Preventive care, doc access improves for women vets

October 4, 2012

by Tom Philpott

For a lot of years, women veterans felt unwelcomed in Department of Veteran Affairs hospitals and clinics as if they weren’t real veterans, they complained. Reinforcing that impression was routine referrals to multiple health care providers, in or out of VA, to get comprehensive primary care.

That is changing rapidly, thanks to VA’s commitment to improve women health services, to hire more gynecologists and other female health specialists, and to close a "gender gap" in preventive health services and screenings, says Dr. Patricia Hayes, chief consultant for Women Health Services for Veterans Health Administration.

Hayes and her staff have studies and data to show recent gains. They range from patient satisfaction surveys to numbers of staff physicians newly trained to provide for female health needs, and to a new report showing a narrowing of gender disparities in preventive health care screening.

In a 45-minute interview, Hayes and Dr. Sally Haskell, her acting director for comprehensive women’s health, conceded that challenges remain to reach full equality of access and services for women vets, particularly in VA community-based outpatient clinics. But the recent gains have been in impressive and will continue, they say.

"Women have told us that VA has not been welcoming, [of] walking a gauntlet to get into VA with a lot of men around…that ‘I walked up to the clerk and the clerk asks ‘Are you here with your husband?’ Hayes said. "They felt unwelcomed and invisible. We are changing that culture."

In 2008, only 33 percent of VA health care facilities offered comprehensive primary care to women. Today, women can get full primary care services at 90 percent of VA’s larger hospitals and medical centers and at almost 75 percent of its community-base outpatient clinics, Haskell said.

Four years ago, many female veterans visited VA clinics and were referred to larger hospitals, having then to travel "hours and hours to get basic primary care for things like birth control and [vaginal] infections and getting their mammograms arranged," said Hayes. Areas of the country where that’s still true have fallen sharply.

From 2000 to 2009, the number of women veterans using VA health services almost doubled, to 293,000. Over the next two years it rose by another 44,000 to reach 337,000 by last October. VA still needs to attract more staff gynecologists and other female health specialists. But it has closed much of its previous gender gap for delivering primary care by improving capabilities of current staff.

"Since 2008 we have trained over 1500 primary care providers in this intensive training on comprehensive women’s health," Hayes said. "We designed what we call a mini-residency in women’s health, a 40-hour program, training 35 to 40 providers at a time…They learn things like birth control, abnormal bleeding but also mental health issues and PTSD in women and an overview of maternity care.

"These are folks were trained in medical school or nurse practitioner school. But they have been seeing men for so long they felt rusty in their proficiency with women," Hayes said.

Despite the gains, Hayes and Haskell said many women veterans still have misconceptions about the quality of VA health care and stay away. Many still believe, for example, that only combat vets can gain access.

Yet women veterans who use VA care decide to stay with it, even if they have other health insurance. Like male veterans, females are rating VA health care as being better than care in the private sector.

That’s today. Four years ago, VA studies confirmed wide gaps in the quality of health services for women veterans compared with men. That was most evident in the number of preventive health care tests that doctors ordered, for example, to track cholesterol for patients with heart disease, or blood tests and retinal exams for diabetics, or the percentage of patients given flu shots and other immunizations, or being screened for depression.

That disparity in preventive care services ordered for men versus women also exists in the private sector, Haskell said. She cited several likely reasons, including a belief that heart disease is more of a risk for men, even though recent studies have shown that to be wrong, Haskell said.

Women probably didn’t realize it was important for them to monitor r cholesterol levels. The same was true of their doctors, she said.

"They weren’t as careful about managing blood pressure, diabetes, cholesterol in woman. Again, those attitudes are changing both in the VA and in the private sector," Haskell said.

Another factor for the gap in preventive health services probably has been that additional health issues for women "take the focus away from preventive care in the confines of short interactions or visits with providers," Haskell said. "Women have reproductive health issues that take up time [and] also tend to have more mental health concerns and psychosocial concerns they need to discuss with primary care providers. So a lot of times the visit grows very short, and time for attention to prevention is limited."

VA "really wanted to take control of this," Haskell said. "One thing that makes our health care system different is we have the ability to monitor performance measure data very carefully" and then "to implement national processes throughout the system."

So, following a 2008 report on deficiencies in primary care delivery to women, VA decided to act.

"That really launched us on an overall plan to implement major changes in health care for women [to] make sure every woman veteran gets the right kind of health care," Hayes said. "We recognize that there’s been a tremendous influx of women. We have beefed up and accomplished a lot, and we recognize we are still facing a large challenge head."

Today 17 percent of female veterans are enrolled in VA health care versus 20 percent of male veterans. But women returning from recent conflicts are using VA in much greater numbers previous generations.

"Word is getting out among women veterans that we have great care [and] a lot more systems and services in place…to be comfortable using VA."

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