The VA San Diego Healthcare System saw nearly 75,000 patients walk or roll through its doors to receive medical, surgical, mental health, geriatric, spinal cord injury and advanced rehabilitation services in fiscal year 2012.
The VASDHS has one of the largest research programs in Veterans Affairs nationally, with a budget of $52 million in fiscal year 2012, according to its most recent annual report.
One would think a large pool of money like that would be feeling the brunt of defense cuts — but it’s not.
“VA has been exempt from sequestration, so as of now we have not had budget cuts,” said Cindy Butler, public affairs director at the VA San Diego Healthcare System, which includes a medical center in La Jolla and six community clinics.
Other medical facilities that treat military personnel aren’t so lucky.
The defense-wide health care budget can expect to be reduced by $2.6 billion, according to a congressional report released last month that looked at sequestration's effects across the government.
The report issued by Democrats on the House Appropriations Committee said “priority will be placed on maintaining operations at the military medical treatment facilities" in order to continue providing health care to service members, their dependents and retirees.
However, facilities will be affected by a temporary loss of health care workers.
Department of Defense officials said in May that 82 percent of the defense civilian workforce will be furloughed due to the $40 billion spending cut under sequestration.
Civilians subject to furlough make up a whopping 40 percent of the total workforce in military hospitals and clinics, which includes civilian doctors, nurses, therapists and other support employees.
“There is no doubt furloughs will affect access to care,” said Joyce Wessel Raezer, executive director of the Alexandria, Va.-based National Military Family Association. “It will be harder to get an appointment, which may mean that issues that could have been treated quickly may become more serious. Delayed access to care then becomes a health care quality issue.”
Naval Medical Center San Diego (NMCSD), a 272-bed multispecialty hospital and ambulatory complex in Balboa Park, has been planning for the furloughs for months.
“We do anticipate some delays in access and longer wait times. Some services may be deferred and elective services may be put off until after the furlough," said Sonja Hanson, public affairs officer at Navy Medicine West and NMCSD.
Primary care and ancillary services, such as lab and radiology, could also be affected. Any delays, deferrals and referrals to the network will occur only if capacity is reached in a particular area of care.
Luckily, she said, NMCSD is part of a robust civilian health care network. The hospital system is the headquarters of Navy Medicine West, which encompasses 10 hospitals from California to Japan.
“Being in a region allows us flexibility to move active duty providers in between treatment facilities,” she said.
That means if Camp Pendleton was furloughing civilians in its pharmacy and needed personnel, they could borrow employees from San Diego.
NMCSD is the largest in its region. In 2012, NMCSD provided medical care for 1.7 million outpatient visits in its hospital and branch clinics and 19,505 in-patient admissions.
In response to sequestration-related cuts, the Navy Medicine West was allowed to apply for exemptions a few months ago. The region was approved for 783 exemptions, with more than half of those, 412, for NMCSD alone.
To get an exemption, providers must be necessary to maintain 24-hour inpatient care and emergency services and continued behavioral health services and Wounded Warrior care, among other areas.
“These exemptions will help us maximize access to care, continuity and ease the burden of labor on active duty staff during this furlough period,” Hanson said.
Managing the budget cuts has been a "leadership initiative," she said, and department heads have come together to figure out how to best keep the system running.
A meeting to discuss preparation was held June 20 in San Diego with commanding officers across the region and Navy Medicine West leadership.
“We are doing things like looking at when is the lightest day for the ER,” she said. “Hypothetically, if it’s Friday, we will have our civilians take furloughs on Fridays."
NMCSD's hours will stay as they are, but other hospitals in the network will adjust their hours slightly, she said.
The 11 eight-hour days of furloughs are expected to begin Monday and run through Sept. 30.
"We want to encourage military beneficiaries to continue to come to us,” Hanson said. “Impacts should be minimal. We've planned for it and will accommodate."
The cuts could drive a ripple effect at other military health systems, causing satellite primary care clinics and operating rooms to close one day a week, Wessel Raezer warned, reducing pharmacy hours or limiting the number of medications carried by the pharmacies.
The furloughs could also have the unintended effect of driving up health care costs for DoD.
If a pharmacy reduces hours, Wessel Raezer said, military families may choose to take their prescriptions to retail stores instead, thus costing the government more.
In addition, if more military families have to be seen by civilian specialists because they can't get an appointment in the military hospital, the government will pay more.
“Generally, military hospitals are making an effort to keep emergency rooms open and to provide access to care for wounded service members,” she said. “But, that means other services might be subject to deeper cuts.”
Since ERs will likely stay open, she predicted wait times will dramatically rise because non-emergency cases will end up coming in.
“Families unable to get a primary care appointment for a child with an ear infection, for example, end up in the ER,” she said.
The “main burden” of defense health care cuts “is likely to fall on TRICARE contracts,” the Democrats’ report states.
The DoD may delay payment to civilian doctors who see TRICARE patients. It's unclear when or how TRICARE contract payments may be deferred, or whether TRICARE network health care providers will continue to provide care if payments are suspended.
Funding for TRICARE for Life and Medicare is protected, but Medicare payments to doctors will be cut by 2 percent under sequestration.
That may not seem like a large slice, but thousands of patients have reportedly been turned away by cancer clinics because of sequestration cuts to Medicare provider payments, according to the report, referring to a story in The Washington Post in April.
“The 2 percent cut is actually much steeper than it appears because cancer treatment centers receive a bundled payment from Medicare equal to the average sales price of the drugs plus 6 percent to cover the costs of handling and administering the medication,” according to the report.