9

ACCESS AND BARRIERS TO CARE

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This chapter begins with a discussion of what access to health care means. It then presents a discussion of how active-duty military and veterans access their health care through the Department of Defense (DOD) and the Department of Veterans Affairs (VA) health care systems with a focus on mental-health care. Mental-health issues are highlighted because of the large numbers of returning Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) that have been diagnosed with posttraumatic stress disorder (PTSD) and other mental-health disorders (see Chapter 4). The chapter then presents a discussion of issues related to fragmentation of care and disparities in care, in particular, disparities based on gender and ethnicity. The chapter highlights many of the barriers to care and examines the DOD’s and VA’s programmatic responses to those barriers; finally, the committee provides its recommendations. Returning OEF and OIF military and veterans have been diagnosed with a host of physical- and mental-health outcomes (as documented in earlier chapters of this report). The DOD and VA health care systems have been struggling in certain health care areas to provide timely care to the over 2 million service members who have been deployed since 2001. While the DOD and VA have excelled in providing acute care and care to patients with polytrauma, areas such as mental-health care services have fallen behind.

As documented and discussed in several chapters of this report and other sources, OEF and OIF deployed service members are returning with high rates of mental-health disorders; concerns regarding the availability and adequacy of mental-health services have been highlighted in numerous reports (e.g., Tanielian and Jaycox, 2008). That is troubling as untreated mental-health disorders are strongly linked to numerous adverse outcomes (see Chapter 4).

A 2009 report of mental-health care for OEF and OIF veterans (Burnam et al., 2009) found that the mental-health workforce had insufficient capacity to address the mental-health needs of service members returning home. The study also found that the workforce lacked sufficient training in evidence-based practices and that there were inadequate organizational systems and tools to support mental-health quality improvements. Other concerns about VA health care have been highlighted and include perceptions that programs and service options are not adequate or uniform across different locations, facilities or providers, that services are not welcoming to certain groups (e.g., women and minorities) (GAO, 2011b), and that their availability differs across regions. For example, studies indicate that VA patients in rural areas have reduced access to health services and fewer alternatives to VA care (Weeks et al., 2004; West and Weeks, 2006).



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9 ACCESS AND BARRIERS TO CARE This chapter begins with a discussion of what access to health care means. It then presents a discussion of how active-duty military and veterans access their health care through the Department of Defense (DOD) and the Department of Veterans Affairs (VA) health care systems with a focus on mental-health care. Mental-health issues are highlighted because of the large numbers of returning Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) that have been diagnosed with posttraumatic stress disorder (PTSD) and other mental- health disorders (see Chapter 4). The chapter then presents a discussion of issues related to fragmentation of care and disparities in care, in particular, disparities based on gender and ethnicity. The chapter highlights many of the barriers to care and examines the DOD’s and VA’s programmatic responses to those barriers; finally, the committee provides its recommendations. Returning OEF and OIF military and veterans have been diagnosed with a host of physical- and mental-health outcomes (as documented in earlier chapters of this report). The DOD and VA health care systems have been struggling in certain health care areas to provide timely care to the over 2 million service members who have been deployed since 2001. While the DOD and VA have excelled in providing acute care and care to patients with polytrauma, areas such as mental- health care services have fallen behind. As documented and discussed in several chapters of this report and other sources, OEF and OIF deployed service members are returning with high rates of mental-health disorders; concerns regarding the availability and adequacy of mental-health services have been highlighted in numerous reports (e.g., Tanielian and Jaycox, 2008). That is troubling as untreated mental- health disorders are strongly linked to numerous adverse outcomes (see Chapter 4). A 2009 report of mental-health care for OEF and OIF veterans (Burnam et al., 2009) found that the mental-health workforce had insufficient capacity to address the mental-health needs of service members returning home. The study also found that the workforce lacked sufficient training in evidence-based practices and that there were inadequate organizational systems and tools to support mental-health quality improvements. Other concerns about VA health care have been highlighted and include perceptions that programs and service options are not adequate or uniform across different locations, facilities or providers, that services are not welcoming to certain groups (e.g., women and minorities) (GAO, 2011b), and that their availability differs across regions. For example, studies indicate that VA patients in rural areas have reduced access to health services and fewer alternatives to VA care (Weeks et al., 2004; West and Weeks, 2006). 413

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414 RETURNING HOME FROM IRAQ AND AFGHANISTAN ACCESS TO HEALTH CARE This section begins with a definition of access to health care and provides information about how active-duty service members and veterans access care through the DOD’s Military Health System (MHS) and the VA’s Health Care System. Access to care has been defined as “the timely use of personal health services to achieve the best possible health outcomes” (IOM, 2001). A related concept is perceived access, defined as the individual’s subjective impression of his or her personal access to services. Perceived access is influenced by personal knowledge, actual experience in obtaining preferred services, and degree of satisfaction with those services. Satisfaction in turn is influenced by utilization, quality, and patient outcomes experience, all of which are influenced by the individual’s perceived need for care. Perceived access may be greater or less than actual access. For example, someone who is not attempting to obtain care may be unaware of impediments they would likely encounter; thus, their perceived access may be greater than actual access (Fortney et al., 2011). TABLE 9.1 Patient, Community, Health System and Provider Determinants of Access Dimension of Access Actual Access Perceived Access Examples of Measures Geographic Road travel distance and travel time Self-report of one’s travel Distance to nearest to nearest provider or nearest provider or telehealth facility with telemedicine provider equipment; number and choice of providers Temporal Time delay between when services Self-reported time burden Appointment wait times are needed and how long it actual and temporal convenience takes to receive the service; length of receiving services of time to get an appointment or to communicate digitally with the provider; time spent waiting in the reception area, receiving the treatment, and wait time for next appointment Financial Eligibility and cost of utilizing the Influenced by perceptions Copayments services, including insurance of eligibility and premiums, out-of-pocket costs, and affordability opportunity costs, cost of digital connectivity, and other computer health applications. Cultural Whether language of the patient is Patients trust and Linguistic match offered, and whether service is understanding of their between provider and discriminatory free provider; trust in their patient treatment plan; degree to which a patient internalizes any provider discrimination or public stigma

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ACCESS AND BARRIERS TO CARE 415 Dimension of Access Actual Access Perceived Access Examples of Measures Digital Connectivity and adequate tools Perception about the Web-based access to required to engage in synchronous opportunity and simplicity health records or asynchronous digital of the digital interaction, communication with providers, which includes caregivers, peers, and computerized connectivity issues, user health applications problems, provider responsiveness, and security and privacy concerns SOURCE: Fortney et al., 2011 (adapted). Successfully achieving “access” requires that there be a unique fit among the above elements, the patient, and health care system (Fortney et al., 2011). Thus, the DOD and VA health systems must be flexible enough to adapt to the individual patient’s characteristics and specific needs as they relate to the domains above (see Table 9.1), both on the actual and perceived level. As noted in Fortney et al. (2011), policy makers are responsible for developing and implementing performance measures across the five dimensions as they relate to all components influencing access and barriers to care. Below is a description of how active-duty service members, their families, and veterans access care through the DOD’s Military Health Care System and the VA’s Health Care System. MILITARY HEALTH CARE SYSTEM The DOD’s MHS provides the resources, health professionals, and direction necessary to promote the health of its beneficiary population. It is one of the largest health care organizations in the country, providing services to 9.6 million beneficiaries and employing 140,000 military, civilian, and contract personnel in the MHS setting who work with an additional 380,000 civilian providers in the United States and overseas (DOD, 2011b). The MHS provides direct care to most active-duty service members through military treatment facilities (MTFs) and clinics. The direct care is supplemented by care purchased from the civilian sector. Retirees and dependent family members of active-duty service members are also eligible to receive care at an MTF on a space-available basis; priority is given to those enrolled in TRICARE Prime (described below). Responsibility for delivering health care to garrisoned and deployed troops remains with the health departments of the individual services—Army, Navy,1 and Air Force—which have considerable autonomy in facility and personnel management (DOD, 2011a; IOM, 2010). In addition to providing health care to its beneficiaries, the health system funds education and training in accredited medical and graduate school programs and devotes approximately $600 million per year on research and development (Merlis, 2012). 1 The medical department of the Navy oversees health care delivery for the Marine Corps.

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416 RETURNING HOME FROM IRAQ AND AFGHANISTAN TRICARE TRICARE refers to the DOD’s collective medical programs, which provide care to all active-duty military, activated members of the National Guard and reserves, retired military personal, and their dependents who are eligible for coverage. Services may be provided through managed-care providers directly in DOD facilities,2 which includes 44 inpatient hospitals and medical centers, 291 ambulatory care clinics, 213 dental clinics in the United States, or through the purchased care system which includes 379,233 network individual providers (primary care, mental-health, and specialty care) and 3,146 TRICARE network acute care hospitals (DOD, 2011a; Merlis, 2012). There is also a fee-for-service option for care administered by civilian providers who are not part of the network (Deployment Health Clinical Center, 2012). Eligibility and Enrollment The total number of eligible beneficiaries stationed or residing in the United States at the end of fiscal year (FY) 2010 was 9.09 million (0.60 million were stationed or residing abroad). Retirees and their family members under the age of 65 constitute the largest percentage of the eligible population (3.07 million, 55%); followed by retirees and their family members over the age of 65 (1.88 million, 215); active-duty family members (1.91 million, 21%); active duty (1.28 million, 14%); and National Guard and reserve family members (0.58 million, 6%) (DOD, 2011a). Figure 9.1 shows the extent to which the MHS population has geographic access to direct care by providing a visual of the US distribution of the 9.09 million beneficiaries eligible for TRICARE coverage overlaid with the DOD MTFs (medical centers, community hospitals, and medical clinics). TRICARE North TRICARE West MHS Population End FY 2010 by ZIP Code more than 10,000 Military Treatment TRICARE South Facilities 5,001-10,000 H USFHP 501-5,000 H Hospital TRICARE Region Boundary 100-500 H Clinic Prime Service Area (PSA) less than 100 FIGURE 9.1 Military Health System population distribution in the United States relative to military treatment facilities in FY2010. SOURCE: DOD, 2011a. 2 Direct care treatment facilities are operated under one of the three service branches: Army, Navy, and Air Force.

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ACCESS AND BARRIERS TO CARE 417 To enroll in any TRICARE plan, service members, their families, and retirees must first establish eligibility through the Defense Enrollment Eligibility Reporting System (DEERS). Active-duty and retired service members, including National Guard and reserve members activated for at least 30 days, are automatically registered in DEERS, but individual service members are responsible for registering their family members, updating their status, and ensuring that their information is current and correct (TRICARE Management Activity, 2009). Active- duty service members, including members of the reserve components activated for at least 30 days, automatically enroll in TRICARE Prime3 at no cost. Eligible service members may also enroll their dependent family members in TRICARE Prime at no cost. Dependents, however, may also choose to pay extra to enroll in TRICARE Extra, an option within the TRICARE Standard program that functions similar to a preferred provider organization where participants may pay lower coinsurance if using a contracted network provider or seek coverage through a civilian health-insurance provider. There is no enrollment fee; however, an annual deductible must be met (Andrews et al., 2009; Military.com, 2012b). In addition to active-duty members and their families, the following beneficiary groups are also eligible for coverage under TRICARE Prime: retired National Guard and reserve members (age 60 and receiving retired pay but not eligible for TRICARE for Life) and their families, survivors, Medal of Honor recipients and their families, and qualified former spouses. However, these individuals (non-active-duty members and their families) are also eligible for and may choose TRICARE Standard, a fee-for-service option that allows beneficiaries to obtain care from any TRICARE-authorized provider; there is a deductible, and coinsurance of 20–25% but no enrollment fee. About one-third of non-active-duty individuals eligible for TRICARE Prime (mostly retirees under the age of 65 and their families) live in areas without access to the Prime network and thus must choose TRICARE Standard (Military.com, 2012b). Reserve component members and their eligible family members are covered by TRICARE up to 180 days prior to reporting to active duty (preactivation) and up to 180 days after deactivation through the Transitional Assistance Management Program (TAMP). When not in mobilized status, reservists may purchase TRICARE Select Reserve coverage, which is premium-based and offers comprehensive health care coverage similar to the TRICARE Standard and TRICARE Extra options (DOD, 2011a). Access to Facilities TRICARE Prime is available in the United States in areas known as Prime Service Areas. After enrolling in TRICARE Prime, a primary care manager (PCM) is assigned to the beneficiary at either an MTF or from the TRICARE network. The PCM will provide referral to care specialists when they are unable to provide the necessary care, coordinate with the regional contractor for authorization, find a specialist in the network, and file claims on the beneficiary’s behalf. Active-duty service members and their families pay no out-of-pocket costs for any type of care as long as it is received from the PCM or from another provider with a referral (DOD, 2012). Military hospitals have historically been defined by two geographic boundaries: a 40- mile catchment area (59 catchment areas) for inpatient and referral care and a 20-mile Provider 3 TRICARE Prime is a point-of-service health-maintenance organization that covers 100% of care at MTFs or any civilian provider that is a member of the TRICARE network.

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418 RETURNING HOME FROM IRAQ AND AFGHANISTAN Requirement Integrated Specialty Model (PRISM) (290 PRISM areas) for outpatient care. Stand- alone clinics or ambulatory care centers have only a PRISM area boundary.4 From FY 2004 to FY 2010 there was a downward trend (from 51 to 46%) in the proportion of beneficiaries living in catchment areas, due mostly to Base Realignment and Closure (BRAC) actions; the percentage living in PRISM has remained relatively constant at 64%. Most active-duty members and their families (91%) live in MTF service areas. Ninety-six percent live in Prime Service Areas, which are geographic areas that in the least include catchment areas where the TRICARE Managed Care Support Contractors offer the TRICARE Prime benefits through an established network of providers. The percentage of Reserve Component members5 and families with access to MTF-PRIME (those living in a catchment or PRISM area) is 44.8%. TRICARE Prime is available at MTFs, in areas around most MTFs, and in some areas where an MTF was recently removed as a result of BRAC (DOD, 2011a). Note that non-active-duty beneficiaries that do not live in a catchment or a PRISM area have limited or no access to MTF-based Prime (DOD, 2011a). Figure 9.2 provides further information on beneficiaries and their geographic access to catchment and PRISM areas. 2 0.30 0.26 0.26 0.27 0.28 0.29 0.29 0.40 0.46 Number of Eligible Beneficiaries (Millions) 0.06 0.05 0.39 0.41 0.44 0.45 0.45 0.05 0.05 0.05 0.05 0.05 0.29 0.28 0.30 0.34 0.34 0.07 0.07 0.07 0.06 0.07 0.34 0.34 0.06 0.06 0.01 0.01 0.01 0.01 0.01 1 0.01 0.01 1.12 1.27 1.24 1.19 1.17 1.18 1.22 1.25 1.09 1.07 1.04 1.06 1.04 1.05 0 FY 2004 FY 2005 FY 2006 FY 2007 FY 2008 FY 2009 FY 2012 FY 2004 FY 2005 FY 2006 FY 2007 FY 2008 FY 2009 FY 2012 Active Duty Active Duty Family Members 2 1 0.30 0.29 0.32 0.35 0.29 0.26 0.26 0.19 0.19 0.16 0.15 0.17 0.19 0.18 0.09 0.10 0.11 0.12 0.09 0.09 0.01 0.07 0.07 0.07 0.08 0.08 0.09 0.09 0.03 0.02 0.02 0.02 0.03 0.02 0.02 0.02 0.02 0.01 0.01 0.01 0.01 0.01 0 0.07 0.08 0.06 0.07 0.08 0.09 0.08 0.10 0.11 0.09 0.09 0.10 0.10 0.10 FY 2004 FY 2005 FY 2006 FY 2007 FY 2008 FY 2009 FY 2012 FY 2004 FY 2005 FY 2006 FY 2007 FY 2008 FY 2009 FY 2012 Mobilized Guard/Reserve Family Members of Mobilized Guard/Reserve In Catchment and PRISM Area In Catchment Area, Not in PRISM Area Not in Catchment Area, in PRISM Area Not in Catchment or PRISM Area FIGURE 9.2 Trend in the number of eligible beneficiaries living in and out of MTF catchment and PRISM areas (year-end population). NOTE: In Catchment and PRISM Area = within 20 miles of a military hospital (proximity to both inpatient and outpatient care); In Catchment, Not in PRISM Area = beyond 20 miles but within 40 miles of a military hospital (proximity to inpatient care); Not in Catchment Area, in PRISM Area = within 20 miles of a freestanding military clinic (no military hospital nearby; proximity to outpatient care only); Not in Catchment or PRISM Area = beyond 20 miles of a freestanding military clinic (lack of proximity to either inpatient or outpatient MTF-based care). SOURCE: DOD, 2011a. 4 The distance-based catchment and PRISM area concepts have been superseded within MHS by a time-based geographic concept referred to as an MTF Enrollment Area. An MTF Enrollment Area is defined as the area within a 30-minute drive time of an MTF in which a commander may require TRICARE Prime beneficiaries to enroll with the MTF. However, because this is a relatively new concept, it has not yet been implemented within DEERS or in MHS administrative data and is consequently unavailable for use in this report. 5 Reserve component includes ready, standby, and retired reserve.

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ACCESS AND BARRIERS TO CARE 419 Since 2007, the population of beneficiaries has grown by about 400,000. However, the direct care system has decreased—70 hospitals in 2004 to 59 in 2009. To handle the increase in eligible beneficiaries while accounting for the decrease in direct care facilities, TRICARE must rely more heavily on civilian providers. Eligible beneficiaries are also choosing TRICARE Prime with more frequency, and, consequently, purchased care workload has grown (DOD, 2011b). In addition, mobilizations of National Guard and reserve contributed disproportionately to the number of beneficiaries living outside the catchment areas. Most members live in noncatchment areas when they are called to and leave for active duty; however, their families usually remain in the same location (DOD, 2011a). That may explain the shift in MHS workload from direct care to purchase care in the 2004–2010 period. Mental-Health Care Within the MHS The DOD provides mental-health services through military treatment facilities and clinics for active-duty service members and their families as well as eligible military retirees, eligible reserve-component members, and their respective families (Burnam et al., 2009). Some combat veterans have access to community-based networks of practitioners through TRICARE. TRICARE requires active-duty service members (ADSMs) to seek nonemergency mental-health care at MTFs, when available. If not available, ADSMs must obtain referrals from their MTFs or service points of contact before receiving civilian care. Non-active-duty service members do not need referrals or prior authorization for the first eight outpatient mental-health care visits per fiscal year to a network provider for a medically diagnosed and covered condition. Services provided include psychotherapy, psychoanalysis, psychologic testing, medical management, telemental-health program, acute inpatient psychiatric care, psychiatric partial hospitalization program, residential treatment center care, inpatient detoxification, rehabilitation, and outpatient substance abuse care. Transitional Health Care Coverage Separating active-duty members and their dependents are eligible for transitional TRICARE coverage for 180 days through TAMP if they were involuntarily separated under honorable conditions, separated following involuntary retention (stop-loss) in support of a contingency operation, separated following a voluntary agreement to stay on active duty in support of contingency operation, received a sole survivorship discharge, or separated and agreed to become a member of Selected Reserve. Deactivated National Guard and reserve members who were called to active duty for at least 30 days in support of a contingency operation and their dependents are also usually eligible to receive health care coverage for 180 days through TAMP (Military.com, 2012a). If not eligible for TAMP or within 60 days of terminating TAMP coverage, active-duty members leaving the military under other than adverse conditions and their dependent family members can purchase a health plan similar to TRICARE Standard for up to 18 months of coverage through the Continued Health Care Benefit Program (CHCBP) if family coverage is selected. Children and spouses who were enrolled in TRICARE and lose eligibility can purchase CHCBP coverage for up to 36 months if individual coverage is selected (Military.com, 2012a).

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420 RETURNING HOME FROM IRAQ AND AFGHANISTAN VA Health Care System VA is the second-largest cabinet-level department in the federal government, next to the DOD. Like other large government agencies, the VA administers its many programs through a number of subcabinet agencies, the primary ones being the Veterans Benefits Administration (VBA), the Veterans Health Administration (VHA), and the National Cemetery Administration (NCA). The VBA administers veteran’s compensation and pension, home loan, educational, life insurance, vocational rehabilitation, and other non–health care benefits; VHA administers the Veterans Health Care System; and the NCA oversees 136 national cemeteries and other memorials. The VA Health Care System was established in the early 1900s to care for disabled and poor veterans. Expansion of the system was catalyzed first by the 2 million veterans returning home from World War I and second by the 12 million new veterans from World War II. The VA Health Care System grew rapidly after 1945. Today, it is the nation’s largest and only national direct care delivery system. Integral to its clinical services, the VA also provides transportation, housing, vocational rehabilitation, and other social support services rarely offered by private health plans (CBO, 2009; Panangala, 2010). The VA began affiliating with academic health centers in 1947 (CBO, 2009). It operates the nation’s largest health care professions training program, providing training on a yearly basis for about 110,000 aspiring health care workers in more than 40 health care disciplines through affiliations with some 1,100 universities, colleges, and other institutions of higher education. VA funds more than 9,500 graduate medical education positions, and 85% of its medical centers are teaching hospitals, and almost one-third of all postgraduate physicians receive some portion of their training at a VA facility. Thus, the VA is the nation’s largest provider of training for nurses, pharmacists, optometrists, podiatrists, clinical psychologists, and other health care professions. The VHA also conducts a broad portfolio of research on veterans. In FY2010, the VHA’s research program had a total budget of $1.8 billion, including intramural funding of $575 million and an additional indeterminate amount of medical care funds to support clinical research. Embedding a biomedical, health services delivery and quality-improvement research program in a national health care delivery system and serving a stable population with an unusually high prevalence of chronic conditions, the VA has been very productive. Because veterans often have been a sentinel population for health conditions affecting the public at large, VA research about amputations and prosthetics, organ transplants, end-stage renal disease, traumatic brain injury, diabetes, geriatrics, mental-health, and quality improvement, among other areas, have materially benefitted all Americans. A description of VHA-funded studies that are currently in progress on the OEF, OIF, and OND population are provided in Appendix D. Health Care Facilities Since 1924, the VA has served as a national health care safety net for veterans (Kizer and Dudley, 2009; Koenig, 2003; Wilson and Kizer, 1997). Approximately 30% of VA enrollees have one or more mental-health conditions (Liu et al., 2005; Ralston et al., 2007; Seal et al., 2007), making VA the nation’s largest provider of mental-health services. In federal FY 2010, the VA Health Care System had an operating budget of $45.1 billion, 8.3 million enrollees, and 222,551 full-time employees, including some 14,000 staff physicians

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ACCESS AND BARRIERS TO CARE 421 and more than 40,000 nurses (CBO, 2009; Panangala, 2010). Medical treatment facilities are located in all 50 states and essentially every major metropolitan area of the country, as well as in Puerto Rico, the US Virgin Islands, Guam, American Samoa, and the Philippines. Health care is delivered through Veterans Affairs Medical Centers (VAMCs) that provide acute and long-term care delivery facilities through 152 hospitals; more than 800 ambulatory care clinics (CBOCs), 135 community living centers, 140 home-based primary care programs, 299 readjustment counseling centers, and 43 residential care facilities. VHA also co-funded 133 state-operated nursing facilities for elderly veterans in FY 2010 and managed 9 purchased care programs that bought more than $6 billion of services from private providers (Himmelstein et al., 2007; Koenig, 2003). The various components of the system provide a wide spectrum of medical services, including inpatient and outpatient care, mental-health care, rehabilitation, complex specialty care, and pharmaceutical benefits and distribution. Finally, services may be provided to veterans in non-VA facilities and fall into two broad categories: contract care and noncontract care purchased on a fee-for-service basis. The use of non-VA care is justified if there is geographic inaccessibility, a lack of clinical capacity, if medical expertise or technology is not available at the local facility, or in an emergency situation. Eligibility With the enactment of the National Defense Authorization Act (PL 110-181), veterans who served in a combat theater (including National Guard and reserves) after November 11, 1998, and were discharged or released for reasons other than dishonorable on or after January 28, 2003, now have 5 years from their date of discharge to enroll in and obtain health care coverage from the VA. This includes all OEF and OIF veterans. Effective January 28, 2003, OEF and OIF veterans who enroll within the first 5 years after separating from the military are eligible for enhanced enrollment placement into priority group 6 (see Table 9.2) for 5 years after discharge. Injuries or conditions related to combat service are treated by the VA health care system free of charge (IOM, 2010). After the designated 5 years, enrolled veterans are placed in the appropriate priority group (see Table 9.2) on the basis of income and disability; placement determines the extent of coverage and copayment amounts. Each year, VA determines whether appropriations are adequate to cover all priority groups; if not, those in the lowest groups may lose coverage (Panangala, 2007). In general, VHA does not provide health care services or coverage to spouses or dependents of veterans (IOM, 2009; VA, 2009). However, in accordance with the Veterans’ Mental-health and Other Care Improvements Act of 2008 (S. 2162, 110th Congress), if VA health care services for family members are necessary for the proper treatment of a veteran, then various family members also will have access. Previously, family members were only allowed to take part in such services if they were initiated during a veteran’s hospitalization and continued only if necessary for hospital discharge (IOM, 2010). TABLE 9.2 Enrollment Priority Groups Priority Group Definition 1 Veterans with VA service-connected disabilities 50% or more disabling. Veterans assigned a total disability rating for compensation based on unemployability.

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422 RETURNING HOME FROM IRAQ AND AFGHANISTAN Priority Group Definition 2 Veterans with VA service-connected disabilities rated 30% or 40%. 3 Veterans who are former Prisoners of War. Veterans awarded a Purple Heart Medal. Veterans awarded the Medal of Honor. Veterans whose discharge was for a disability incurred or aggravated in the line of duty. Veterans with VA service-connected disabilities rated 10% or 20%. Veterans awarded special eligibility classification under Title 38, U.S.C. § 1151, “benefits for individuals disabled by treatment or vocational rehabilitation.” 4 Veterans receiving increased compensation or pension based on their need for regular Aid and Attendance or by reason of being permanently Housebound. Veterans determined by VA to be catastrophically disabled. 5 Non-service-connected Veterans and noncompensable service-connected Veterans rated 0%, whose annual income and/or net worth are not greater than the VA financial thresholds. Veterans receiving VA Pension benefits. Veterans eligible for Medicaid benefits. 6 Compensable 0% service-connected veterans. Veterans exposed to ionizing radiation during atmospheric testing or during the occupation of Hiroshima and Nagasaki. Project 112/SHAD participants. Veterans who served in the Republic of Vietnam between January 9, 1962, and May 7, 1975. Veterans who served in the Southwest Asia theater of operations from August 2, 1990, through November 11, 1998. Veterans who served in a theater of combat operations after November 11, 1998, as follows: Veterans discharged from active duty on or after January 28, 2003, for 5 years post discharge. 7 Veterans with incomes below the geographic means test (GMT) income thresholds and who agree to pay the applicable copayment. 8 Veterans with gross household incomes above the VA national income threshold and the geographically adjusted income threshold for their resident location and who agrees to pay copays. Veterans eligibility for enrollment: Noncompensable 0% service-connected and:  Subpriority a: Enrolled as of January 16, 2003, and who have remained enrolled since that date and/ or placed in this subpriority due to changed eligibility status.  Subpriority b: Enrolled on or after June 15, 2009, whose income exceeds the current VA National Income Thresholds or VA National Geographic Income Thresholds by 10% or less Veterans eligible for enrollment: Non-service-connected and:  Subpriority c: Enrolled as January 16, 2003, and who remained enrolled since that date and/ or placed in this subpriority due to changed eligibility status  Subpriority d: Enrolled on or after June 15, 2009, whose income exceeds the current VA National Income Thresholds or VA National Geographic Income Thresholds by 10% or less Veterans not eligible for enrollment: Veterans not meeting the criteria above:  Subpriority e: Noncompensable 0% service-connected  Subpriority g: Non-service-connected SOURCE: Department of Veterans Affairs website: http://www.va.gov/healthbenefits/resources/priority_groups.asp (accessed October 3, 2012).

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ACCESS AND BARRIERS TO CARE 423 Cost of Care All enrolled veterans are provided treatment and medications for service-connected illness of injury by the VA free of charge. Those who are in the higher-priority groups usually do not pay a copayment for services unrelated to their military service, while those veterans in the lower-priority groups usually pay $15 for a primary care visit and $50 for a specialist care visit (VA, 2012a). With the passage of the Veterans Millennium Health Care Act in 1999 (effective in FY 2002) the copayment for outpatient prescriptions increased from $2 to $7 per 30-day supply (Zeber et al., 2007). As of January 2006, the copayment for veterans in priority categories 2 through 6 increased to $8 per prescription with a maximum annual copayment of $960. Veterans with higher incomes (priority group 7 and 8) pay $9 per 30-day supply; there is no annual cap for this group (VA, 2012a). For those with very low income or a disability rating of 50% of higher, all copayments are waived (CBO, 2009; Stroupe et al., 2007). Thus, veteran’s health care is provided at no cost to veterans in high-priority groups and at low cost to veterans in other priority categories. Furthermore, in its attempt to reduce or eliminate costs for some treatments, the VA no longer requires a copayment for telehealth (discussed later in this chapter) (VA, 2012b). VA Electronic Health Record In an effort to improve access through communication between health care provider and patient, the website MyHealtheVet was introduced by the VHA in 2003. It is a Web-based personal health record that provides information on health conditions, benefits, and VA facility locations and contains a personalized patient health record, which allows patients to perform certain functions related to their health care, such as refilling prescriptions, making appointments, and viewing the results of certain laboratory tests (Jackson et al., 2011; Turvey et al., 2012). More broadly, it is intended to improve co-managed care and empower patients to play a more active role in their health care (Nazi et al., 2010). In 2010, a survey was conducted using the American Customer Satisfaction Index. Veterans who had viewed at least four pages of MyHealtheVet were invited to participate in the survey regarding utilization of the website. The majority of the users were male (91%), between 51 and 70 years old (68%), and served during Vietnam (60%). Most rated their health in the “good” or “very good” category, one-third live 1 or more hours away from a VA facility, and 75% use the system to refill prescriptions (Nazi, 2010). Results also indicated that 40% of users printed out their information, 21% saved their information to their computers, 4% sent to other users, 18% shared their medication lists with VA providers, and 9.6% shared with non-VA providers. As of April 2011, the website had registered over 1.2 million users. While MyHealtheVet has the capacity to improve access through increased coordination of care, VHA will need to determine how to increase usage among veterans. Mental-Health Care Within the VA The VA offers acute inpatient care, intensive and regular outpatient care (e.g., psychotherapy, pharmacotherapy, and telemedicine), residential care, and supported work settings. Services include treatment for depression and anxiety, substance abuse, PTSD, severe mental illnesses (e.g., schizophrenia, schizoaffective disorder, and bipolar disorder), and special programs for veteran populations with special needs (e.g., suicide prevention services, sexual

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446 RETURNING HOME FROM IRAQ AND AFGHANISTAN issues related to women’s circumstances and stressors—such as military workplace stress, sexual harassment and assault, posttraumatic stress disorder, and premilitary trauma—in an effort to reduce disparities and to provide health care that is sensitive to their needs and preferences. REFERENCES Adler, A. B., P. D. Bliese, D. McGurk, C. W. Hoge, and C. A. Castro. 2009a. Battlemind debriefing and battlemind training as early interventions with soldiers returning from Iraq: Randomization by platoon. Journal of Consulting and Clinical Psychology 77(5):928-940. Adler, A. B., C. A. Castro, and D. McGurk. 2009b. Time-driven battlemind psychological debriefing: A group-level early intervention in combat. Military Medicine 174(1):21-28. Ames, G. M., C. B. Cunradi, R. S. Moore, and P. Stern. 2007. Military culture and drinking behavior among US Navy careerists. Journal of Studies on Alcohol and Drugs 68(3):336-344. Andrews, K., K. Bencio, J. Brown, L. Conwell, C. Fahlman, and E. Schone. 2009. Health Care Survey of DOD Beneficiaries 2008 Annual Report. Washington, DC: Mathematica Policy Research, Inc. Antonacci, D. J., R. M. Bloch, S. A. Saeed, Y. Yildirim, and J. Talley. 2008. Empirical evidence on the use and effectiveness of telepsychiatry via videoconferencing: Implications for forensic and correctional psychiatry. Behavioral Sciences and the Law 26(3):253-269. Avery, G. H., and S. MacDermid Wadsworth. 2011. Access to mental-health services for active duty and National Guard TRICARE enrollees in Indiana. Military Medicine 176(3):261-264. Bagchi, A., K. Bencio, J. Kim, M. Lee, and E. Schone. 2007. Health Care Survey of DOD Beneficiaries 2007 Annual Report. Washington, DC: Mathmatica Policy Research, Inc. Barton, P. L., A. G. Brega, P. A. Devore, K. Mueller, M. J. Paulich, N. R. Floersch, G. K. Goodrich, S. G. Talkington, J. Bontrager, B. Grigsby, C. Hrincevich, S. Neal, J. L. Loker, T. M. Araya, R. E. Bennett, N. Krohn, and J. Grigsby. 2007. Specialist physicians’ knowledge and beliefs about telemedicine: A comparison of users and nonusers of the technology. Telemedicine Journal and E-Health 13(5):487- 499. Beals, J., S. M. Manson, J. H. Shore, M. Friedman, M. Ashcraft, J. A. Fairbank, and W. E. Schlenger. 2002. The prevalence of posttraumatic stress disorder among American Indian Vietnam veterans: Disparities and context. Journal of Traumatic Stress 15(2):89-97. Bean-Mayberry, B., C. Huang, F. Batuman, C. Goldzweig, D. L. Washington, E. M. Yano, and I. M. Miake-Lye. 2010. Systematic Review of Women Veterans Health Research 2004-2008. Los Angeles, CA: Evidence-based Synthesis Program (ESP) Center. Bean-Mayberry, B., E. M. Yano, D. L. Washington, C. Goldzweig, F. Batuman, C. Huang, I. Miake-Lye, and P. G. Shekelle. 2011. Systematic review of women veterans’ health: Update on successes and gaps. Womens Health Issues 21(4 Suppl):S84-S97. Bertakis, K. D., R. Azari, L. J. Helms, E. J. Callahan, and J. A. Robbins. 2000. Gender differences in the utilization of health care services. Journal of Family Practice 49(2):147-152. Britt, T. W. 2000. The stigma of psychological problems in a work environment: Evidence from the screening of service members returning from Bosnia. Journal of Applied Social Psychology 30(8):1599-1618. Britt, T. W., T. M. Greene-Shortridge, S. Brink, Q. B. Nguyen, J. Rath, A. L. Cox, C. W. Hoge, and C. A. Castro. 2008. Perceived stigma and barriers to care for psychological treatment: Implications for reactions to stressors in different contexts. Journal of Social and Clinical Psychology 27:19.

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