When doctors at the Veterans Affairs hospital in Fresno determined that Ron Heatherly had a torn rotator cuff, they sent him on to surgery -- four hours away in San Francisco.
The small Fresno VA, which struggles to attract and keep doctors and nurses, sends hundreds of patients out of the area each year for surgeries and complex procedures, putting a strain on veterans and their families.
Heatherly's case is but one example. The 68-year-old from Visalia made two trips to the VA hospital in San Francisco -- once for an early-morning pre-operation examination and then again the night before the surgery. He paid more than $300 for the motel stays.
It's been over a month since the surgery and Heatherly's shoulder is healing, but the Navy vet, who did two tours in Vietnam, bristles at having to travel so far. "It's a burden," he said. "They should have some option to do something locally."
Veterans hospitals have come under fire this year for long waiting times for doctor appointments. Congress is working on legislation that would let veterans see private doctors if VA care takes too long or is too far away. Veterans in the central San Joaquin Valley face both obstacles: They have the longest waits to see specialists at any of the eight VA health systems in California, and they often travel the farthest to be seen.
The proposed federal legislation could offer relief, but some medical professionals say long waiting times at the Fresno VA are a symptom of a communitywide physician shortage. They doubt if sending veterans to doctors outside the government health system will speed up care.
It's not all bad at the VA in Fresno. Veterans have quick access to primary care. It's tough to get an appointment with a private doctor in fewer than two weeks, but at the Fresno VA the average wait for an established patient is less than a day. That's the shortest wait of any of the California hospitals, according to a report by the U.S. Department of Veterans Affairs.
Where the Fresno VA is limited is the specialty care it can provide and how quickly it can provide it.
The average wait in Fresno for a new appointment with a specialist: 61.4 days. Fresno veterans wait more than 20 days longer than veterans in Sacramento, who have the shortest wait. And they wait nearly 20 days longer than veterans at the Palo Alto VA and more than 10 days longer than those in San Francisco.
And when Fresno veterans do get an appointment with a specialist, often it's with a doctor in Palo Alto or San Francisco.
The 57-bed Fresno hospital is the smallest of the veterans hospitals in the state and lacks the capacity and medical staff to perform complex surgeries and procedures that the larger hospitals offer.
Patients arrive daily in Palo Alto from the Fresno area -- on average 32 veterans a month.
"We transfer more patients in from Fresno than from Reno or Northern California," said Shelly Segall, in charge of bed control for acute-medicine and surgery at the Palo Alto VA hospital.
A Fresno patient arrived that morning and would have hip surgery that afternoon, Segall said in an interview June 27. "On any given day, we have more requests (from Fresno) than ... beds we have available."
Patients are sicker
Going to the Bay Area is taxing for patients, many of whom are elderly, and it's not cheap for the veterans health system.
The Fresno VA offers a shuttle bus and many veterans drive themselves. But the hospital spent more than $151,000 to take 52 veterans by ambulance to Palo Alto in fiscal year 2013. It cost $67,680 to fly four veterans to the hospital by air ambulance.
A ground-ambulance ride from the VA at Fresno Street and Clinton Avenue to Palo Alto costs about $3,000. By comparison, it's $600 for an ambulance trip to Community Regional Medical Center at Fresno and R streets.
Heatherly said he's never tried to take the VA shuttle and he's never needed an ambulance. The drive to the Bay Area is long and traffic is a nightmare, but he'd rather drive: "I'm going to get there and get back."
There's no getting around having to spend a night in the Bay Area before an early-morning appointment, however. The San Francisco hospital has free accommodations for veterans but not for a friend or family member to join the patient -- there's just not enough beds. Heatherly's friend drives him to the hospital, so the two have to stay in a motel.
Patients with serious health problems may have to remain in the Bay Area for days or weeks. In Palo Alto, veterans' families stay for free in a house designed for them. San Francisco doesn't have a house for families.
The number of Fresno patients with problems that require specialty care at VA hospitals in the Bay Area is likely to increase.
Patients seen at the Fresno VA are becoming older and sicker, acting director Wessel Meyer said, "and with that comes a need for more complex services."
The volume of patients at the Fresno VA also is growing. Between 2005 and 2013, the health system saw a 25% increase in patients, from 23,642 to 29,486. And the number is expected to increase in coming years.
Across California, there are more than 1.8 million veterans, including more than 237,000 who served in Iraq and Afghanistan, according to the Iraq and Afghanistan Veterans of America.
With more patients, the Fresno VA needs to expand services, but it's limited by how many doctors and staff it can recruit and hire.
For now, the hospital is short 21 doctors and 10 nurse practitioners.
Recruiting physicians is an ongoing challenge. The hospital had four urologists four years ago and now is down to one, Meyer said. "We've been recruiting for two years and no success."
There's a part-time ophthalmologist -- but the hospital could keep two busy, he said. There's no ear, nose and throat surgeon -- the hospital had one, but he retired in September 2013.
Doctor shortages are not unique to the Fresno VA -- but it has a big disadvantage: It's in a physician shortage area.
Some areas of California are flush with physicians, but the Valley is not. The Bay Area, for example, has 86 primary care doctors and 175 specialists per 100,000 people. The San Joaquin Valley has 48 primary care doctors and 80 specialists per 100,000. The government recommends 60 to 80 primary care doctors and 85 to 105 specialists per 100,000 people, according to the California HealthCare Foundation.
Doctors in the Valley earn less money than those in the coastal regions of the state, making it harder to recruit them.
A salary gap also exists between what a specialist can earn in private practice and what the VA pays. According to the 2014 Medscape Physician Compensation Report, physicians in single-specialty private group practices earn an average of $273,000 a year compared to $198,000 for doctors working for the military or government.
The Fresno VA lost a couple of recruits this year because of salary, said Dr. Michael Peterson, chief of medicine at the University of California at San Francisco-Fresno Medical Education Program. "You have to be willing to pay people what their market value is, and I think the VA has fallen way behind," he said.
But the Fresno VA has made some strides in filling positions, Peterson said.
Two new oncologists will start this summer and fall, he said. The VA has added a cardiologist and UCSF-Fresno is helping to recruit more, he said. Recruitment of a gastroenterologist is in the final stage. The VA is a teaching partner with UCSF-Fresno, and faculty and residents are based there.
Besides the struggle to find and keep doctors, the Fresno VA also has a problem retaining registered nurses.
According to a June 2014 internal hospital performance scorecard by the Department of Veterans Affairs, the Fresno VA has a 9% nurse turnover rate, the highest among the California VA hospitals. San Francisco had the next highest at 8.3%. Palo Alto's turnover was 6%. The lowest turnover was at Loma Linda at 4.2%.
The Fresno VA has 32 nurse vacancies, but Meyer said it's doing better filling them than six months ago. "If there was any way we can boost our salaries on this end, that would help us attract nurses," he said.
The hospital also is reviewing its mortality rate from the VA performance scorecard. The Fresno VA scored poorly compared to the other California hospitals in several categories, including pneumonia and chronic heart failure. The hospital also had a higher rate of in-hospital complications.
However, "a team looked at all the pneumonia cases on the list and didn't find any deviation from the standard of care," Meyer said.
The hospital has a heart failure clinic where patients can be followed after discharge from the hospital, but it had a turnover of cardiologists. "We now have two full-time cardiologists," he said.
Letting veterans choose
Valley veterans give the VA Central California Health Care System overall satisfactory ratings.
Henry Wegermann, 65, of Fresno, has no complaints. "I've had things done there and they did well," he said. "I have a doctor who actually calls me occasionally to see if everything is going well."
A Marine Corps veteran who served in Vietnam, Wegermann said he has Medicare and outside medical insurance and tries not to use the VA health system, but it's always been available.
But other veterans said they are unhappy with VA health care in Fresno: Appointments are canceled, the wait to see doctors is too long and trips to the Bay Area are too frequent. The option of using private doctors is appealing, they said.
"I've been to San Francisco about 20 times," said Kevin Knoll, 58, of Hanford. Knoll, an Air Force veteran, said he had a 2006 colonoscopy at the Fresno VA that was botched and has needed continuing care since.
The shuttle bus ride to San Francisco "really gets old," Knoll said.
Heatherly says veterans should be allowed to get care from private doctors in their communities if they have to travel long distances to receive specialized care at a VA hospital, regardless of the timeliness of the appointment.
If he was given the option of having surgery with a skilled private surgeon in Fresno instead of at the VA in Palo Alto or San Francisco, his choice would be to stay local, Heatherly said: "I'd choose it in a heartbeat."
Millions of veterans nationwide could have the choice to go outside the VA for health services if Congress moves on legislation to allow wider access to private doctors. Members have said they hope to have a bill before the end of this month, but paying for outside care could be a stumbling block: The cost has been estimated at $35 billion to $45 billion.
According to the U.S. Department of Veterans Affairs, about 9% to 10% of the VA's health-care budget already goes to non-VA care. This fiscal year, through April, the VA provided outside medical care nationwide to 904,714 veterans at a cost of $3.38 billion, the VA said.
Under the "Accelerated Care Initiative," the Fresno VA received more than $3.8 million this year for non-VA care to address the needs of patients waiting more than 30 days for a VA appointment. The money is used for everything from audiology and neurology services, cataract surgery and heart treadmill tests. The Fresno VA's total annual operating budget is $224 million.
Some veterans are cautiously supportive of using outside care.
George Hawley, 71, of O'Neals, is a Navy veteran who was a tugboat sailor during the Vietnam War. He's no fan of the VA bureaucracy. His most recent battle was over getting healthier food in the hospital cafeteria.
The option of going to a private doctor is a good one, Hawley said, but added: Once you leave the VA system, the private hospital's "motivation is to make a profit."
And health professionals have their own reservations, in large part because of the Valley's chronic shortage of private physicians and specialists.
Sandi Palumbo, executive director of the Fresno-Madera Medical Society, doubts there are enough doctors to handle a government push to send veterans into the private health-care system.
Doctors already are struggling to absorb thousands of patients newly insured this year through the Affordable Care Act, Palumbo said. "Physicians are having to take on more and more patients and having to spend less and less time with them."
Meyer has mixed feelings about letting veterans be seen by health professionals outside the VA system. It's far easier to track and manage a patient's health from within the system, he said. But he's not opposed to legislation that would make it easier for the VA to provide timely care.
It all depends on whether Congress allocates enough money to pay for it, Meyer said. "I don't know which way it's going to go."
The reporter can be reached at (559) 441-6310, firstname.lastname@example.org or @beehealthwriter on Twitter.