Local VA forced to hire specialists for patients

Monday, Dec. 22, 2003 | 10:54 a.m.

Two years ago, Dr. Susan Bannick-Mohrland left her Las Vegas private practice as a geriatrics specialist to take a similar post with the local Veterans Administration.

Although she occasionally works weekends doing administrative work because she also took on the added responsibility of chief of medical services, she says the move was the right one: She gave up the headaches of private practice to have plenty of off time to enjoy a stable family life -- albeit for lesser pay.

The VA wishes it had a lot more specialists like Bannick-Mohrland.

The VA Southern Nevada Healthcare System has long struggled to hire specialists and has to contract out to the private sector for some of its specialist care.

John Hempel, director of the local VA system that treats 32,000 patients a year, says in the past year, the local VA has spent $17 million on outside specialists -- a 40 percent increase over 2002.

And, Hempel said it takes less than 30 days to get a local veteran who needs routine, non-emergency specialized care an appointment with a specialist -- a statistic he would stack up against the private sector.

It also stacks up well against his own VA region that includes facilities in Southern California. Regionwide, it takes 20 to 40 days for VA patients to see specialists, Hempel said.

Local VA statistics for November show it took about a week for a veteran in Southern Nevada to see a primary care doctor or orthopedic specialist, about two weeks to see a heart or stomach specialist, three weeks to see a urologist and four weeks to see a neurologist.

The problem, Hempel says, is that good neurologists, urologists, radiologists or anesthesiologists can earn $250,000 to $500,000 in the private sector while the base pay at the VA is $110,000 plus incentives.

Also, while a private sector geriatrics specialist can earn more than $150,000 a year, Bannick-Moore gets paid about $135,000. She is the only geriatrics specialist the local VA has on staff.

Critics say because there are not enough VA doctors and specialists, many of the 67 full-time and 14 part-time doctors at the local VA are overworked, do not have enough time to properly diagnose patients and that veterans are not getting to see specialists in a timely manner.

"The shortage of specialists at the VA is a problem that needs to be better addressed," said Chris Christoff, a local veterans and political activist who, as head of the Independent Veterans of Nevada, voluntarily drives veterans to their clinic appointments.

"I hear it all the time from veterans who say their doctors are so overworked they don't have time to diagnose them for specialist needs. If a veteran goes several months without being properly diagnosed, it means little that the VA can quickly get him to a specialist after the damage has been done."

Bannick-Mohrland said primary care physicians handle "90 to 95 percent of an average patient's needs," including chronic medical problems. A doctor will contact a specialist if there is a procedure that is needed or if he needs advice on a less common disease, she said.

"Our primary care doctors know what they can do, but more importantly, they know what they cannot do," Bannick-Mohrland said. "Believe me, they are not shy about calling a specialist if they need help."

As for VA doctors being overworked, Bannick-Mohrland said that while at one time VA doctors were "overpaneled at 1,300 or 1,400 patients," those levels have been reduced to near the normal panel of 1,200. She said a private sector physician can have a normal panel of as many as 3,000 to 3,500 patients.

The difference, Bannick-Mohrland said, is that 80 percent of VA patients see their doctors regularly because of health problems related to aging or their military service, while a number of healthy patients in the private sector go an entire year or more without seeing their primary care physician.

"Our doctors schedules are full every day," she said.

Donald Zurfluh, Jr., chief of human resources for the local VA, says the agency currently is about 10 percent understaffed for doctors, noting that 11 physicians and six nurse practitioners are picking up the slack in areas including primary care, psychology, dermatology and pulmonary care.

"Providing the best care for those who served our country is our No. 1 priority," Hempel said. "If we have (doctor) vacancies, we do our best to fill them. But I will not fill a position just for the sake of filling a position. All of our doctors are board-certified in their fields."

Still, having no specialists in some areas, such as urology, and lacking staff specialists in other areas has come at a hefty cost, as the local VA pumps millions of dollars into the Las Vegas economy to contract local specialists.

"Yes we would like to reduce what we spend for fee-basis or contract specialists because it will help our dollars go further," Hempel said. "But we have to adapt to make sure the level of care remains high."

Christoff says he does not think the contract physician philosophy is working as well as it should because the private sector has its own burdens.

"Last week, I drove a veteran to see a private sector heart specialist and we waited for three hours past his appointment time because the doctor was overloaded with his own patients and VA patients as well. You could tell he was working his butt off but he was frustrated with the workload."

Hempel said patients who need specialists are getting top-notch care even if it means sending them out of state. That too has drawn criticism because the average age of a local VA patient is 61 and some are in poor shape for a four-hour van ride to Loma Linda, Los Angeles or San Diego, Calif.

"I empathize with those who have to go out of state for care," Hempel said. "But if that is where the best doctors are to meet their needs, then that is where we have to send them.

"However, because of our recruitment efforts for specialists and by contracting specialists locally, we have reduced the number of those trips from 1,500 (in fiscal 2002) to 700 in the fiscal year that ended Sept. 30."

The VA operates 12 satellite clinics and leases three other buildings since the Addeliar D. Guy III VA Ambulatory Care Clinic on Martin Luther King Boulevard closed in June. The $16 million center that opened in 1997 had fallen into disrepair.

Doctors and specialists are based the various clinics. That has resulted in patients with multiple specialty needs having to go to several clinics in addition to their neighborhood facility for treatment. The circuitous route linking all of the satellite offices is 150 miles.

While the VA has worked to overcome those obstacles, obtaining funds to provide doctors with pay nearer private sector salaries remains a challenge.

Hempel said his staff doctors receive less than $175,000 a year including legislatively approved incentive bonuses. Some of those incentives are:

Christoff says money should not be an issue when it comes to a federal agency hiring doctors to treat military service veterans.

"This should not be an issue of getting the best physicians available or the best physicians the VA can afford -- it should be about getting the best doctors, period," Christoff said.

"If the VA does not get enough money to go after the best -- and enough -- doctors then the government is not fulfilling its promise to those who risked their lives in defense of our country."

Hempel said to counteract the pay shortfall, the VA offers good work hours, a chance to teach residency doctors from the University Medical School, an opportunity to do clinical research and -- perhaps the biggest bonus -- no medical malpractice insurance premiums.

With private sector medical malpractice rates soaring amid insurers' fears of large jury awards for negligence, a number of local doctors have pulled up stakes to look for better rates in other states or with the VA and other government agencies that have caps on liability.

But Bannick-Mohrland, who in addition to running her local practice for three years had a private practice in Minnesota from 1990 to 1998, points out that "for many of us who decide to work for the VA, this is more than just a job --it's more than just about money.

"My father was a veteran, my two brothers are veterans and my husband is a veteran," she said. "One of my brothers just retired from the Air Force where he served (in a mounted unit) in the Philippines and fell off of his horse more than once. Because of that, he has fairly significant arthritis. I want him and others like him to have the best care from the VA."

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