VA Health Care For Women: Progress Made in Providing Services to Women
Veterans (Letter Report, 01/29/99, GAO/HEHS-99-38).

Pursuant to a congressional request, GAO reviewed the status of the
Department of Veterans Affairs' (VA) health care program for women,
focusing on: (1) the progress VA made in removing barriers that may
prevent women veterans from obtaining VA health care services; and (2)
the extent to which VA health care services, particularly
gender-specific services, are available to and used by women veterans.

GAO noted that: (1) VA has made considerable progress in removing
barriers that prevent women veterans from obtaining care; (2) VA has
increased outreach to women veterans to inform them of their eligibility
for health care services and designated women veterans coordinators to
assist women veterans in accessing VA's health care system; (3) VA has
also improved the health care environment in many of its medical
facilities, especially with respect to accommodating the privacy needs
of women veterans; (4) however, VA recognizes that it has more working
these areas and plans to address concerns about the effectiveness of its
outreach efforts and privacy barriers that still exist in some
facilities; (5) in response to women veterans' concerns, VA has begun to
assess its capacity to women veterans; (6) with regard to
gender-specific services, VA's efforts to emphasize women veterans'
health care have contributed to a significant increas of all services
over the last 3 years; (7) the range of services differs by facility;
services may be provided in clinics designated specifically for women
veterans, or they may be provided in the overall medical facility health
care system; (8) more importantly, utilization has increased
significantly between 1994 and 1997; (9) for example, gender-specific
services grew from over 85,000 to more than 121,000; and (10) during the
same time period, the number of women veterans treated for all health
care services on an outpatient basis increased by about 32 percent or
119,300.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  HEHS-99-38
     TITLE:  VA Health Care For Women: Progress Made in Providing 
             Services to Women Veterans
      DATE:  01/29/99
   SUBJECT:  Women
             Veterans
             Veterans hospitals
             Health care services
             Mental health care services
             Health resources utilization
             Veterans benefits
IDENTIFIER:  VA Veterans Integrated Service Network
             DOD Transition Assistance Program
             
******************************************************************
** This file contains an ASCII representation of the text of a  **
** GAO report.  Delineations within the text indicating chapter **
** titles, headings, and bullets are preserved.  Major          **
** divisions and subdivisions of the text, such as Chapters,    **
** Sections, and Appendixes, are identified by double and       **
** single lines.  The numbers on the right end of these lines   **
** indicate the position of each of the subsections in the      **
** document outline.  These numbers do NOT correspond with the  **
** page numbers of the printed product.                         **
**                                                              **
** No attempt has been made to display graphic images, although **
** figure captions are reproduced.  Tables are included, but    **
** may not resemble those in the printed version.               **
**                                                              **
** Please see the PDF (Portable Document Format) file, when     **
** available, for a complete electronic file of the printed     **
** document's contents.                                         **
**                                                              **
** A printed copy of this report may be obtained from the GAO   **
** Document Distribution Center.  For further details, please   **
** send an e-mail message to:                                   **
**                                                              **
**                                            **
**                                                              **
** with the message 'info' in the body.                         **
******************************************************************


Cover
================================================================ COVER


Report to the Chairman, Subcommittee on Health, Committee on
Veterans' Affairs, House of Representatives

January 1999

VA HEALTH CARE FOR WOMEN -
PROGRESS MADE IN PROVIDING
SERVICES TO WOMEN VETERANS

GAO/HEHS-99-38

Health Care Services for Women Veterans

(406156)


Abbreviations
=============================================================== ABBREV

  OIG - Office of the Inspector General
  TAP - Transition Assistance Program
  VA - Department of Veterans Affairs
  VBA - Veterans Benefits Administration
  VHA - Veterans Health Administration
  VISN - Veterans Integrated Service Network
  WVPO - Women Veterans' Program Office

Letter
=============================================================== LETTER


B-281516

January 29, 1999

The Honorable Cliff Stearns
Chairman, Subcommittee on Health
Committee on Veterans' Affairs
House of Representatives

Dear Mr.  Chairman: 

The Department of Veterans Affairs (VA) is required to provide health
care to men and women who have served in the U.S.  military.  Because
male veterans account for 95 percent--24.3 million of the total
veteran population and VA's total outpatient workload (29.4 million
visits)--it has been difficult for women veterans to obtain health
care services, especially gender-specific care, within VA medical
facilities.  By 2010, however, women are expected to represent over
10 percent--over 2 million of the projected 20 million
veterans--compared to about 5 percent in 1997. 

In response to past criticisms, VA has taken a number of steps to
improve its accommodation of the special health care needs of women
and plans to continue its efforts.  For example, last April, we
testified on VA's efforts to provide counseling services to women who
had been sexually traumatized and found that, as a result of VA's
efforts, women veterans were increasingly using these services.\1

Concerned about women veterans' access to other, more general
services, you asked us to review the current status of the women
veterans' health care program.  Specifically, you asked us to (1)
describe the progress VA has made in removing barriers that may
prevent women veterans from obtaining VA health care services and (2)
determine the extent to which VA health care services, particularly
gender-specific services, are available to and used by women
veterans. 

To conduct our work, we interviewed officials at VA's Readjustment
Counseling Center (Vet Center), medical centers, and Center for Women
Veterans in the Office of the Secretary; the Veterans Health
Administration (VHA); and two Veterans Benefits Administration (VBA)
regional offices.  In addition, we reviewed and analyzed VA's health
care plans for women, patient utilization data, and prior reports and
studies on women veterans' health care programs.  (For a complete
description of our scope and methodology, see app.  I).  We performed
our work between September 1998 and December 1998 in accordance with
generally accepted government auditing standards. 


--------------------
\1 See Women Veterans' Health Care:  VA Efforts to Respond to the
Challenge of Providing Sexual Trauma Counseling (GAO/T-HEHS-98-138,
Apr.  23, 1998). 


   RESULTS IN BRIEF
------------------------------------------------------------ Letter :1

VA has made considerable progress in removing barriers that prevent
women veterans from obtaining care.  For example, VA has increased
outreach to women veterans to inform them of their eligibility for
health care services and designated women veterans coordinators to
assist women veterans in accessing VA's health care system.  VA has
also improved the health care environment in many of its medical
facilities, especially with respect to accommodating the privacy
needs of women veterans.  However, VA recognizes that it has more
work to do in these areas and plans to address concerns about the
effectiveness of its outreach efforts and privacy barriers that still
exist in some facilities.  In addition, in response to women
veterans' concerns, VA has begun to assess its capacity to provide
inpatient psychiatric care to women veterans. 

With regard to gender-specific services, VA's efforts to emphasize
women veterans' health care have contributed to a significant
increase in the availability and use of all services over the last 3
years.  The range of services differs by facility; services may be
provided in clinics designated specifically for women veterans, or
they may be provided in the overall medical facility health care
system.  More importantly, utilization has increased significantly
between 1994 and 1997.  For example, gender-specific services--pap
smears, mammograms, and reproductive health care--grew from over
85,000 to more than 121,000.  During the same time period, the number
of women veterans treated for all health care services on an
outpatient basis increased by about 32 percent or 119,300. 


   BACKGROUND
------------------------------------------------------------ Letter :2

Women represent a small but rapidly growing segment of the nation's
veteran population.  In 1982, there were about 740,000 women
veterans.  By 1997, that number had increased by 66 percent to over
1.2 million, or 4.8 percent, of the veteran population.  Today, women
make up nearly 14 percent of the active duty force and, with the
exception of the Marine Corps, 20 percent of new recruits.  By 2010,
women are expected to represent over 10 percent of the total veteran
population. 

Like male veterans, female veterans who serve on active duty in the
uniformed services for the minimum amount of time specified by law
and who were discharged, released, or retired under conditions other
than dishonorable are eligible for some VA health care services. 
Historically, veterans' eligibility for health care services depended
on factors such as the presence and extent of service-connected
disabilities, income, and period and conditions of military service. 

In 1996, the Congress passed the Veterans Health Care Eligibility
Reform Act (P.L.  104-262), which simplified the eligibility criteria
and made all veterans eligible for comprehensive outpatient care.  To
manage its health care services, the act requires VA to establish an
enrollment process for managing demand within available resources. 
The seven priorities for enrollment are (1) veterans with
service-connected disabilities rated at 50 percent or higher\2 ; (2)
veterans with service-connected disabilities rated at 30 or 40
percent; (3) former prisoners of war, veterans with service-connected
disabilities rated at 10 or 20 percent, and veterans whose discharge
from active military service was for a compensable disability that
was incurred or aggravated in the line of duty or veterans who with
certain exceptions and limitations are receiving disability
compensation; (4) catastrophically disabled veterans and veterans
receiving increased non-service-connected disability pensions because
they are permanently housebound; (5) veterans unable to defray the
cost of medical care; (6) all other veterans in the so-called "core"
group,\3 including veterans of World War I and veterans with a
priority for care based on presumed environmental exposure; and (7)
all other veterans.  VA may create additional subdivisions within
each of these enrollment groups. 

With the growing women veteran population came the need to provide
health care services equivalent to those provided to men.  Over the
past 15 years, GAO, VA, and the Advisory Committee on Women Veterans
have assessed VA services available to women veterans.  In 1982, GAO
reported that VA lacked adequate general and gender-specific health
care services, effective outreach for women veterans, and facilities
that provided women veterans appropriate levels of privacy in health
care delivery settings.\4 In 1992, GAO reported that VA had made
progress in correcting previously identified deficiencies, but some
privacy deficiencies and concerns about availability and outreach
remained.\5 In response to concerns about the availability of women
veterans' health care and to improve VA's delivery of health care to
women veterans, the Congress enacted the Women Veterans Health
Programs Act of 1992 (P.L.  102-585).  This act authorized new and
expanded health care services for women.  In 1993, VA's Office of the
Inspector General (OIG) for Health Care Inspections reported that
problems--such as women veterans' not always being informed about
eligibility for health care services as well as VA's lack of
appropriate accommodations, medical equipment, and supplies to treat
women patients in VA medical facilities--still existed.\6

In December 1993, the Secretary of the Department of Veterans
Affairs, established VA's first Women Veterans' Program Office
(WVPO).  In November 1994, the Congress enacted legislation (P.L. 
103-446) that required VA to create a Center for Women Veterans to
oversee VA programs for women.  As a result, WVPO was reorganized
into the Center for Women Veterans.  The Center Director reports
directly to the VA Secretary. 

In compliance with the Government Performance Results Act, VA has a
strategic plan that includes goals for (1) monitoring the trends in
women's utilization of VA services from fiscal years 1998 through
2001, (2) reporting on barriers and actions to address
recommendations to correct them, and (3) assessing progress in
correcting deficiencies from fiscal years 1999 through 2001.  VA's
performance plan also includes goals that target women veterans
currently enrolled in VA for aggressive prevention and health
promotion activities to screen for breast and cervical cancer. 


--------------------
\2 VA assigns disability ratings to compensate veterans for physical
or mental conditions incurred or aggravated during military service. 
These ratings are assigned in increments of 10, ranging from 0 to 100
percent, and are used to determine compensation for service-connected
conditions. 

\3 "Core" refers to World War I and Mexican-border veterans, veterans
solely seeking care for disorders associated with exposure to toxins
or environmental hazards in service, and compensable 0-percent
service-connected veterans. 

\4 Actions Needed to Ensure That Female Veterans Have Equal Access to
VA Benefits (GAO/HRD-82-98, Sept.  24, 1982). 

\5 VA Health Care for Women:  Despite Progress, Improvements Needed
(GAO/HRD-92-23, Jan.  23, 1992). 

\6 Office of the Inspector General for Health Care Inspections,
Report of Inspection of Women Veterans' Health Care Programs,
3HI-A99-129 (Washington, D.C.:  Department of Veterans Affairs, June
1993). 


   VA HAS REDUCED MANY BARRIERS TO
   CARE
------------------------------------------------------------ Letter :3

VA has taken several actions to remove barriers identified by GAO,
VA, and women veteran proponents over the years that prevent women
veterans from obtaining care in VA medical facilities.  First, VA has
increased outreach efforts to inform women veterans of their
eligibility for benefits and health care services.  However, it has
not evaluated these efforts, so it is not known how knowledgeable
women veterans are about their eligibility for health care services. 
VA has also designated coordinators to assist women veterans in
accessing the system. 

In addition, VA has identified and begun to correct patient privacy
deficiencies in inpatient and outpatient settings.  VA has surveyed
its facilities on two occasions to determine the extent to which
privacy deficiencies exist.  In fiscal year 1998, VA spent more than
$67 million correcting deficiencies and has developed plans for
correcting remaining deficiencies.  However, VA continues to face
obstacles addressing the inpatient mental health needs of women
veterans in a predominantly male environment and has established a
task force to look at this and other issues. 


      EFFORTS INCREASED TO INFORM
      WOMEN VETERANS OF SERVICES,
      BUT EFFECTIVENESS UNKNOWN
---------------------------------------------------------- Letter :3.1

Over the last few years, VA has increased its outreach efforts to
inform women veterans of their eligibility for care in response to
problems highlighted by GAO, VA, and veteran service organizations
between 1982 and 1994.  We and others reported that (1) women
veterans were not aware that they were eligible to receive health
care in VA and (2) VA did not target outreach to women veterans,
routinely disseminate information to service organizations with
predominantly female memberships, or adequately inform women of
changes in their eligibility.  To address these concerns, VA has
targeted women veterans during outreach efforts at the headquarters,
regional, and local levels. 

At the headquarters level, a number of outreach strategies have been
implemented.  For example, the Center for Women Veterans, as part of
its strategic and performance goals for 1998 through 2000, is placing
greater emphasis on the importance of outreach to women and the need
for improved communication techniques.  Since the inception of WVPO
and the Center for Women Veterans, VA has held an average of 15 to 20
town meetings a year, along with other informational seminars.  The
Center also provided informational seminars at the annual conventions
of the Women's Army Corp and the Women Marines; American Legion;
American Veterans of World War II, Korea, and Vietnam; and Disabled
American Veterans.  The Center also provided information on VA
programs for women veterans and other women veterans' issues at
national training events for county and state veteran service
officers and their counterparts in the national Veterans' Service
Organizations.  Further, the Center established a web site within the
VA home page to provide women veterans with information about health
care services and other concerns as well as the opportunity to
correspond with the Center via electronic mail. 

At the regional and local levels, VBA regional and benefit offices,
VA medical centers, and Vet Centers display posters, brochures, and
other materials that focus specifically on women veterans.  They also
send representatives to distribute these materials and talk to women
veterans during outreach activities, such as health fairs and media
events, that are used to publicize the theme that "Women Are
Veterans, Too." The VA facilities we visited were conducting similar
activities.  For example, the medical center in New Orleans directed
its Office of Public Relations to work closely with the women
veterans coordinator to develop an outreach program.  The New Orleans
Vet Center women veterans coordinator told us that she expanded her
outreach efforts to colleges with nursing schools in an effort to
reach women veterans who do not participate in veteran-related
activities. 

In addition, VBA regional offices coordinate with the Department of
Defense to provide information on VA benefits and services to
prospective veterans during Transition Assistance Program (TAP)
briefings.  In addition to providing information to active-duty
personnel who plan to separate from the military on how to transition
into civilian life, TAP briefings provide information on the benefits
they may be eligible for as veterans as well as how to obtain them. 

Although VA has greatly increased its outreach efforts, it has not
yet evaluated the effectiveness of these efforts.  Women veterans
organizations have acknowledged the increase in VA's outreach efforts
directed at women veterans but continue to express concern about
whether women veterans are being reached and adequately informed
about their eligibility for benefits and health care services. 
Several women veterans we talked with during our site visits said
they found out by chance--during casual conversations--that they were
eligible for care.  Women veterans and agency staff acknowledged that
"word of mouth" from satisfied patients appears to be one of the most
effective ways to share information about various benefits and
services to which women veterans may be entitled. 

In March 1998, the Advisory Committee for Women Veterans, the Center
for Women Veterans, and the National Center for Veterans Statistics
provided specific questions for inclusion in VA's Survey of Veterans
for Year 2000 to address the extent to which women veterans are
becoming more knowledgeable about their eligibility for services. 
This survey should allow VA to assess the effectiveness of its
outreach to women veterans. 


      WOMEN VETERANS COORDINATORS
      MORE EFFECTIVE IN ASSISTING
      WOMEN VETERANS IN OBTAINING
      CARE
---------------------------------------------------------- Letter :3.2

Women veterans coordinators assist in obtaining care, advocate for
women veterans' health care, and collaborate with medical center
management to make facilities more sensitive to women veterans.  This
role was established in 1985 because women veterans did not know how
to obtain health care services once they became aware of their
eligibility for these services.  However, in 1994, VA's OIG reported
that these coordinators often lacked sufficient training and time to
perform effectively; many women veterans coordinators performed in
this capacity on a part-time basis.\7

VA has since provided women veterans coordinators training and more
time to carry out their roles and help them provide better assistance
to women veterans in accessing VA's health care system and obtaining
care.  In an effort to make them more effective in this role, in
1994, VA implemented a national training program designed to increase
women veterans coordinators' awareness of their roles and familiarize
them with women veterans' issues.  The program is administered by a
full-time women veterans' national education coordinator and staff at
the Birmingham Regional Medical Education Center.  In addition, the
women veterans coordinators at VA's medical centers in Tampa and Bay
Pines developed a mini-residency training program for women veterans
coordinators.  This program, approved in 1995, is the only training
program of its kind and is offered for newly appointed women veterans
coordinators. 

To allow women veterans coordinators more time to perform their
duties, in 1994, VA established positions for additional full-time
women veteran coordinators at selected VA medical centers and four
full-time VBA regional women veterans coordinators.  As of January
1998, about 40 percent of the women veterans coordinators in VA
medical facilities were full-time.  According to VA's Advisory
Committee on Women Veterans, the women veterans coordinator program
has proven to be one of the most successful initiatives recommended
by the committee. 


--------------------
\7 Office of the Inspector General for Health Care Inspections,
Report of Inspection of Women Veterans' Health Care Programs, Privacy
Issues--Part II, 4HI-A19-042 (Washington, D.C.:  Department of
Veterans Affairs, Mar.  1994). 


      VA IS ADDRESSING PRIVACY
      DEFICIENCIES, BUT BARRIERS
      REMAIN
---------------------------------------------------------- Letter :3.3

Patient privacy for women veterans has been a long-standing concern,
and VA acknowledges that the correction of physical barriers that
limit women's access to care in VA facilities will be an ongoing
process.  Between 1982 and 1994, GAO and VA's OIG reported that
physical barriers, including hospital wards with large open rooms
having 8 to 16 beds and a lack of separate bath facilities, concerned
women veterans and inconvenienced staff.  Female patients had to
compete with patients in isolation units for the limited number of
private rooms in VA hospitals.  Also, hospitals with communal
bathrooms sometimes required staff to stand guard or use signs
indicating that the bathroom was occupied by female patients. 

As required by section 322 of the Veterans' Health Care Eligibility
Reform Act of 1996, VA conducted nationwide privacy surveys of its
facilities in fiscal years 1997 and 1998 to determine the types and
magnitude of privacy deficiencies that may interfere with appropriate
treatment in clinical areas.  The surveys revealed numerous patient
privacy deficiencies in both inpatient and outpatient settings.  The
fiscal year 1998 survey also showed that 117 facilities from all 22
Veterans Integrated Service Networks (VISN) spent nearly $68 million
in construction funds in fiscal year 1998 to correct privacy
deficiencies.  Another 91 facilities from 20 of the 22 VISNs used a
total of 130 alternatives to construction to eliminate deficiencies. 
These alternatives included actions such as initiating policy changes
that would admit female patients only to those areas of the hospital
that have the appropriate facilities or issuing policy statements
that gynecological examinations would only be performed in the
women's clinics or contracted out.  In addition, VISN and medical
center staff developed plans for correcting and monitoring the
remaining deficiencies. 

Although the 1998 survey showed that VA has improved the health care
environment to afford women patients comfort and a feeling of
security, the survey also revealed that many deficiencies still
exist.  (See table 1.) Of those facilities with deficiencies, the
most prevalent inpatient deficiency was a lack of sufficient toilet
and shower privacy, and the most prevalent outpatient deficiency was
the lack of curtain tracks in various rooms. 



                                Table 1
                
                      Prevalent VA Patient Privacy
                   Deficiencies and the Number of VA
                 Medical Facilities Where Deficiencies
                   Still Exist as of October 1, 1998

                                 Facilities having deficiency
                        ----------------------------------------------
Patient privacy
deficiency                      Number                 Percent
----------------------  ----------------------  ----------------------
Inpatient unit\a
----------------------------------------------------------------------
Lack of sufficient,               42                      24
 appropriate bedroom
 privacy
Lack of sufficient                63                      36
 toilet and shower
 privacy
Lack of sufficient,               58                      34
 private, handicapped-
 accessible shower
 facilities
Lack of privacy                   40                      23
 curtain tracks in
 patient bedrooms,
 examination rooms,
 and other types of
 rooms

Ambulatory care (outpatient)\b
----------------------------------------------------------------------
Lack of privacy                   63                      10
 curtain tracks in
 various rooms\c
Lack of toilet rooms              53                      9
 adjacent to
 gynecological rooms
 and urinary clinic
 changing rooms
Inappropriate location            51                      8
 of existing toilet
 rooms\d
Lack of designated                26                      4
 changing areas for
 women in diagnostic
 and day surgical
 areas, clinics,
 mammography, and
 other imaging areas
Inappropriate location            22                      4
 of changing areas for
 women in certain
 areas that are near
 general waiting areas
 or common hallways
Lack of a private                 14                      2
 examination room in
 or near the emergency
 or urgent care area
Lack of a private                 45                      7
 intake interview room
 in the admission area
Lack of personal                  23                      4
 hygiene dispensers in
 toiletrooms in
 clinics and other
 patient areas
----------------------------------------------------------------------
\a Percentages for facilities with inpatient deficiencies are based
on VA's 173 hospital facilities as defined in VA's 1998 survey. 

\b We used 612 as the denominator in computing these percentages: 
173 hospitals, 37 nonhospital-based clinics that reported having
deficiencies, and 402 clinics that did not report a deficiency. 

\c Includes examination rooms (gynecological and nongynecological),
procedure rooms, emergency and urgent care rooms, treatment cubicles,
ambulatory surgery patient holding and recovery areas, and other
cubicles and rooms. 

\d Requires women patients to pass through general waiting areas to
access this room from a nongynecological examination room. 

Source:  Department of Veterans Affairs, Veterans Health
Administration, Women Veteran Patient Privacy Survey Results, 1998
Data (Milwaukee, Wisc.:  National Center for Cost-Containment, Sept. 
1998). 

Consistent with VA's strategic plan for fiscal years 1998 through
2003, a task force with representatives from VHA and the Center for
Women Veterans was established to identify, prioritize, and develop
plans for addressing five major issues related to women veterans'
health care, one of which was patient privacy.  Further, VA plans to
assess the progress made in correcting patient privacy deficiencies
on an annual basis between fiscal years 1999 and 2001.  VA requires
that each facility have a plan for corrective action and a timetable
for completion; VA has also directed each VISN to integrate the
planned corrections into their construction programs. 

To correct the remaining deficiencies, VA projects it will spend
$49.3 million in fiscal year 1999 and $41 million in fiscal year
2000.  Over this same period, medical centers are estimated to spend
approximately $647,000 more in discretionary funds to make some of
these corrections.  Beyond fiscal year 2000, VA projects it will
spend an additional $77 million in capital funds; six facilities in
VISNs 6 and 7 account for 58 percent of the total projected spending
for beyond fiscal year 2000.\8


--------------------
\8 VA's survey shows that the correction of patient privacy
deficiencies in facilities identified in VISNs 6 and 7 will require
renovation and modernization of wards and other conversions.  The age
of these facilities, among other factors, contributed to the costs
involved. 


      TASK FORCE IS ASSESSING VA'S
      ABILITY TO PROVIDE INPATIENT
      PSYCHIATRIC CARE TO WOMEN
      VETERANS
---------------------------------------------------------- Letter :3.4

While correcting privacy deficiencies has allowed VA to better
accommodate women veterans' health care needs, VA faces other
problems accommodating women veterans who need inpatient mental
health treatment.  In the summer of 1998, VA established a task force
of clinicians and women veterans coordinators to assess mental health
services for women veterans and make recommendations by June 1999 for
improving VA's capacity to provide inpatient psychiatric care to this
population.  This task force is chaired by the Director of the Center
for Women Veterans. 

VA data show that in fiscal year 1997, mental disorder was the most
prevalent diagnosis--26.4 percent--for women veterans hospitalized. 
While inpatient psychiatric accommodations are available in VA
facilities, in most instances the environment is not conducive to
treating women veterans.  In 1997, VA's Center for Women Veterans
reported that women veterans hospitalized on VA mental health wards
for post-traumatic stress disorder, substance abuse, or other
psychiatric diagnoses are often the only female on a ward with 30 to
40 males.  This disparate ratio of women to men discourages women
from discussing gender-specific issues and also makes it difficult to
provide group therapy addressing women's treatment issues.  Women
veterans also noted that they were concerned about their safety in
this environment.  These concerns included male patients engaging in
inappropriate remarks or behavior and inappropriate levels of
privacy.  During our site visits, two women veterans expressed
similar concerns. 

VA has inpatient psychiatric facilities that have separate
psychiatric units for women veterans within five areas:  Battle
Creek, Michigan; Brockton-West Roxbury, Massachusetts; Central Texas
Health Care System; Brecksville-Cleveland, Ohio; and Palo Alto,
California, Health Care System.  Women veterans often do not want to
or are unable to leave families and support systems to travel to one
of these facilities for treatment.  Staff at one of the medical
centers we visited in Florida told us that a few of their women
patients who had been sexually traumatized would be better served in
an inpatient setting, but the nearest suitable inpatient facilities
were those in California and Ohio, and the patients did not want to
go that far from home. 


   AVAILABILITY AND USE OF
   SERVICES HAVE INCREASED FOR
   WOMEN VETERANS
------------------------------------------------------------ Letter :4

VA's greater emphasis on women veterans' health has resulted in an
increase in both the availability and use of general and
gender-specific services, such as pap smears, mammograms, and
reproductive health care.  Some VA facilities offer a full complement
of health care services, including gender-specific care, on a
full-time basis in separate clinics designated for women.  Others may
only offer certain services on a contractual or part-time basis. 
According to program officials and the women veterans coordinators at
the locations we visited, the variation in the availability and
delivery of services is generally influenced by the medical center
directors' views of the health needs of the potential patient
population, available resources, and demand for services. 

The increase in the availability of services and the emphasis on
women veterans' health have contributed to increases in the number of
women veterans served and visits made, with the exception of
inpatient care.\9

Between fiscal years 1994 and 1997, the number of gender-specific
services provided to women veterans increased about 42 percent, from
over 85,000 to over 121,000.  The total number of inpatient and
outpatient visits made during this same period increased nearly 56
percent, from about 893,000 to almost 1.4 million. 


--------------------
\9 This decline is consistent with the general reduction of inpatient
services throughout the VA health care system and mirrors the trend
in health care in the private sector to deliver services in
outpatient settings where feasible rather than in hospitals. 


      VA HAS MODIFIED ITS HEALTH
      CARE SYSTEM TO BETTER
      ACCOMMODATE WOMEN VETERANS
---------------------------------------------------------- Letter :4.1

Over the past 10 years, GAO, VA's OIG, and VA's Advisory Committee on
Women Veterans reported that VA was not providing adequate care to
women veterans and was not equipped to do so.  These organizations
found that VA (1) was not providing complete physical examinations,
including gynecological exams for women; (2) lacked the equipment and
supplies to provide gender-specific care to women, such as
examination tables with stirrups and speculums; and (3) lacked
guidelines for providing care to women.  As a result, VA began to
place more emphasis on women veterans' health and looked for ways to
respond to these criticisms. 

For example, to ensure equity of access and treatment, VA designated
women veterans' health as a special emphasis program that merited
focused attention.  In 1983, VA began requiring medical centers to
develop written plans that show how they will meet the health care
needs of women veterans.  At a minimum, these plans must define (1)
that a complete physical examination for women is to include a breast
and gynecological exam, (2) provisions for inpatient and outpatient
gynecology services, and (3) referral procedures for necessary
services unavailable at VA facilities. 

VA also procured the necessary equipment and supplies to treat women. 
In addition, VA established separate clinics for women veterans in
some of its medical facilities.  The locations with separate women's
clinics that we visited had written plans that contained the required
information and the necessary equipment and supplies to provide
gender-specific treatment to women.  Also, we found evidence that
women veterans coordinators were monitoring services provided to
ensure proper care and follow-up. 

VA is more able to accommodate women patients than they were prior to
the early 1990s.  In 1997, VA provided inhouse 94 percent of the
routine gynecological care sought by women veterans, even though its
number of women's clinics fell from 126 in 1994 to 96 in 1998.  Some
VA facilities closed their women's clinics because of consolidation
or implementation of primary care.  Others are phasing their women's
programs into primary care, especially the facilities that had
limited services available in the women's clinic.  This is consistent
with VA's efforts to enhance the efficiency of its health care
system.  For example, since September 1995, VA has or is in the
process of merging the management and operations of 48 hospitals and
clinic systems into 23 locally integrated systems. 


      SERVICES FOR WOMEN ARE
      AVAILABLE BUT VARY BY
      FACILITY
---------------------------------------------------------- Letter :4.2

While women veterans can obtain gender-specific services as well as
other health care services at most VA medical facilities, the extent
to which care, especially gender-specific care, is available varies
by facility.  Some facilities offer a full array of routine and acute
gender-specific services for women--such as pap smears, pelvic
examinations, mammograms, breast health, gynecological oncology, and
hormone therapy--while others offer only routine or preventive
gender-specific care. 

Of the five sites we visited, two--Tampa and Boston--are Women
Veterans' Comprehensive Health Centers,\10 which enable women
veterans to obtain almost all of their health care within the center. 
Generally, these centers have full-time providers who may also be
supported by other clinicians who provide specialty care on a
part-time basis.  For example, the Tampa Women Veterans'
Comprehensive Health Center, which provided care to about 3,000 women
in 1997, is run by a full-time internist, who is supported by another
internist, four nurse practitioner primary care providers, a
gynecologist, a psychologist, a psychiatrist, and other health care
and administrative support staff.  The Tampa center as well as the
Boston center provide their services 5 days a week. 

Other facilities offer less extensive services than those offered
within the comprehensive centers.  For example, the VA medical center
in Washington, D.C., offers only routine or preventive
gender-specific care by a nurse practitioner about 4.5 days a week;
acute or more specialized gynecological care is only offered one-half
day a week with the assistance of a gynecologist and general surgeon
through a sharing agreement with a local Department of Defense
facility.  Other health care services are available within the
medical center. 

The range of services provided by VA's nonhospital-based clinics
varies as well.  Some nonhospital-based clinics, like the one in
Orlando, may provide services almost comparable to those provided by
the medical center or comprehensive center.  Other centers, however,
offer services on a more limited basis.  For example, the
nonhospital-based clinic associated with one of the medical centers
we visited only offers gynecological services once a week.  According
to the women veterans coordinator, the average waiting time to get a
gynecology appointment at this clinic is 51 days.  She explained that
if the situation is urgent, arrangements are made to have the patient
seen in the urgent care clinic or at the medical center. 

Variation in services at VA medical facilities may be attributable to
one or more factors, such as medical center management's views on the
level of services needed, funding, staffing, and demand for services. 
The specific services offered and the manner in which they are
delivered within VA facilities are left to the discretion of medical
center or VISN management.  Most VA facilities did not receive
additional funding to establish health care programs for women and
had to provide these additional services while maintaining or
minimally affecting existing programs.  Initially, VHA provided
additional funding for the comprehensive centers, which was
supplemented by funds from the medical center's budget.  VHA also
provided some additional funding in 1994 to help VA facilities obtain
resources to counsel women veterans who had been sexually
traumatized. 

The women veterans coordinators at the five medical center locations
we visited told us that the medical center directors have a strong
commitment to providing quality health care to women veterans and
that without such support, it would be difficult to meet women
veterans' needs or improve the women's health program.  Some women's
programs had to be established and operated using the medical
center's existing funding and resources, which included no provisions
for these services.  Although the Tampa and Boston centers received
VHA funding to establish a comprehensive health center, they still
had to obtain additional funding from the medical center, which
required management's support. 

The availability of gender-specific services may also be influenced
by the demand for these services.  At two locations we visited, the
women veterans coordinators told us that when they first opened their
women's clinics, they operated on a very limited scale--one-half to 1
day a week.  However, the demand was so overwhelming that they
increased their operations to 5 days a week.  On the other hand, the
women veterans population in some areas is small and may not generate
a high enough demand for gender-specific services to provide them in
a separate women veterans' health care program or within the medical
center on a full-time basis.  In such instances or if a very small
number of female veterans have historically availed themselves of the
services, it may not be cost-effective to provide these services
in-house, as pointed out by VA's OIG in 1993.\11 Instead, it may be
appropriate to contract out for these services. 


--------------------
\10 VA has a total of eight Women Veterans' Comprehensive Health
Centers.  The other six centers are located in Chicago, Illinois
(Chicago Area Network); Durham, North Carolina; Minneapolis,
Minnesota; Philadelphia, Pennsylvania, and Wilmington, Delaware
(Southeast Pennsylvania Network); San Francisco, California; and
Sepulveda and West Los Angeles, California. 

\11 Office of the Inspector General for Health Care Inspections,
Report of Inspection of Women Veterans' Health Care Programs. 


      WOMEN VETERANS' USE OF
      HEALTH SERVICES HAS
      INCREASED
---------------------------------------------------------- Letter :4.3

In the 1990s, women veterans' utilization of gender-specific services
has increased significantly.  Outpatient and inpatient visits among
women veterans at VA facilities increased more than 50 percent
between fiscal years 1994 and 1997.  Based on VA's survey of its
medical facilities, the number of women veterans receiving
gender-specific services increased about 42 percent from more than
85,000 to almost 121,200 during the same period.  (See table 2.)



                          Table 2
          
          Gender-Specific Health Care Utilization
            by Source, Fiscal Years 1994 Through
                            1997

                 Pap                Reproductive
Source        smears    Mammograms        health     Total
----------  --------  ------------  ------------  --------
Fiscal year 1994
----------------------------------------------------------
In-house      30,654        11,943        25,632    68,229
Referral         454           623           556     1,633
Contract       1,357        12,174         2,233    15,764
Total FY      32,465        24,740        28,421    85,626
 1994

Fiscal year 1995
----------------------------------------------------------
In-house      35,491        15,110            \a  50,601\b
Referral         335           696            \a   1,031\b
Contract       1,270        12,542            \a  13,812\b
Total FY      37,096        28,348            \a  65,444\b
 1995

Fiscal year 1996
----------------------------------------------------------
In-house      40,115        15,537        23,405    79,057
Referral         216           609            \a     825\b
Contract       2,521        14,657         4,053    21,231
Total FY      42,852        30,803        27,458  101,113\
 1996                                                    b

Fiscal year 1997
----------------------------------------------------------
In-house      49,799        17,539        28,233    95,571
Referral         255           412           663     1,330
Contract       2,867        18,483         2,928    24,278
Total FY      52,921        36,434        31,824   121,179
 1997
FY 1994-       63.0%         47.3%         12.0%     41.5%
 1997
 increase
----------------------------------------------------------
\a Reproductive health data were not collected for these reporting
periods. 

\b Excludes reproductive health services. 

Source:  Department of Veterans Affairs, Veterans Health
Administration, Health Care Services and Research Related to Women
Veterans as Required by P.L.  102-585, as amended by P.L.  104-262. 
Reports for fiscal years 1994 through 1997. 

Between fiscal years 1994 and 1997, the number of pap smears and
mammograms provided to women veterans increased dramatically.  In
fiscal year 1997, almost 53,000 women veterans received pap smears, a
63-percent increase over fiscal year 1994.  Similarly, in fiscal year
1997, about 36,400 women veterans received mammograms, a 47-percent
increase over fiscal year 1994.  Reproductive health care services,
which cover the entire range of gynecological services, were provided
to over 31,800 women veterans in fiscal year 1997, 12 percent more
than in fiscal year 1994.  According to VA, the pap smear and
mammography examination rates among appropriate and consenting women
veterans in 1997 are 90 percent and 87 percent, respectively.  VA has
set goals to increase the mammography and pap smear examination rates
from their current base rates to 92 percent and 90 percent,
respectively, by fiscal year 2003. 

Women veterans have also used more health care services in general,
consistent with VA's goal to meet women veterans' total health care
needs.  With the exception of inpatient care, the number of women
veterans who use VA health care services and the frequency of their
usage continue to increase.  For the 5-year period between fiscal
years 1992 and 1997, the women veteran population increased only
slightly, from about 1.2 million to 1.23 million.  However, between
fiscal years 1994 and 1997, the number of women veterans who received
outpatient care increased 32 percent, from about 90,000 to more than
119,000, and the total number of outpatient visits increased 57
percent, from nearly 870,000 to over 1.3 million.  (See table 3.)
During this same period, the number of women veterans who received
inpatient care decreased about 5 percent, from about 14,350 to
13,700, which is consistent with VA's--and the nation's--current
health care trend to deliver services in the least costly, most
appropriate setting. 



                                Table 3
                
                 Outpatient and Inpatient Care Provided
                   to Women Veterans in VA Facilities
                 During Fiscal Years 1994 Through 1997

                                  Outpatient
                                     care       Inpatient care
                                --------------  --------------
                                                                 Total
                                                                inpati
                                                                   ent
                                                                   and
                                Unique          Unique          outpat
                                patien   Total  patien   Total    ient
Fiscal year                       ts\a  visits    ts\a  visits  visits
------------------------------  ------  ------  ------  ------  ------
1994                            90,182  869,56  14,342  23,802  893,36
                                             7                       9
1995                            100,44  1,043,  14,821  24,533  1,067,
                                     5     316                     849
1996                            107,34  1,210,  14,554  23,783  1,234,
                                     4     839                     622
1997                            119,31  1,369,  13,679  23,070  1,392,
                                     2     085                     155
Percent change                    32.3    57.4      (-      (-    55.8
                                                  4.6)    3.1)
----------------------------------------------------------------------
\a VA counts unique visits by facility.  Since some patients may
visit more than one facility, they may be counted as a unique more
than once.  Therefore, VA's reported number of uniques may be more
than the actual number of uniques. 

Sources:  VA outpatient treatment files (1994-1997) and Department of
Veterans Affairs, Veterans Health Administration, Health Care
Services and Research Related to Women Veterans as Required by P.L. 
102-585, as amended by P.L.  104-262.  Reports for fiscal years 1994
through 1997. 


   CONCLUDING OBSERVATIONS
------------------------------------------------------------ Letter :5

VA's health care program for women veterans has made important
strides in the last few years.  VA has made good progress informing
women veterans about their eligibility for services and the services
available, assisting women veterans in accessing the system,
correcting patient privacy deficiencies, and increasing health care
services for women veterans.  Most importantly, VA's efforts are
reflected in the increased availability of services and utilization
by women veterans. 

While progress has been made, the importance of sustaining efforts to
address the special needs of women veterans will only increase, as
their percentage of the total veteran population is projected to
double by 2010.  Coincident with these demographic changes, VA is
making changes to the way it delivers health care, including
integrating and consolidating facilities while maintaining quality of
care and implementing eligibility reform.  VA will need to be
especially vigilant to ensure that women veterans' needs are
appropriately addressed as it implements these overall changes. 


   AGENCY COMMENTS
------------------------------------------------------------ Letter :6

In its comments on a draft of this report, VA agreed with our
findings that progress has been made in serving women veterans
through the Women Veterans' Health Program but that additional work
is required to improve outreach to women, rectify privacy issues, and
improve inpatient environments for women undergoing inpatient
psychiatric treatment.  VA also provided some technical comments,
which we have incorporated as appropriate.  VA's comments are
included as appendix II. 


---------------------------------------------------------- Letter :6.1

Copies of this report are being sent to the Secretary of Veterans
Affairs, other appropriate congressional committees, and interested
parties.  We will also make copies available to others on request. 
If you have any questions about the report, please call me or Shelia
Drake, Assistant Director, at (202) 512-7101.  Jacquelyn Clinton,
Evaluator-in-Charge, was a major contributor to this report. 

Sincerely yours,

Stephen P.  Backhus
Director, Veterans' Affairs and
 Military Health Care Issues


SCOPE AND METHODOLOGY
=========================================================== Appendix I

To determine the barriers to women veterans obtaining care within VA,
we talked with officials in the Center for Women Veterans, within the
Office of the Secretary; VHA; two VBA regional offices; and
Readjustment Counseling Centers (Vet Centers) in Tampa, Florida; St. 
Petersburg, Florida; and New Orleans, Louisiana.  We also reviewed
Women Veterans Advisory Committee reports and talked with women
veterans and VA program officials in five medical centers:  Bay
Pines, Florida; Boston, Massachusetts; Tampa; New Orleans; and
Washington, D.C.  These medical centers were selected because they
offered different levels of health care services to women veterans. 

To determine the availability and use of gender-specific care, we
discussed women veterans' health care services with officials at VA's
Central Office and the five medical centers we visited.  We reviewed
VA medical centers' women veterans health care plans, relevant VA
policy directives, and women veterans health care utilization data. 
We also reviewed quality assurance plans, annual reports, minutes of
Women Veterans Advisory Committee meetings, outreach materials, and
other written documentation and materials. 




(See figure in printed edition.)Appendix II
COMMENTS FROM THE DEPARTMENT OF
VETERANS AFFAIRS
=========================================================== Appendix I



(See figure in printed edition.)


*** End of document. ***