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Editor’s note: This is the first in a series of articles in which Mississippi Today’s Larrison Campbell explores issues around access to health care in the state.  

Since Dr. Melissa Bacon began working at the VA’s women’s clinic in Jackson last month, she has spent most of her time on the phone, checking in with patients on the clinic’s long waiting list.

Last Monday, she followed up with a veteran who had called in April with heavy menstrual bleeding. Three months later, the office still hadn’t scheduled the patient for an appointment.

“She needed the appointment three months ago,” Bacon said. “That’s so sad.”

For almost a year, the women’s clinic at the G.V. “Sonny” Montgomery VA Medical Center ran without a full-time gynecologist. And as the months ticked by, the clinic’s waiting list grew, eventually reaching what Bacon estimates are hundreds of veterans. By spring, the wait time for a new patient appointment surpassed 90 days, the highest wait time of any VA clinic in the country.

Only one other VA clinic came close, with a wait time of 75 days. It’s the primary care clinic, also at Jackson’s VA Medical Center.

Dr. David Walker, the medical center’s director, said resolving the issue has been his “number one priority.” He has the funding to hire 25 full-time doctors. What he doesn’t have, however, is a large pool of doctors either in Mississippi or willing to move here.

“We are hurting because we don’t have enough primary care doctors. But it is hard to recruit doctors to Mississippi,” Walker said in a recent town hall meeting at the VA. “And if veterans don’t choose this VA, we won’t survive.”

The VA isn’t alone in this challenge. Mississippi has fewer doctors per capita than any other state in the country, according to a report from the Association of Academic Medical Colleges.

“We’re listed as one of those states at risk because we have such a void for physicians, particularly primary care physicians, all over the entire state,” said Sen. Terry Burton, R-Newton, who is on the Senate Public Health Committee and has sponsored several pieces of legislation over the last decade aimed at increasing access to providers in Mississippi.

“I don’t know why the VA is having trouble, other than everyone is having trouble getting people to come to Mississippi. They’re not unique in that regard.”

“I felt like I was a problem”

One morning this spring Jinnie Brown, a veteran of Operation Desert Storm, drove to the women’s clinic and sat down in the waiting room. As she had done half a dozen times the last few months, she took out her phone and caught up on emails. She watched Family Feud on the TV, just because that’s what was playing. But she mostly waited.

And waited.

Like the patients on Bacon’s list, Brown had tried calling to schedule an appointment. But Bacon’s predecessor had left last summer, following her husband out of state, where they both had jobs. And, as the staff explained, the patient list far exceeded what the clinic’s one primary care physician and part-time gynecologist could handle.

If Brown wanted to see a doctor, her best bet was to come as a walk-in. But once she arrived, Brown said she discovered that just because she was given a time to see a doctor didn’t mean the doctor actually had time to see her.

“I wasn’t taken care of. I felt like I was a problem,” said Brown, who has several pre-existing conditions that require regular maintenance. “My situation wasn’t something that you could just flash right by, the doctor has to come in, ask questions. And then my frustration, I get my test done, and I don’t get the results.

“I think the most frustrating thing for me is all the pieces are right there, they just were not being connected because of the lapse in follow-through and care.”

Mississippi is certainly not the first VA to struggle with wait times.

In 2014, a Veterans Affairs internal investigation identified 35 veterans who had died while waiting for care in the Phoenix VA system. Soon after, the VA’s Office of Inspector General began conducting an investigation of delays in treatment throughout the Veterans Health Administration system, and the U.S. House of Representatives voted to fund a $1 million criminal investigation by the Justice Department.

President Donald Trump has vowed to make the issue a priority for his administration and in June a bill he championed, which would make it easier to fire VA employees accused of wrongdoing — such as lying about wait times — passed both houses with bipartisan support. The VA is also one of the few agencies targeted to receive a funding increase under the Trump administration’s proposed budget.

In an effort to increase transparency, this spring the VA launched a website listing wait times for each clinic at each hospital across the country. After Bacon started working in the women’s clinic, wait times on the site decreased dramatically — from 90 days for new patients down to eight.

But the data itself has come under fire. A 2017 audit showed that three years after the Office of the Inspector General trained its eye on VA hospitals, they continue to experience “significant issues with the reliability of veteran wait times.”

Walker said that the VA determines wait times by measuring the distance between the date a patient was seen and the date the patient requested an appointment. The data is updated weekly, and he believes it’s accurate.

Bacon, for her part, was surprised to hear that the wait times had fallen so quickly. One benefit of going through the wait list is that occasionally she gets to cross patients off, such as the woman she spoke to Monday, who told her that the bleeding had eventually resolved itself. But since Bacon joined the staff in June, she’s only been able to see eight patients a week, which she said has “barely made a dent” in the waiting list.

According to Bacon, this is the result of not only the hours she spends on the phone, trying to clear the backlog, but also a dramatic nursing shortage in her department. The clinic currently needs four nurses. Right now it has two.

“I had the expectation that I’d be seeing more patients, and that’s not the case right now. The system would implode if they put patients in here without the infrastructure.” Bacon said. “It really takes a team to take care of a veteran and see them through the system.”

But Bacon said that, so far, the VA has been supportive of her measured approach. 

“And that’s very respectful of the leadership because they’re getting pressure,” she said. “So it’s really a testament to the leadership here that they’re giving me the time to deliver the best possible care.”

Brown, for her part, said she hasn’t tried to make another appointment since Bacon joined the staff last month. She said she’s waiting until the situation has “fully resolved.” From what she has heard, it hasn’t yet.

Lack of choices

Walker has certainly received his fair share of pressure.

At last month’s town hall, more than half a dozen veterans asked Walker why they couldn’t get an appointment. Some were polite, others more brusque. But all were visibly frustrated that they had been unable to get the care promised to them by the U.S. government.

“You don’t have enough doctors. You don’t have enough care,” said James Meyers, a vet who said he had struggled to get addiction treatment at the VA’s mental health clinic.

Walker was apologetic, acknowledging that the VA’s staffing issues were affecting the quality of care that the hospital could provide.

“Primary care and mental health are two basic things we have to provide or else we’re not relevant,” Walker said. “And that’s why we have the Choice program, so you have access to that care outside until we’re fully staffed.”

The Veteran’s Choice Program, enacted in 2014 in the wake of the Phoenix VA investigation, allows veterans who have been given wait times of more than 30 days to choose a provider at a hospital or clinic outside of the VA.

But the program, which has proven more popular than anticipated, has been wracked with funding woes and was in danger of running out of funds this month. After several days of negotiations, the House on Thursday unanimously passed legislation that staved off a shutdown, infusing $2.1 billion in new funding into Choice over the next six months. A permanent solution, however, has not yet been reached.

There are other drawbacks to leaving the hospital for care, according to some veterans. For Brown — whose medical file include diabetes, high cholesterol, a previous heart attack and a stent — playing what she calls “musical chairs” with her providers isn’t an option. Things get lost or overlooked.

“Consistency in care is very important to me,” Brown said. My preference is the VA because (all the clinics) are right there, and it’s one stop. My primary care provider is right there on the first floor, so that’s very convenient, and your records are more easily accessible and read from one provider to the next. And that enhances the quality of care you receive.”

Billing is also an issue. After the law establishing Choice passed in 2014, the Veterans Health Administration was given only 60 days to set the program up. And that, Walker acknowledges, has led to countless billing issues.

“It’s very complex, we had some struggles with making sure we were paying everything, and for a while there we weren’t doing near as well as we should have,” Walker said.

Access to Care

In conversations with Walker, a Mississippi native who arrived at the VA three years ago, his ease with rattling off numbers makes it clear that he is acutely aware of the medical center’s staffing needs.

“I could easily put 5-8 primary care doctors to work.”

“Eleven percent of our 44,000 patients are women.”

“At this time we have 105 physicians full-time and another 47 part-time.”

But knowing and actually doing are two different things. And staffing the VA with doctors who will stay in Mississippi takes more than just paychecks, though Walker calls the salaries at this VA “competitive.” It also means knowing who to hire. For Walker, the goal is to find people who will stay in the job.

“People who are from here or who train here are more likely to stay here than someone you bring from out of state,” Walker said.

But for some medical professionals, the VA’s connection with federal government is its eternal Achilles heel.

“I know Dr. Walker, and he’s working hard to turn the VA around. But one of the problems with recruiting physicians to the VA is the VA,” said Dr. Randy Easterling, a member of the Board of Medical Licensure. “It’s a government job. And it doesn’t pay as well as you do in the private sector, and you have to work for the government. And a lot of doctors don’t like working for the government.”

As a result, Walker said that one of the things that has most benefited the VA has been its partnership with the University of Mississippi Medical Center. Currently the VA employs 47 doctors part-time. Almost all of these, Walker says, also work at UMMC.

“It’s a selling point especially if you get someone who wants to work with residents and medical students, they know they’re going to have that opportunity,” Walker said. “So we see that as a very attractive thing that we have to offer.”

The VA also funds 88 stipends for UMMC residents, and Walker said he tries to hire as many as he can after they complete their residency.

“If you have experience with what our system is like, then I believe you’re more likely to consider working for us when you’ve had exposure to and been trained in our system,” Walker said.

Other UMMC partnerships, however, are less formal. This spring UMMC announced it would be laying off 195 employees in an attempt to cope with a $32 million dollar cut from the state. Walker said he was able to bring some of the providers who lost their jobs at UMMC to the VA. Unlike UMMC, the VA is fully federally funded.

“We have a lot to offer our employees,” said Walker. “As unstable as health care is in the country, we have the potential to be the most stable one there.”

Then there are other long-term partnerships, such as marriage. Bacon’s husband was appointed head of UMMC’s anesthesiology department three years ago. After waiting for their son to finish school in Michigan, she followed.

“It’s fair to say I moved to Mississippi largely for my husband’s career,” Bacon said.

Bacon, who describes her work at the VA as “the most rewarding of my career,” said she’s here for the long haul. Although she’s not from Mississippi, she said that her background growing up in rural New York allows her to relate to the state and many of its patients.

“I grew up poor and grew up struggling with money and felt like I was given an opportunity to help people who were considered poor or underserved and give them the good product I got (during my training) at Mayo Clinic,” Bacon said.

Walker agrees. Perhaps even better than hiring providers from Mississippi, he said, is hiring providers who understand the state.

“We’re in essence a rural state and with rural areas. It’s not uncommon for them to be poor. And if you’re someone with that experience, I could see how that would resonate with you. And that becomes helpful when recruiting,” Walker said.

He will need this. Earlier this month, the women’s clinic’s part-time gynecologist gave his notice. He had accepted a teaching position at Eastern Virginia Medical School in Norfolk, Va.

Walker said he’s already begun looking for a replacement.