Military and Veterans Administration Health Systems

CHAPTER 39

The United States Military and Veterans Administration Health Systems

Contemporary Overview and Policy Challenges

John S. Murray

“No one who fights for this country should ever have to fight for a job, or a roof over their head, or the care that they have earned.”

President Barack Obama

The U.S. Military Health System (MHS) provides a number of important health care services to as many as 8.3 million service members, military retirees, and their families (Murray & Chaffee, 2011; The Kaiser Foundation, 2012). Military health care is provided by approximately 140,000 military, civilian, and contract personnel working around the globe at 59 military treatment facilities (MTFs) capable of providing diagnostic, therapeutic, and inpatient care. Additionally, care is delivered at hundreds of military outpatient clinics and by private sector civilian providers (Government Accountability Office [GAO], 2012; Murray & Chaffee, 2011).

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Military nursing consists of several components: active duty, reserve, National Guard, enlisted medical technicians, and federal civilian registered nurses. The Army Nurse Corps is comprised of 40,000 nursing team members, whereas the Air Force has 18,000 and the Navy approximately 5,800 (U.S. Senate Committee on Appropriations, 2012). Active duty military nurses in all armed forces must have a bachelor’s degree in nursing (BSN) from an accredited school to serve in the military.

The MHS has two missions (Figure 39-1):

• A military readiness mission: supporting wartime and other deployments (GAO, 2012; Murray & Chaffee, 2011).

• A health care benefits mission: providing medical services and support to members of the armed forces, retirees, and their dependents (GAO, 2012; Murray & Chaffee, 2011).

The Veterans Health Administration (VHA) is home to the United States’ largest integrated health care system consisting of 152 medical centers, nearly 1,400 community-based outpatient clinics, community living centers, Vet Centers, and residential homes for disabled veterans. More than 239,000 staff, including 53,000 licensed health care clinicians, work to provide comprehensive care to more than 8.3 million veterans each year at these facilities. The VHA nursing team consists of 77,000 personnel nationwide composed of registered nurses, licensed practical/vocational nurses, and nursing assistants. Of these, approximately 5440 are advanced practice nurses (Certified Registered Nurse Anesthetists, Nurse Practitioners, and Clinical Nurse Specialists). A BSN degree is not a requirement to work for the VHA (U.S. Department of Veterans Affairs Office of Nursing Services, 2010). The VHA’s primary mission is to honor America’s veterans by providing exceptional comprehensive care that improves their health and well-being. It accomplishes this benchmark of excellence by

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providing exemplary services that are both patient centered and evidence based (U.S. Department of Veterans Affairs, 2013a).

Military and Veterans Administration Health Systems

FIGURE 39-1 The Military Health System Mission.

The MHS and VHA Budgets

The National Defense Authorization Act (NDAA) is passed by Congress annually and specifies the overall budget for the Department of Defense (DoD), which includes funding for the MHS. Funding supports the delivery of health care to service members and their families as well as supporting education and training of military medical personnel, research, and purchasing medical equipment and supplies for MTFs and clinics (Murray & Chaffee, 2011). Each year, senior military nursing leaders speak before Congress regarding accomplishments and challenges over the previous year as well as identifying what new programs and policies are needed. In 2012 the Chief of the Army Nurse Corps presented information to support the need for a new trauma-training program for nurses. This program would allow the nurses to continue to develop their full capability to manage critical trauma patients across the battlefield. In response, Congress provided funding to support the development of the Army’s first Trauma Nurse Course that prepares nurses for the ever-changing traumatic injuries treated on the battlefield (U.S. Senate Committee on Appropriations, 2012). Patient outcomes from advanced treatment of traumatic injuries on the battlefield that have resulted from this training will inform policy regarding what nurses need to know to provide this specialty care.

As with U.S. health care costs over the past decade, expenses for the MHS have also significantly increased, more than doubling from $19 billion dollars in 2001 to a projected budget of $49.4 billion in 2014, equivalent to approximately 9.5% of the entire DoD budget. Although reasons for this large increase are many, two in particular receive great attention from Congress. There currently exists a vast amount of duplication and redundancy within the current three service medical departments (Air Force, Army, and Navy). This includes personnel, processes, and equipment, which add to growing defense health care costs. Additionally, wartime requirements have led to increased expenditures. When military health care personnel are deployed, patient care is often shifted to civilian care, which is more expensive (Beasley, 2012). To be fiscally responsible, the DoD has completed a comprehensive analysis of military health care spending. Strategic planning is aimed at eliminating duplication and redundancy as well as controlling costs, while continuing to provide optimal care (Office of the Under Secretary of Defense, 2013). Since 2007, military nurses have taken the lead role in standardizing health care policies and procedures related to education, training, and research for the DoD (Murray, 2009; Murray & Chaffee, 2011). For example, instead of creating new simulation programs to meet training needs in the National Capital Region, nurses brought together the three military services and civilian academic and health care institutions to create a robust platform reducing duplication of services. This initiative met the directive set forward by the Deputy Secretary of Defense for the three branches of the military to partner on education and training initiatives to reduce defense health care costs (Murray, 2010).Military and Veterans Administration Health Systems

Historically, the VHA has been underfunded. However, for 2014, the VHA requested and received $64 billion dollars to provide reliable and timely

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resources to support the delivery of accessible and high-quality medical services to veterans. This is a 4.5% increase over the 2012 budget and approximately 40% of the total Department of Veterans Affairs budget (Merlis, 2012). One reason for escalating costs is the financial outlay required to cover the increased number of veterans seeking care from the VHA as a result of physical and mental injuries to personnel who have been deployed multiple times in Iraq and Afghanistan. Funding will support acute hospital, rehabilitative, psychiatric, nursing home, noninstitutional extended state home domiciliary, and outpatient care. The budget also supports upgrading of treatment facilities as well as the purchase of equipment and supplies. In addition, the VHA is the United States’ largest provider of graduate medical and nursing education as well as a major contributor to medical research which is supported by the annual budget (U.S. Department of Veterans Affairs, 2013b; 2013c).

Like the MHS, the VHA is expected to provide exceptional care while controlling costs, and has implemented a number of performance measures aimed at continually monitoring the provision of high-quality care, access to care, revenue cycle improvement to improve efficiency and accuracy, as well as partnering with the MHS to improve collaboration and sharing of resources. In fact, for many years the VHA was considered an industry leader because of its safety and quality measures (U.S. Department of Veterans Affairs, 2013c).

Advanced Nursing Education and Career Progression

The MHS places great importance on advanced nursing education. During war, health care continues to evolve based on the nature of combat as well as the challenges posed by working in the austere environments characteristic of the battlefield (Spencer & Favand, 2006). Military nurses must possess the advanced practice specialty skills needed during conflict. Additionally, master’s degrees are required to be obtained before being promoted to more senior military ranks. Professional growth and development is continuously provided throughout a nurse’s career in the MHS by way of leadership experiences, on-the-job training, and continuing education. A variety of educational programs, including postgraduate opportunities, are available. Full funding, in addition to continuing to receive full salary and benefits, is provided for nurses earning advanced practice degrees as well as those pursuing doctoral studies. The armed services are committed to advancing military nursing science to optimize the health of military members and their families. Graduate education in civilian programs is available for selected promising nurse researchers. Additionally, to further advance the nursing research needs of the MHS, in 1992 Congress established the TriService Nursing Research Program (TSNRP), which is the only program funding and supporting rigorous scientific research in the field of military nursing (Duong et al., 2005).

TSNRP funds a wide range of studies to advance military nursing science. For example, in 2011 a pilot study was conducted to determine the sensitivity and specificity of small animal positron emission tomography-computed tomography (PET-CT) in identifying metabolic changes in muscle tissue surrounding simulated shrapnel injuries, and comparing this imaging with traditional x-ray images. Results showed the PET-CT to be more sensitive in identifying tissue changes. Military nurses now have a unique opportunity to educate patients and military health care providers, as well as to inform policy changes, about the possibility of early tissue changes around embedded shrapnel fragments and the use of PET-CT imaging as a possible surveillance tool. Another study supported by TSNRP in 2010 sought to understand how posttraumatic stress symptoms (PTSS) affect couple functioning in Army soldiers returning from combat. Findings included that almost 50% of couples had at least one person in the relationship with a high level of PTSS. Based on these results, development of interventions and policies designed to mitigate, or even prevent, negative outcomes such as divorce, violence, and suicide for military couples facing combat deployment are under way (TSNRP, 2013).Military and Veterans Administration Health Systems