorized new and
                      expanded health care services for women. In 1993, VA’s Office of the
                      Inspector General (OIG) for Health Care Inspections reported that
                      problems—such as women veterans’ not always being informed about
                      eligibility for health care services as well as VA’s lack of appropriate
                      accommodations, medical equipment, and supplies to treat women
                      patients in VA medical facilities—still existed.6

                      In December 1993, the Secretary of the Department of Veterans Affairs,
                      established VA’s first Women Veterans’ Program Office (WVPO). In
                      November 1994, the Congress enacted legislation (P.L. 103-446) that
                      required VA to create a Center for Women Veterans to oversee VA programs
                      for women. As a result, WVPO was reorganized into the Center for Women
                      Veterans. The Center Director reports directly to the VA Secretary.

                      In compliance with the Government Performance Results Act, VA has a
                      strategic plan that includes goals for (1) monitoring the trends in women’s
                      utilization of VA services from fiscal years 1998 through 2001, (2) reporting
                      on barriers and actions to address recommendations to correct them, and
                      (3) assessing progress in correcting deficiencies from fiscal years 1999
                      through 2001. VA’s performance plan also includes goals that target women
                      veterans currently enrolled in VA for aggressive prevention and health
                      promotion activities to screen for breast and cervical cancer.

                      VA has taken several actions to remove barriers identified by GAO, VA, and
VA Has Reduced Many   women veteran proponents over the years that prevent women veterans
Barriers to Care      from obtaining care in VA medical facilities. First, VA has increased
                      outreach efforts to inform women veterans of their eligibility for benefits
                      and health care services. However, it has not evaluated these efforts, so it
                      is not known how knowledgeable women veterans are about their
                      eligibility for health care services. VA has also designated coordinators to
                      assist women veterans in accessing the system.

                      In addition, VA has identified and begun to correct patient privacy
                      deficiencies in inpatient and outpatient settings. VA has surveyed its
                      facilities on two occasions to determine the extent to which privacy

                       VA Health Care for Women: Despite Progress, Improvements Needed (GAO/HRD-92-23, Jan. 23, 1992).
                      Office of the Inspector General for Health Care Inspections, Report of Inspection of Women Veterans’
                      Health Care Programs, 3HI-A99-129 (Washington, D.C.: Department of Veterans Affairs, June 1993).

                      Page 4                              GAO/HEHS-99-38 Health Care Services for Women Veterans

                              deficiencies exist. In fiscal year 1998, VA spent more than $67 million
                              correcting deficiencies and has developed plans for correcting remaining
                              deficiencies. However, VA continues to face obstacles addressing the
                              inpatient mental health needs of women veterans in a predominantly male
                              environment and has established a task force to look at this and other

Efforts Increased to Inform   Over the last few years, VA has increased its outreach efforts to inform
Women Veterans of             women veterans of their eligibility for care in response to problems
Services, but Effectiveness   highlighted by GAO, VA, and veteran service organizations between 1982 and
                              1994. We and others reported that (1) women veterans were not aware
Unknown                       that they were eligible to receive health care in VA and (2) VA did not target
                              outreach to women veterans, routinely disseminate information to service
                              organizations with predominantly female memberships, or adequately
                              inform women of changes in their eligibility. To address these concerns, VA
                              has targeted women veterans during outreach efforts at the headquarters,
                              regional, and local levels.

                              At the headquarters level, a number of outreach strategies have been
                              implemented. For example, the Center for Women Veterans, as part of its
                              strategic and performance goals for 1998 through 2000, is placing greater
                              emphasis on the importance of outreach to women and the need for
                              improved communication techniques. Since the inception of WVPO and the
                              Center for Women Veterans, VA has held an average of 15 to 20 town
                              meetings a year, along with other informational seminars. The Center also
                              provided informational seminars at the annual conventions of the
                              Women’s Army Corp and the Women Marines; American Legion; American
                              Veterans of World War II, Korea, and Vietnam; and Disabled American
                              Veterans. The Center also provided information on VA programs for
                              women veterans and other women veterans’ issues at national training
                              events for county and state veteran service officers and their counterparts
                              in the national Veterans’ Service Organizations. Further, the Center
                              established a web site within the VA home page to provide women veterans
                              with information about health care services and other concerns as well as
                              the opportunity to correspond with the Center via electronic mail.

                              At the regional and local levels, VBA regional and benefit offices, VA medical
                              centers, and Vet Centers display posters, brochures, and other materials
                              that focus specifically on women veterans. They also send representatives
                              to distribute these materials and talk to women veterans during outreach
                              activities, such as health fairs and media events, that are used to publicize

                              Page 5                     GAO/HEHS-99-38 Health Care Services for Women Veterans

                         the theme that “Women Are Veterans, Too.” The VA facilities we visited
                         were conducting similar activities. For example, the medical center in New
                         Orleans directed its Office of Public Relations to work closely with the
                         women veterans coordinator to develop an outreach program. The New
                         Orleans Vet Center women veterans coordinator told us that she expanded
                         her outreach efforts to colleges with nursing schools in an effort to reach
                         women veterans who do not participate in veteran-related activities.

                         In addition, VBA regional offices coordinate with the Department of
                         Defense to provide information on VA benefits and services to prospective
                         veterans during Transition Assistance Program (TAP) briefings. In addition
                         to providing information to active-duty personnel who plan to separate
                         from the military on how to transition into civilian life, TAP briefings
                         provide information on the benefits they may be eligible for as veterans as
                         well as how to obtain them.

                         Although VA has greatly increased its outreach efforts, it has not yet
                         evaluated the effectiveness of these efforts. Women veterans organizations
                         have acknowledged the increase in VA’s outreach efforts directed at
                         women veterans but continue to express concern about whether women
                         veterans are being reached and adequately informed about their eligibility
                         for benefits and health care services. Several women veterans we talked
                         with during our site visits said they found out by chance—during casual
                         conversations—that they were eligible for care. Women veterans and
                         agency staff acknowledged that “word of mouth” from satisfied patients
                         appears to be one of the most effective ways to share information about
                         various benefits and services to which women veterans may be entitled.

                         In March 1998, the Advisory Committee for Women Veterans, the Center
                         for Women Veterans, and the National Center for Veterans Statistics
                         provided specific questions for inclusion in VA’s Survey of Veterans for
                         Year 2000 to address the extent to which women veterans are becoming
                         more knowledgeable about their eligibility for services. This survey should
                         allow VA to assess the effectiveness of its outreach to women veterans.

Women Veterans           Women veterans coordinators assist in obtaining care, advocate for
Coordinators More        women veterans’ health care, and collaborate with medical center
Effective in Assisting   management to make facilities more sensitive to women veterans. This
                         role was established in 1985 because women veterans did not know how
Women Veterans in        to obtain health care services once they became aware of their eligibility
Obtaining Care           for these services. However, in 1994, VA’s OIG reported that these

                         Page 6                     GAO/HEHS-99-38 Health Care Services for Women Veterans

                             coordinators often lacked sufficient training and time to perform
                             effectively; many women veterans coordinators performed in this capacity
                             on a part-time basis.7

                             VA has since provided women veterans coordinators training and more
                             time to carry out their roles and help them provide better assistance to
                             women veterans in accessing VA’s health care system and obtaining care.
                             In an effort to make them more effective in this role, in 1994, VA
                             implemented a national training program designed to increase women
                             veterans coordinators’ awareness of their roles and familiarize them with
                             women veterans’ issues. The program is administered by a full-time
                             women veterans’ national education coordinator and staff at the
                             Birmingham Regional Medical Education Center. In addition, the women
                             veterans coordinators at VA’s medical centers in Tampa and Bay Pines
                             developed a mini-residency training program for women veterans
                             coordinators. This program, approved in 1995, is the only training program
                             of its kind and is offered for newly appointed women veterans

                             To allow women veterans coordinators more time to perform their duties,
                             in 1994, VA established positions for additional full-time women veteran
                             coordinators at selected VA medical centers and four full-time VBA regional
                             women veterans coordinators. As of January 1998, about 40 percent of the
                             women veterans coordinators in VA medical facilities were full-time.
                             According to VA’s Advisory Committee on Women Veterans, the women
                             veterans coordinator program has proven to be one of the most successful
                             initiatives recommended by the committee.

VA Is Addressing Privacy     Patient privacy for women veterans has been a long-standing concern, and
Deficiencies, but Barriers   VA acknowledges that the correction of physical barriers that limit

Remain                       women’s access to care in VA facilities will be an ongoing process.
                             Between 1982 and 1994, GAO and VA’s OIG reported that physical barriers,
                             including hospital wards with large open rooms having 8 to 16 beds and a
                             lack of separate bath facilities, concerned women veterans and
                             inconvenienced staff. Female patients had to compete with patients in
                             isolation units for the limited number of private rooms in VA hospitals.
                             Also, hospitals with communal bathrooms sometimes required staff to
                             stand guard or use signs indicating that the bathroom was occupied by
                             female patients.

                              Office of the Inspector General for Health Care Inspections, Report of Inspection of Women Veterans’
                             Health Care Programs, Privacy Issues—Part II, 4HI-A19-042 (Washington, D.C.: Department of
                             Veterans Affairs, Mar. 1994).

                             Page 7                              GAO/HEHS-99-38 Health Care Services for Women Veterans

As required by section 322 of the Veterans’ Health Care Eligibility Reform
Act of 1996, VA conducted nationwide privacy surveys of its facilities in
fiscal years 1997 and 1998 to determine the types and magnitude of privacy
deficiencies that may interfere with appropriate treatment in clinical areas.
The surveys revealed numerous patient privacy deficiencies in both
inpatient and outpatient settings. The fiscal year 1998 survey also showed
that 117 facilities from all 22 Veterans Integrated Service Networks (VISN)
spent nearly $68 million in construction funds in fiscal year 1998 to correct
privacy deficiencies. Another 91 facilities from 20 of the 22 VISNs used a
total of 130 alternatives to construction to eliminate deficiencies. These
alternatives included actions such as initiating policy changes that would
admit female patients only to those areas of the hospital that have the
appropriate facilities or issuing policy statements that gynecological
examinations would only be performed in the women’s clinics or
contracted out. In addition, VISN and medical center staff developed plans
for correcting and monitoring the remaining deficiencies.

Although the 1998 survey showed that VA has improved the health care
environment to afford women patients comfort and a feeling of security,
the survey also revealed that many deficiencies still exist. (See table 1.) Of
those facilities with deficiencies, the most prevalent inpatient deficiency
was a lack of sufficient toilet and shower privacy, and the most prevalent
outpatient deficiency was the lack of curtain tracks in various rooms.

Page 8                      GAO/HEHS-99-38 Health Care Services for Women Veterans

Table 1: Prevalent VA Patient Privacy
Deficiencies and the Number of VA                                                                                       Facilities having
Medical Facilities Where Deficiencies                                                                                     deficiency
Still Exist as of October 1, 1998       Patient privacy deficiency                                                     Number          Percent
                                        Inpatient unita
                                        Lack of sufficient, appropriate bedroom privacy                                       42               24
                                        Lack of sufficient toilet and shower privacy                                          63               36
                                        Lack of sufficient, private, handicapped-accessible shower                            58               34
                                        Lack of privacy curtain tracks in patient bedrooms,                                   40               23
                                        examination rooms, and other types of rooms
                                        Ambulatory care (outpatient)b
                                        Lack of privacy curtain tracks in various roomsc                                      63               10
                                        Lack of toilet rooms adjacent to gynecological rooms and                              53                9
                                        urinary clinic changing rooms
                                        Inappropriate location of existing toilet roomsd                                      51                8
                                        Lack of designated changing areas for women in diagnostic                             26                4
                                        and day surgical areas, clinics, mammography, and other
                                        imaging areas
                                        Inappropriate location of changing areas for women in certain                         22                4
                                        areas that are near general waiting areas or common hallways
                                        Lack of a private examination room in or near the emergency                           14                2
                                        or urgent care area
                                        Lack of a private intake interview room in the admission area                         45                7
                                        Lack of personal hygiene dispensers in toiletrooms in clinics                         23                4
                                        and other patient areas
                                         Percentages for facilities with inpatient deficiencies are based on VA’s 173 hospital facilities as
                                        defined in VA’s 1998 survey.
                                         We used 612 as the denominator in computing these percentages: 173 hospitals, 37
                                        nonhospital-based clinics that reported having deficiencies, and 402 clinics that did not report a
                                         Includes examination rooms (gynecological and nongynecological), procedure rooms,
                                        emergency and urgent care rooms, treatment cubicles, ambulatory surgery patient holding and
                                        recovery areas, and other cubicles and rooms.
                                         Requires women patients to pass through general waiting areas to access this room from a
                                        nongynecological examination room.

                                        Source: Department of Veterans Affairs, Veterans Health Administration, Women Veteran Patient
                                        Privacy Survey Results, 1998 Data (Milwaukee, Wisc.: National Center for Cost-Containment,
                                        Sept. 1998).

                                        Consistent with VA’s strategic plan for fiscal years 1998 through 2003, a
                                        task force with representatives from VHA and the Center for Women
                                        Veterans was established to identify, prioritize, and develop plans for

                                        Page 9                               GAO/HEHS-99-38 Health Care Services for Women Veterans

                             addressing five major issues related to women veterans’ health care, one
                             of which was patient privacy. Further, VA plans to assess the progress
                             made in correcting patient privacy deficiencies on an annual basis
                             between fiscal years 1999 and 2001. VA requires that each facility have a
                             plan for corrective action and a timetable for completion; VA has also
                             directed each VISN to integrate the planned corrections into their
                             construction programs.

                             To correct the remaining deficiencies, VA projects it will spend
                             $49.3 million in fiscal year 1999 and $41 million in fiscal year 2000. Over
                             this same period, medical centers are estimated to spend approximately
                             $647,000 more in discretionary funds to make some of these corrections.
                             Beyond fiscal year 2000, VA projects it will spend an additional $77 million
                             in capital funds; six facilities in VISNs 6 and 7 account for 58 percent of the
                             total projected spending for beyond fiscal year 2000.8

Task Force Is Assessing      While correcting privacy deficiencies has allowed VA to better
VA’s Ability to Provide      accommodate women veterans’ health care needs, VA faces other problems
Inpatient Psychiatric Care   accommodating women veterans who need inpatient mental health
                             treatment. In the summer of 1998, VA established a task force of clinicians
to Women Veterans            and women veterans coordinators to assess mental health services for
                             women veterans and make recommendations by June 1999 for improving
                             VA’s capacity to provide inpatient psychiatric care to this population. This
                             task force is chaired by the Director of the Center for Women Veterans.

                             VA data show that in fiscal year 1997, mental disorder was the most
                             prevalent diagnosis—26.4 percent—for women veterans hospitalized.
                             While inpatient psychiatric accommodations are available in VA facilities,
                             in most instances the environment is not conducive to treating women
                             veterans. In 1997, VA’s Center for Women Veterans reported that women
                             veterans hospitalized on VA mental health wards for post-traumatic stress
                             disorder, substance abuse, or other psychiatric diagnoses are often the
                             only female on a ward with 30 to 40 males. This disparate ratio of women
                             to men discourages women from discussing gender-specific issues and
                             also makes it difficult to provide group therapy addressing women’s
                             treatment issues. Women veterans also noted that they were concerned
                             about their safety in this environment. These concerns included male
                             patients engaging in inappropriate remarks or behavior and inappropriate

                              VA’s survey shows that the correction of patient privacy deficiencies in facilities identified in VISNs 6
                             and 7 will require renovation and modernization of wards and other conversions. The age of these
                             facilities, among other factors, contributed to the costs involved.

                             Page 10                               GAO/HEHS-99-38 Health Care Services for Women Veterans

                          levels of privacy. During our site visits, two women veterans expressed
                          similar concerns.

                          VA has inpatient psychiatric facilities that have separate psychiatric units
                          for women veterans within five areas: Battle Creek, Michigan;
                          Brockton-West Roxbury, Massachusetts; Central Texas Health Care
                          System; Brecksville-Cleveland, Ohio; and Palo Alto, California, Health Care
                          System. Women veterans often do not want to or are unable to leave
                          families and support systems to travel to one of these facilities for
                          treatment. Staff at one of the medical centers we visited in Florida told us
                          that a few of their women patients who had been sexually traumatized
                          would be better served in an inpatient setting, but the nearest suitable
                          inpatient facilities were those in California and Ohio, and the patients did
                          not want to go that far from home.

                          VA’s greater emphasis on women veterans’ health has resulted in an
Availability and Use of   increase in both the availability and use of general and gender-specific
Services Have             services, such as pap smears, mammograms, and reproductive health care.
Increased for Women       Some VA facilities offer a full complement of health care services,
                          including gender-specific care, on a full-time basis in separate clinics
Veterans                  designated for women. Others may only offer certain services on a
                          contractual or part-time basis. According to program officials and the
                          women veterans coordinators at the locations we visited, the variation in
                          the availability and delivery of services is generally influenced by the
                          medical center directors’ views of the health needs of the potential patient
                          population, available resources, and demand for services.

                          The increase in the availability of services and the emphasis on women
                          veterans’ health have contributed to increases in the number of women
                          veterans served and visits made, with the exception of inpatient care.9
                          Between fiscal years 1994 and 1997, the number of gender-specific
                          services provided to women veterans increased about 42 percent, from
                          over 85,000 to over 121,000. The total number of inpatient and outpatient
                          visits made during this same period increased nearly 56 percent, from
                          about 893,000 to almost 1.4 million.

                           This decline is consistent with the general reduction of inpatient services throughout the VA health
                          care system and mirrors the trend in health care in the private sector to deliver services in outpatient
                          settings where feasible rather than in hospitals.

                          Page 11                               GAO/HEHS-99-38 Health Care Services for Women Veterans

VA Has Modified Its Health   Over the past 10 years, GAO, VA’s OIG, and VA’s Advisory Committee on
Care System to Better        Women Veterans reported that VA was not providing adequate care to
Accommodate Women            women veterans and was not equipped to do so. These organizations
                             found that VA (1) was not providing complete physical examinations,
Veterans                     including gynecological exams for women; (2) lacked the equipment and
                             supplies to provide gender-specific care to women, such as examination
                             tables with stirrups and speculums; and (3) lacked guidelines for providing
                             care to women. As a result, VA began to place more emphasis on women
                             veterans’ health and looked for ways to respond to these criticisms.

                             For example, to ensure equity of access and treatment, VA designated
                             women veterans’ health as a special emphasis program that merited
                             focused attention. In 1983, VA began requiring medical centers to develop
                             written plans that show how they will meet the health care needs of
                             women veterans. At a minimum, these plans must define (1) that a
                             complete physical examination for women is to include a breast and
                             gynecological exam, (2) provisions for inpatient and outpatient gynecology
                             services, and (3) referral procedures for necessary services unavailable at
                             VA facilities.

                             VA also procured the necessary equipment and supplies to treat women. In
                             addition, VA established separate clinics for women veterans in some of its
                             medical facilities. The locations with separate women’s clinics that we
                             visited had written plans that contained the required information and the
                             necessary equipment and supplies to provide gender-specific treatment to
                             women. Also, we found evidence that women veterans coordinators were
                             monitoring services provided to ensure proper care and follow-up.

                             VA is more able to accommodate women patients than they were prior to
                             the early 1990s. In 1997, VA provided inhouse 94 percent of the routine
                             gynecological care sought by women veterans, even though its number of
                             women’s clinics fell from 126 in 1994 to 96 in 1998. Some VA facilities
                             closed their women’s clinics because of consolidation or implementation
                             of primary care. Others are phasing their women’s programs into primary
                             care, especially the facilities that had limited services available in the
                             women’s clinic. This is consistent with VA’s efforts to enhance the
                             efficiency of its health care system. For example, since September 1995, VA
                             has or is in the process of merging the management and operations of 48
                             hospitals and clinic systems into 23 locally integrated systems.

                             Page 12                    GAO/HEHS-99-38 Health Care Services for Women Veterans

Services for Women Are   While women veterans can obtain gender-specific services as well as other
Available but Vary by    health care services at most VA medical facilities, the extent to which care,
Facility                 especially gender-specific care, is available varies by facility. Some
                         facilities offer a full array of routine and acute gender-specific services for
                         women—such as pap smears, pelvic examinations, mammograms, breast
                         health, gynecological oncology, and hormone therapy—while others offer
                         only routine or preventive gender-specific care.

                         Of the five sites we visited, two—Tampa and Boston—are Women
                         Veterans’ Comprehensive Health Centers,10 which enable women veterans
                         to obtain almost all of their health care within the center. Generally, these
                         centers have full-time providers who may also be supported by other
                         clinicians who provide specialty care on a part-time basis. For example,
                         the Tampa Women Veterans’ Comprehensive Health Center, which
                         provided care to about 3,000 women in 1997, is run by a full-time internist,
                         who is supported by another internist, four nurse practitioner primary care
                         providers, a gynecologist, a psychologist, a psychiatrist, and other health
                         care and administrative support staff. The Tampa center as well as the
                         Boston center provide their services 5 days a week.

                         Other facilities offer less extensive services than those offered within the
                         comprehensive centers. For example, the VA medical center in
                         Washington, D.C., offers only routine or preventive gender-specific care by
                         a nurse practitioner about 4.5 days a week; acute or more specialized
                         gynecological care is only offered one-half day a week with the assistance
                         of a gynecologist and general surgeon through a sharing agreement with a
                         local Department of Defense facility. Other health care services are
                         available within the medical center.

                         The range of services provided by VA’s nonhospital-based clinics varies as
                         well. Some nonhospital-based clinics, like the one in Orlando, may provide
                         services almost comparable to those provided by the medical center or
                         comprehensive center. Other centers, however, offer services on a more
                         limited basis. For example, the nonhospital-based clinic associated with
                         one of the medical centers we visited only offers gynecological services
                         once a week. According to the women veterans coordinator, the average
                         waiting time to get a gynecology appointment at this clinic is 51 days. She
                         explained that if the situation is urgent, arrangements are made to have
                         the patient seen in the urgent care clinic or at the medical center.

                           VA has a total of eight Women Veterans’ Comprehensive Health Centers. The other six centers are
                         located in Chicago, Illinois (Chicago Area Network); Durham, North Carolina; Minneapolis, Minnesota;
                         Philadelphia, Pennsylvania, and Wilmington, Delaware (Southeast Pennsylvania Network); San
                         Francisco, California; and Sepulveda and West Los Angeles, California.

                         Page 13                            GAO/HEHS-99-38 Health Care Services for Women Veterans

Variation in services at VA medical facilities may be attributable to one or
more factors, such as medical center management’s views on the level of
services needed, funding, staffing, and demand for services. The specific
services offered and the manner in which they are delivered within VA
facilities are left to the discretion of medical center or VISN management.
Most VA facilities did not receive additional funding to establish health care
programs for women and had to provide these additional services while
maintaining or minimally affecting existing programs. Initially, VHA
provided additional funding for the comprehensive centers, which was
supplemented by funds from the medical center’s budget. VHA also
provided some additional funding in 1994 to help VA facilities obtain
resources to counsel women veterans who had been sexually traumatized.

The women veterans coordinators at the five medical center locations we
visited told us that the medical center directors have a strong commitment
to providing quality health care to women veterans and that without such
support, it would be difficult to meet women veterans’ needs or improve
the women’s health program. Some women’s programs had to be
established and operated using the medical center’s existing funding and
resources, which included no provisions for these services. Although the
Tampa and Boston centers received VHA funding to establish a
comprehensive health center, they still had to obtain additional funding
from the medical center, which required management’s support.

The availability of gender-specific services may also be influenced by the
demand for these services. At two locations we visited, the women
veterans coordinators told us that when they first opened their women’s
clinics, they operated on a very limited scale—one-half to 1 day a week.
However, the demand was so overwhelming that they increased their
operations to 5 days a week. On the other hand, the women veterans
population in some areas is small and may not generate a high enough
demand for gender-specific services to provide them in a separate women
veterans’ health care program or within the medical center on a full-time
basis. In such instances or if a very small number of female veterans have
historically availed themselves of the services, it may not be cost-effective
to provide these services in-house, as pointed out by VA’s OIG in 1993.11
Instead, it may be appropriate to contract out for these services.

 Office of the Inspector General for Health Care Inspections, Report of Inspection of Women
Veterans’ Health Care Programs.

Page 14                             GAO/HEHS-99-38 Health Care Services for Women Veterans

Women Veterans’ Use of                 In the 1990s, women veterans’ utilization of gender-specific services has
Health Services Has                    increased significantly. Outpatient and inpatient visits among women
Increased                              veterans at VA facilities increased more than 50 percent between fiscal
                                       years 1994 and 1997. Based on VA’s survey of its medical facilities, the
                                       number of women veterans receiving gender-specific services increased
                                       about 42 percent from more than 85,000 to almost 121,200 during the same
                                       period. (See table 2.)

Table 2: Gender-Specific Health Care
Utilization by Source, Fiscal Years                                                                      Reproductive
1994 Through 1997                      Source                   Pap smears          Mammograms                 health                 Total
                                       Fiscal year 1994
                                       In-house                       30,654              11,943                  25,632          68,229
                                       Referral                           454                 623                    556              1,633
                                       Contract                         1,357             12,174                   2,233          15,764
                                       Total FY 1994                  32,465              24,740                  28,421          85,626
                                       Fiscal year 1995
                                       In-house                       35,491              15,110                                  50,601b
                                       Referral                           335                 696                                     1,031b
                                       Contract                         1,270             12,542                                  13,812b
                                       Total FY 1995                  37,096              28,348                                  65,444b
                                       Fiscal year 1996
                                       In-house                       40,115              15,537                  23,405          79,057
                                       Referral                           216                 609                                      825b
                                       Contract                         2,521             14,657                   4,053          21,231
                                       Total FY 1996                  42,852              30,803                  27,458         101,113b
                                       Fiscal year 1997
                                       In-house                       49,799              17,539                  28,233          95,571
                                       Referral                           255                 412                    663              1,330
                                       Contract                         2,867             18,483                   2,928          24,278
                                       Total FY 1997                  52,921              36,434                  31,824         121,179
                                       FY 1994-1997
                                       increase                          63.0%               47.3%                  12.0%              41.5%
                                       Reproductive health data were not collected for these reporting periods.
                                           Excludes reproductive health services.

                                       Source: Department of Veterans Affairs, Veterans Health Administration, Health Care Services
                                       and Research Related to Women Veterans as Required by P.L. 102-585, as amended by P.L.
                                       104-262. Reports for fiscal years 1994 through 1997.

                                       Page 15                               GAO/HEHS-99-38 Health Care Services for Women Veterans

Between fiscal years 1994 and 1997, the number of pap smears and
mammograms provided to women veterans increased dramatically. In
fiscal year 1997, almost 53,000 women veterans received pap smears, a
63-percent increase over fiscal year 1994. Similarly, in fiscal year 1997,
about 36,400 women veterans received mammograms, a 47-percent
increase over fiscal year 1994. Reproductive health care services, which
cover the entire range of gynecological services, were provided to over
31,800 women veterans in fiscal year 1997, 12 percent more than in fiscal
year 1994. According to VA, the pap smear and mammography examination
rates among appropriate and consenting women veterans in 1997 are
90 percent and 87 percent, respectively. VA has set goals to increase the
mammography and pap smear examination rates from their current base
rates to 92 percent and 90 percent, respectively, by fiscal year 2003.

Women veterans have also used more health care services in general,
consistent with VA’s goal to meet women veterans’ total health care needs.
With the exception of inpatient care, the number of women veterans who
use VA health care services and the frequency of their usage continue to
increase. For the 5-year period between fiscal years 1992 and 1997, the
women veteran population increased only slightly, from about 1.2 million
to 1.23 million. However, between fiscal years 1994 and 1997, the number
of women veterans who received outpatient care increased 32 percent,
from about 90,000 to more than 119,000, and the total number of
outpatient visits increased 57 percent, from nearly 870,000 to over
1.3 million. (See table 3.) During this same period, the number of women
veterans who received inpatient care decreased about 5 percent, from
about 14,350 to 13,700, which is consistent with VA’s—and the
nation’s—current health care trend to deliver services in the least costly,
most appropriate setting.

Page 16                    GAO/HEHS-99-38 Health Care Services for Women Veterans

Table 3: Outpatient and Inpatient Care
Provided to Women Veterans in VA                                                                                                        Total
Facilities During Fiscal Years 1994                                                                                                  inpatient
                                                                         Outpatient care                 Inpatient care                   and
Through 1997
                                                                        Unique             Total       Unique             Total     outpatient
                                         Fiscal year                   patientsa           visits     patientsa           visits        visits
                                         1994                             90,182        869,567          14,342          23,802        893,369
                                         1995                            100,445      1,043,316          14,821          24,533     1,067,849
                                         1996                            107,344      1,210,839          14,554          23,783     1,234,622
                                         1997                            119,312      1,369,085          13,679          23,070     1,392,155
                                         Percent change                      32.3           57.4           (–4.6)          (–3.1)          55.8
                                          VA counts unique visits by facility. Since some patients may visit more than one facility, they may
                                         be counted as a unique more than once. Therefore, VA’s reported number of uniques may be
                                         more than the actual number of uniques.

                                         Sources: VA outpatient treatment files (1994-1997) and Department of Veterans Affairs, Veterans
                                         Health Administration, Health Care Services and Research Related to Women Veterans as
                                         Required by P.L. 102-585, as amended by P.L. 104-262. Reports for fiscal years 1994 through

                                         VA’s health care program for women veterans has made important strides
Concluding                               in the last few years. VA has made good progress informing women
Observations                             veterans about their eligibility for services and the services available,
                                         assisting women veterans in accessing the system, correcting patient
                                         privacy deficiencies, and increasing health care services for women
                                         veterans. Most importantly, VA’s efforts are reflected in the increased
                                         availability of services and utilization by women veterans.

                                         While progress has been made, the importance of sustaining efforts to
                                         address the special needs of women veterans will only increase, as their
                                         percentage of the total veteran population is projected to double by 2010.
                                         Coincident with these demographic changes, VA is making changes to the
                                         way it delivers health care, including integrating and consolidating
                                         facilities while maintaining quality of care and implementing eligibility
                                         reform. VA will need to be especially vigilant to ensure that women
                                         veterans’ needs are appropriately addressed as it implements these overall

                                         In its comments on a draft of this report, VA agreed with our findings that
Agency Comments                          progress has been made in serving women veterans through the Women
                                         Veterans’ Health Program but that additional work is required to improve
                                         outreach to women, rectify privacy issues, and improve inpatient

                                         Page 17                              GAO/HEHS-99-38 Health Care Services for Women Veterans

environments for women undergoing inpatient psychiatric treatment. VA
also provided some technical comments, which we have incorporated as
appropriate. VA’s comments are included as appendix II.

Copies of this report are being sent to the Secretary of Veterans Affairs,
other appropriate congressional committees, and interested parties. We
will also make copies available to others on request. If you have any
questions about the report, please call me or Shelia Drake, Assistant
Director, at (202) 512-7101. Jacquelyn Clinton, Evaluator-in-Charge, was a
major contributor to this report.

Sincerely yours,

Stephen P. Backhus
Director, Veterans’ Affairs and
  Military Health Care Issues

Page 18                    GAO/HEHS-99-38 Health Care Services for Women Veterans
Page 19   GAO/HEHS-99-38 Health Care Services for Women Veterans

Letter                                                                                            1

Appendix I                                                                                       22
Scope and
Appendix II                                                                                      23
Comments From the
Department of
Veterans Affairs
Tables              Table 1: Prevalent VA Patient Privacy Deficiencies and the                    9
                      Number of VA Medical Facilities Where Deficiencies Still Exist as
                      of October 1, 1998
                    Table 2: Gender-Specific Health Care Utilization by Source, Fiscal           15
                      Years 1994 Through 1997
                    Table 3: Outpatient and Inpatient Care Provided to Women                     17
                      Veterans in VA Facilities During Fiscal Years 1994 Through 1997


                    OIG        Office of the Inspector General
                    TAP        Transition Assistance Program
                    VA         Department of Veterans Affairs
                    VBA        Veterans Benefits Administration
                    VHA        Veterans Health Administration
                    VISN       Veterans Integrated Service Network
                    WVPO       Women Veterans’ Program Office

                    Page 20                   GAO/HEHS-99-38 Health Care Services for Women Veterans
Page 21   GAO/HEHS-99-38 Health Care Services for Women Veterans
Appendix I

Scope and Methodology

             To determine the barriers to women veterans obtaining care within VA, we
             talked with officials in the Center for Women Veterans, within the Office
             of the Secretary; VHA; two VBA regional offices; and Readjustment
             Counseling Centers (Vet Centers) in Tampa, Florida; St. Petersburg,
             Florida; and New Orleans, Louisiana. We also reviewed Women Veterans
             Advisory Committee reports and talked with women veterans and VA
             program officials in five medical centers: Bay Pines, Florida; Boston,
             Massachusetts; Tampa; New Orleans; and Washington, D.C. These medical
             centers were selected because they offered different levels of health care
             services to women veterans.

             To determine the availability and use of gender-specific care, we discussed
             women veterans’ health care services with officials at VA’s Central Office
             and the five medical centers we visited. We reviewed VA medical centers’
             women veterans health care plans, relevant VA policy directives, and
             women veterans health care utilization data. We also reviewed quality
             assurance plans, annual reports, minutes of Women Veterans Advisory
             Committee meetings, outreach materials, and other written documentation
             and materials.

             Page 22                   GAO/HEHS-99-38 Health Care Services for Women Veterans
Appendix II

Comments From the Department of
Veterans Affairs

              Page 23   GAO/HEHS-99-38 Health Care Services for Women Veterans
           Appendix II
           Comments From the Department of
           Veterans Affairs

(406156)   Page 24                      GAO/HEHS-99-38 Health Care Services for Women Veterans
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