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Ambulatory Care Among Women Veterans: Access and Utilization

Women are one of the fastest growingsegments of the veteran population, projected to comprise 14 percent of VA health care users by 2010. However, their numerical minority within the VA has created challenges to designing delivery systems that ensure their equitable access to high quality, gender-appropriate care. Determining current patterns of VA and non-VA ambulatory care use by women veterans is important in gauging how well the VA is meeting its access and patient satisfaction goals. These patterns also have implications for the organization and scope of services that the VA should provide to women veterans to improve their access to care.

In numerous veteran studies, sociodemographic and health-related predictors of VA use included: being low income, lacking private medical insurance, having poor health status, having a serviceconnected disability, and being an ethnic minority group member. Compared with male veterans, women veterans are more likely to have low income, lack insurance, have poor health status, and be an ethnic minority group member. However, women veterans' proportionate use of VA ambulatory care and inpatient services is less than that of male veterans. This finding suggests that additional gender-related influences on VA use remain.

Perceptions Among Women Veterans

A population-based VISN22 regional study of women veterans' ambulatory care use identified several additional influences on VA use. This study identified numerous barriers to women veterans' VA use, including lack of information about VA eligibility and services, perceptions of limited availability of gender-appropriate services, concerns about the VA environment, privacy and quality of care, and inconvenient VA locations and hours. ^{1, 2}
In contrast, reasons cited for VA use included affordability, women's health clinic availability, quality of care, and convenience. Interestingly, the study identified several factors that serve as both barriers and facilitators to VA use, highlighting a VA user/nonuser paradox in perceptions about VA accessibility, service availability, and health care quality.

In qualitative research, conducted to gain greater insight into the factors underlying women veterans' perceptions about and experiences with VA care, VA nonusers described dated Hollywood images of old soldiers in ward beds, antiquated facilities, and less qualified doctors.² A few women veterans based their perceptions on remote VA contact that occurred prior to the VA quality transformation and expansion of women's health care services. However, most VA nonusers based their perceptions on non-VA sources--primarily media portrayals of VA health care or word-of-mouth. Some women who had used VA health care services refuted these perceptions. But only an actual visit dispelled this image for both VA users and VA nonusers. Women veterans often started using VA health care after losing health insurance or other access to non-VA care, but remained VA users after becoming familiar with available health care services and their quality.

At VA medical centers and larger community-based outpatient clinics (i.e., those serving 400 or more women), basic women's health care services--those deliverable by a primary care provider--are almost universally available onsite. Delivery arrangements include designated providers in general primary care clinics, women's health clinics for gender-specific examinations only, and comprehensive women's health clinics. By contrast, to ensure availability of lower volume specialized women's health services, VA sites have adopted varied onsite and off-site arrangements, including referral to larger VA sites, contract care, fee-basis care, or onsite delivery in gynecology clinics. Internal marketing to VA clinicians and other staff, about the scope and referral mechanisms for women's health services, may improve women veterans' access to and use of these services.

Barriers for Women Veterans Merit Further Study

Women veterans prefer to receive both women's health care and other primary care from the same provider or clinic.¹ However, women veterans often received fragmented care. Fragmentation means that different components of women's basic health care are provided by different types of providers and in different settings, with varying degrees of coordination of care. In addition to the fragmentation inherent in the VA women's health service delivery arrangements, we found that 51 percent of women veteran VA users also split their care across VA and non-VA systems of care. Barriers to VA use that lead some women veterans to go outside the VA for selected health care services, and others to forego VA care altogether, are foci for interventions to improve women veterans-- equitable access to coordinated comprehensive care.

References

1. Washington DL, et al. To Use or Not to Use--What Influences Why Women Veterans Choose VA Health Care? Journal of General Internal Medicine 2006; 21 Supplement 3:S11-8.
2. Washington DL, et al.Women Veterans' Perceptions and Decision-making about VA Health Care. Military Medicine 2007; 172(8):812-7.