Ever since last year’s ruling from the Supreme Court, which paved the way for states to ban abortion, confusion among the medical community in certain states is at an all-time high as to the treatments they are able to provide. The same goes for those working for the Veterans Health Administration. To get a sense on how VA facilities are handling the ongoing changes, the Veterans Affairs Office of Inspector General recently conducted a review of its reproductive care for female veterans. For what the review found, Federal Drive with Tom Temin, Executive Producer Eric White got the chance to speak with Julie Kroviak, Principal Deputy Assistant Inspector General for the Office of Healthcare Inspections at VA OIG.
Eric White So VA has made it an initiative to provide some more care for female veterans, certainly more than they have in the past. And there are more female veterans than ever before. But this also, I believe, branches out into other areas. Let’s just start from the beginning and tell me, you know, how this audit was initiated and what you all were looking for.
Julia Kroviak So let me just stop. It really wasn’t an audit. So within the Office of Health Care Inspections, we do inspections or reviews. And I only you know, I don’t play semantics with that. I just want to say upfront, this was intended to be a descriptive review. So there isn’t really any validation of the data that was provided to us. So when facility leaders might have thrown numbers out or service lines, we didn’t go and check it. We really wanted to talk about their perceptions of what barriers exist to providing a wide variety of reproductive health care services to veterans. So we really weren’t locking it into women. And there are a couple of places where that becomes more apparent in the report itself. We have a women’s health group within OIG that these are dedicated professionals who look at allegations specific to care for women veterans, national topics, you know, things that are on the health care horizon that are really relevant to women veterans. And we listen to VSOs, we have roundtables, we try to get information on what’s really, really important to women veterans. We try to conduct projects on that. So prior to even the IFR and, you know, the decision in 2022 to limit access for abortions, we were planning work to look at reproductive health care across the system. Just didn’t know quite what angle we were going to use. But with women being the fastest growing demographic in the VA, it started to make sense that this was the right time to look at this across the system.
Eric White All right. And so what was your methodology for taking a snapshot of access to VHA’s reproductive care?
Julia Kroviak It’s a great question, because typically when we look at things on a national landscape, we try to sample a random sample so that we can put out conclusions and even then, which would prompt recommendations that would suggest we could aggregate that data and apply it across the system. But we didn’t play that way for very specific reasons. We wanted to capture a mix of sizes and complexities of facilities, so we wanted to include facilities that offer level one trauma services, but also have much more restricted options, you know, availability of resources. We wanted to hit urban and rural centers, and then with the issue with abortion, we wanted to touch a variety of systems across the country that were either going to be likely stable in their ability at a state level to provide abortion services or in the middle of the road of that decision as we understood it, and were likely going to increase their restrictions on those services. So that was our sample. That was our approach to making sure we had a good nonrandomized sample to really tell a story. And we did that through interviews mostly. So we went, ultimately chose 26 facilities across the country and we also wanted to make sure that we included every VISN. And so VISNs are those veterans integrated service networks. Those are the regional collections of hospitals. So we wanted to make sure we had at least one facility in each VISN as well. To describe what we did. We went in, we did interviews, we looked at facility and we talked to facility leaderships, the director, chief of staff. We wanted to make sure we got the women’s health, medical directors, the chiefs of primary care, where a lot of these provisions are managed and then, of course, chiefs of urology. So urology services played a big role in this review as well.
Eric White So you had your sample size and your methodology for finding out what were some of the reproductive care services or the state of reproductive care services that you all saw? What were the I guess, the results of those interviews.
Julia Kroviak Pretty much what you would expect for any type of facility, regardless of complexity. Most of the facilities had limited issues with taking care of the contraception needs and preconception care, sexual dysfunction. They typically were very comfortable and well-suited to provide those services. Maternity care well served, and I don’t mean that they provide it, but there’s a process in place that when a woman veteran is pregnant, that they have the processes in place to refer them out to get the care they need, and then just genuine pelvic urinary health, certainly management of menopause. When I talk about those 600,000 women, half of them are childbearing age, the other half are not. So menopause is something that facility providers have to be well versed on in managing and then throw on now with the IFR, the pregnancy options, including not only the procedures, but the counseling for those procedures. So we wanted to talk about all of those with all of these leaders to understand where there were barriers or where there were not. And that’s basically what we did.
Eric White All right. And I know that the IG did not issue any recommendations on this topic for myriad of reasons. But what were some of the challenges that you heard from the interviews that you conducted? Were there some people who felt that they were not hearing from leadership maybe on what they were allowed to do or things of that nature?
Julia Kroviak That’s basically the gist of it. So for the things that we consider routine reproductive health, the barriers were what you would see in other facilities for other health care services. So you’re in a rural area. Yeah, it can be really tough to find a gynecologist, but that’s because of the area. There’s shortages of providers of the facility. There might be shortages of providers in that area. But when the conversations got really sticky, I don’t mean sticky politically, but when they described where they’re finding barriers, it’s out of confusion and it’s out of concern for their providers who are would potentially be meeting patients who were in need and met requirements for abortion services, counseling and the procedures medical procedure itself.
Eric White And so when they did run into those barriers and, you know, they had a patient that in their medical opinion, is in need of abortion services, you know, and they are not necessarily in an area that they can provide them. Do they have a standard practice for handling that or is that where the confusion lies.
Julia Kroviak Yes, so no. There was no standard. It’s evolving. So and again, so we were doing these interviews in March so that six months after the IFR. So at that point we still found leaders who mostly explained to us the concerns their providers brought forward. Depending on the state, they were licensed in, because VA providers don’t have to be licensed in the state, they practice and depending on the state they’re practicing in and depending on the availability of resources. So what we saw facilities who were already tested in the space, they were usually either able to do it at their own facility, able to refer within the VISN, or accessing community care if they had to use a facility or resource that had to be over state lines for a wide variety of reasons that were influenced by the recent Dobbs decision.
Eric White And so it sounds as if a lot of the issues that they had are the same issues that you hear from just doctors in that same area. So it seems like it’s just they’re a symptom of a geographic crisis that the medical care community in general is facing down in those areas.
Julia Kroviak Yeah. And basically, you know, it gets confusing because we have this IFR. So these providers, you know, have some guise of protection, but it really hasn’t been tested yet. So the fear and the frustration of the unknown and the lack of guidance, the lack of training, it seems to be a real presence within these VA facilities for the providers who feel they might be put on the line to be part of a test. So while there are quote unquote guaranteed protections, it would still have to be tested. And that can be a painful process for a provider. We’re talking about am I going to go to jail for performing a procedure? But also, is this going to be reported to a state licensing board? What are the implications? And no one’s giving really concrete guidance to these people or to the leaders who they’re looking to get that guidance.
Eric White So let’s bring the focus to leadership. Did the VA have any response or did they mention how they were going? So no response from VA, did they? You know, how do you think that they’ll be using these results and or is this just a review for your all purposes?
Julia Kroviak It wasn’t for our purposes. We very rarely do work that just suits us. It was really meant to inform stakeholders that there are significant concerns we have with confusion across the system. You know, you would think, well, why didn’t you put the recommendation in? And you’re right, there’s a ton of reasons we didn’t, but it’s still an evolving issue. It was just meant to remind or inform leaders that you’ve got providers out there who are really in need of guidance and their local leaders don’t have the information enough to provide it to them. So we’ve got to get this together to make sure that, A. veterans are getting the care they need and providers are protected while doing it or at least understands what the protections are. We did give this to VHA to review and they were welcomed to comment on it. They chose not to. I wouldn’t weigh too deeply into that because when we have exchanges with the VHA and our drafts. It really is to respond to recommendations, to lay out action plans. So I think our sharing the draft was just to make sure that they didn’t find anything erroneous in our description, which they really couldn’t because it’s a perceptions thing. But I don’t want to lay it out that VA was unresponsive or dismissive of this work.