The VA in Indy
If you need to be reminded that this country is at war, visit the parking lot at the Roudebush Veterans Administration Medical Center on West 10th Street. You'll find long rows of pickup trucks and cars showing every conceivable form of patriotic bumper sticker, magnet and window treatment. There are bald eagles and flags and an unruly gaggle of updated variations on the theme "Don't tread on me." Given the notoriously high administrative costs associated with private sector health care, the VA may provide an alternative health care model that the rest of the country could benefit from.
A stone's throw from the White River, the VA Med Center sits on the edge of the IUPUI campus and takes up at least a city block. Dedicated in 1952, the original building of what is now a complex of additions presents a no-nonsense institutional front. A small clutch of men sit and stand outside what used to be the 10th Street entrance, smoking cigarettes and staring laconically toward the bare treetops that signal the riverbank across the road.
Inside, the Med Center is a maze of teeming hallways connecting the old building with 1970 and 1994 expansions. People, mostly men, come and go. They span generations, eras, wars. They may have done their service in North Africa or France in the 1940s, Korea in the 1950s, Vietnam in the '60s or Grenada, Panama or Lebanon. Maybe they saw action during the first Gulf War in '91. The youngest faces belong to those, men and women both, coming back from the fighting in Iraq and Afghanistan.
So far, the Med Center has seen about 175 Iraqi and Afghanistan vets, including 17-18 female soldiers. "Some are coming in with early signs of combat fatigue," observes Julie Jackson, the center's facility planner. She says that battle stress and orthopedic injuries are the two main reasons for treatment.
Local Iraqi and Afghanistan veterans are returning to a VA health care system that earns high marks from its users, but that is also bursting at the seams. The combination of longer-lived veterans from the 1940s and '50s, the influx of soldiers from more recent conflicts and a generally improved quality of care has translated into a staggering workload.
An alternative health care model
In fiscal year 2004, the Medical Center has treated 46,689 unique patients with medical, surgical, psychiatric, neurological and rehabilitation care. The outpatient workload for this year has exceeded 400,000 visits, a 5 percent increase over 2003. Treating these patients are 88 full-time equivalent physicians, 28 full-time equivalent contract physicians and a full-time nursing staff of 424.
"We're seeing an increase in the number of veterans we see every year," Jackson says. There has also been a change in the approach to health care. At one time, the Med Center had 400 beds and patients came in for extended stays. Now there are 150 beds and the average length of a stay is a little over six days. "When I first started here 16 years ago," Jackson recalls, "we had 58,000 outpatient visits."
Overall, Jackson says, the VA budget has increased over the past four years. One consequence of this is that the Med Center will shortly embark on its latest building project, which will add two new floors and 96 in-patient beds.
"The VA has always been forced to be more efficient than the private sector due to funding limitations," Jackson says. "The VA is funded upfront and we're expected to provide the services. So we have to be very efficient and I think in the cost-per-case we are more efficient. We're more efficient than Medicare cost-per-patient. We're more efficient than the private sector. And that's been forced on us because of the budget. We take care of the veterans. We make sure their health care needs are met."
Given the notoriously high administrative costs associated with private sector health care, the VA may provide an alternative health care model that the rest of the country could benefit from. Jackson says that the VA's ability to standardize care across a national system, move toward measured outcomes and its system of clinical reminders aimed at protecting patient safety have contributed to veterans rating their health care higher than other Americans rate their private sector care in a recent independent survey conducted by the University of Michigan Business School.
At the Indianapolis Center, 83 cents out of every dollar is spent on veteran care.
"I think one of the big misconceptions is that the quality is lower," Jackson says, "and the VA has repeatedly shown, over and over, that we perform better on a lot of indexes benchmarking against the private sector ... against such things as cancer screening, care of the heart patient that comes in with acute coronary syndrome, care of the diabetic. The VA performs better on these measures.
"Veterans should not want for care," Jackson says. "Either primary care or specialty care. So we've been working very hard to see that veterans get the care they need within the time frame that is medically appropriate."
But the sheer numbers that the local VA Med Center is handling, coupled with the return of another generation of veterans from action in the Middle East, can only add more stress to an already crowded situation. This is particularly true when it comes to dealing with the inevitable cases of Post Traumatic Stress Disorder (PTSD). When the Army surveyed 3,671 Iraqi veterans following the first phase of the conflict, they found 17 percent were already suffering from early PTSD symptoms, which include depression, anxiety and feelings of isolation. Over 170,000 soldiers are now serving in Iraq.
"We do have in-patient mental health services, but it's very short term," Jackson says. "The patients come in, they get the treatment that they need and then we move them to the out-patient because that's better for everyone. When they can survive in the community and receive on-going treatment but yet they're more in a home environment - that's our goal."
"There's nothing glorious about war"
Steve Gross will be seeing many of these veterans. Gross is the team leader at the Veterans Readjustment Counseling Center located at 3833 N. Meridian St. Gross spent 20 years in military mental health before retiring from service. Now he serves the mental health needs of his fellow vets.
The Counseling Center deals only with combat veterans - and, according to Gross, approximately 700 new clients have checked in at the center for each of the past three years. Gross estimates that his team of four to six staff members receives between 6,000 and 7,000 visits per year. "Iraqi vets from the first Persian Gulf war and the second one are beginning to come in," Gross says, "and they have some of the same symptoms as the Vietnam vets. That has not changed. That's the nature of war."
The Counseling Center gets referrals from the Med Center, but they also treat walk-ins and people who find out about them via word of mouth. Gross calls treating PTSD his center's "forte." Job loss, marital breakdowns and homelessness are among the symptoms he regularly sees.
In addition to PTSD, Gross is also beginning to see cases of sexual trauma in a growing segment of the veteran population. "There are a lot of sexual attacks - whether they be harassment or actual physical attacks - rape - while in service. There are so many more females in service now, and they're in isolated positions and they're with men," Gross explains, "whether they're overseas or whatever assignment they're in. Whenever men and women get together, things like that happen. But men are also sexually abused or attacked by other men.
"I think we're on top of what we need to do," Gross continues. But he notes that staffing at counseling centers like his has remained the same regardless of the demand for services. "We're mandated to handle that, so we handle it."
Gross, like Jackson, is proud of the efficiencies his center has accomplished. The average cost of a visit with a counselor is $69-$70, which he says compares favorably with the cost of visiting a private psychologist or psychiatrist.
Those efficiencies will be put to the test as soldiers who have survived the war in Iraq come back to face daily life in Indianapolis. "There's nothing glorious about war," Gross says. "It takes a toll on everyone involved, either now or later. People need to realize that is a very stressful environment - and it will affect everyone."