The Evolution of Women's Health Care Services in VA
The number of women veterans utilizing VA health care will likely double in the next 2 to 4 years. Given this growth, the VA must evaluate current services and develop an implementation plan to enhance services for women veterans.
Women veterans have been chronically underserved by VA. The market penetration for women from 2003 to 2007 increased only from 11 percent to 14.6 percent, while the market penetration for male veterans during the same period was consistently at 22 percent.1 In addition, we know that even while utilizing VA services, women more often have sought outside services than have men, especially for women’s gynecological conditions.2
Women Veterans' View of Health Care
A very worrisome outcome of our predominant models of primary care is fragmentation, with women seeing one provider for primary care, and another in a separate clinic visit for gender-specific care. VA recently released data indicating poorer performance for women vs. men on quality clinical indicators, raising questions about the overall care provision to women and how examination of the various models of care might inform quality improvement efforts.
Women's view of health care varies on their own particular experience and whether they see a primary care internal medicine practitioner, a family medicine provider, or an Ob/Gyn who meets most or all of their health care needs. To a large extent, the health care services delivered to women veterans have grown up in a patchwork fashion, with the delivery model based in part on the academic leanings of the women’s health champion on site. In some facilities, no particular model was developed and a default system of heavy utilization of fee basis care arose. Fortunately, a significant body of research defining health care provision models now exists, and this research provides data on the outcomes associated with each model.
The face of women veterans is changing. Even though the greatest proportion of women veterans seen in VA is from the Vietnam War era, there is a tremendous influx of women recently deployed and discharged from service in OEF/OIF, where the active duty military is 14 percent female. Among new military recruits, the proportion of females is growing, with women comprising 20 percent of the "freshman class." Cumulative data indicates that 42.2 percent of all discharged women have utilized VA health care at least once, and of that group, 45.6 percent have visited from 2 to 10 times.3 While the number of male veterans is steadily declining, the number of women veterans is and will continue to be on a pronounced upward course. Given this trajectory, the proportion of women veterans seeking VA health services will likely top 15 percent by 2020.
In FY 2006, the mean age of women veterans was 49.5 years; this compares with a mean age for male users of 61 years. However, it is important to realize that almost all new women veterans entering VA care are under age 40, and of childbearing age, creating a need for a significant shift in provision of health care. A major project is underway to involve patients and providers in counseling about desire for conception, informed consent, and use of teratogenic medications. Some classes of medication that are prescribed frequently to women and that carry a high birth defect risk include psychotropics and medications for some dermatological conditions. In VA, we have an opportunity to address intentions for becoming pregnant, utilizing CPRS VISTA to address veterans' sexual activity and risks, and to reduce the potential risk of birth defects from some prescription medications.
A National Model for Women's Health Care Delivery
Leadership and policy have played an important role in driving change in care provision to women veterans. While in earlier VHA Handbooks provision of gender related care onsite in VA was mandated, in the 2003 VHA Handbook 1330.1 genderspecific care provision was relegated to "preferred." A decline in onsite offering of gynecology has occurred in the interim.4 In March 2008, the Under Secretary for Health, Michael Kussman, M.D., charged a workgroup to establish women’s health at every VA, with a consensus definition:
That every women veteran has access to a VA primary care provider who can meet all her primary care needs, including gender-specific care, in the context of an ongoing patient-clinician relationship.
And in July 2008, Secretary Peake and Dr. Kussman announced that the position of Women Veterans Program Manager would be full-time at every facility by December 2008.
The tides have changed, and VA is moving quickly to implement clinic enhancements and provision of care that will address the needs of women veterans. In addition, a major campaign is underway to involve every service and every aspect of VA care in the responsibility to provide the best care anywhere. The goal is not simply to provide a model for care of women in the VA, but to provide a national model for delivery of comprehensive women’s health care.
Research plays an important role in this evolution. Not only do sufficient populations of women veterans now exist for inclusion in research paradigms, research is needed to inform specific health care strategies and models. The time may be here for additional focused supports for research on the health of women veterans.