Ensuring equitable health care for veterans

Peter Groeneveld, a Penn physician and director of the Veterans Affairs Center for Health Equity Research and Promotion, discusses why this work is so crucial right now and how the VA has evolved in the past three decades.

Pete Groeneveld

Though Peter Groeneveld isn’t a veteran himself, he comes from a family steeped in that tradition. “I’m the son and the nephew of veterans. My dad was in the Navy in the 1950s, and my uncle was in the Air Force in the early 1960s. Both were very proud of their time in the service.”

That background has made Groeneveld particularly attuned to the population of patients he cares for now, as a physician at Penn and since July as director of the Veterans Affairs Center for Health Equity Research and Promotion (CHERP), where he had previously been associate director. “I first walked in the door of a VA hospital in 1993, almost 30 years ago, as a bright-eyed medical student in Boston,” he says. “I never left.”

At CHERP, he oversees nearly two dozen research projects run by some 20 investigators jointly appointed at the Perelman School of Medicine and the VA, taking the helm from Penn colleagues that have included David Asch, Judith Long, and Said Ibrahim. The Center’s work focuses on improving the delivery of health care for veterans, backed by several million dollars in government funding.

Penn Today spoke with Groeneveld about his long career caring for veterans, how the VA has changed in the past three decades, and why the center’s research is especially important right now.

What initially drew you to the VA?

My dad served on the United States Ship Wasp, which was an aircraft carrier. He had a model of it in his office. Only a few of the sister ships of the Wasp still exists; one is called the USS Hornet, and it’s docked in the San Francisco Bay area. My dad gave me a tour of the Hornet because it was identical to his ship. He could show me details of his life on an aircraft carrier, which was incredibly formative for him. As you can hear, I’m tremendously appreciative of my family’s military background, and that makes me attuned to this community. I think they deserve our nation’s support after they’ve served.

What made you stay within the VA system after working there in medical school and during your medical residency training?

To me, it felt like the best fit for my personality and interest. The thing about the VA that many people don’t appreciate is that, sure, a lot of vets come here because they don’t have insurance or maybe they can’t get health care anywhere else, but also they come here because when they do they feel like part of a family. They’re not just here receiving a service; they belong, and I like that. Even as a 25-year-old medicine intern a long time ago I could tell this was a special place. I enjoy practicing medicine in that environment.

What is the mission of CHERP?

It was founded in 2001 with a goal of engaging researchers in improving equity and reducing disparities of care for veterans. We’ve been around for 21 years with continuous funding, and at the moment we have $4 million in extramural funding from the VA Office of Research and Development. It’s not the same as what larger enterprises might have, but it’s a lot of support for disparities research in the nation’s largest integrated health system.

Most people may not know that the VA provides care for nearly 10 million American veterans at about 150 hospitals across the country and about 600 additional freestanding outpatient facilities. So, it’s a huge health care system. The work that we do, we hope it has both a national and local impact.

Can you talk through a couple of the research projects currently running?

One is an initiative primarily led by Leslie Hausmann out of the University of Pittsburgh, where we have a second site. It’s called the VA Equity Dashboard, and it’s a measurement for clinicians to assess their own equity of care.

If you don’t measure it, you can’t change it, so our dashboard is designed to provide feedback that clinical leaders can use to understand the equity of care delivered in real time, the idea being that without this kind of information there will be no incentive to change. This was based on research we initially did to see what would shift the way providers behave. We found that it was being able to see the impact of their care and the differences in care they were providing for different racial and ethnic groups. This is a big deal.

Another big project, this one out of Philadelphia, is called the Safer Aging through Geriatrics-Informed Evidence-based practices Quality Enhancement Research Initiative. Robert Burke is heading up this work, which is focused on implementation science, figuring out how we can improve evidence-based care delivery in situations where we know what the right move is scientifically, but it’s just not happening.

There are many scientifically proven ways to reduce the risk of individuals having bad outcomes. Bob is testing various ways to incentivize the delivery of that care, seeing which ones succeed and can then be scaled up. This is the kind of work we do, trying to make a practical difference in the way that care is delivered.

The military has a fraught history with marginalized groups. How has it changed in the three decades you’ve been involved?

The mantra of the U.S. military is that race and ethnicity—and, thankfully, increasingly gender and sexual orientation—should not matter in the job that soldiers and sailors and marines and others do in defending the nation. That hasn’t always been the case, and there’s a long history of discrimination in the military. But the military in many ways has led the nation in evening the playing field. I have seen the VA undergo a remarkable transformation from a fairly hidebound bureaucracy to an organization that is increasingly focused on delivering high-quality, veteran-centric care, on improving the veteran experience.

Our mission as a VA facility is to take care of the individuals who served in the military, many of whom suffered injuries or illnesses as a direct result of their service. It is a moral obligation to provide care that is equitable, but not color blind, because we need to recognize that our veterans come through institutions that are infused with racism or sexism or other ‘isms’ that are unjust. The VA has to actively combat structural racism and sexism. That’s the only way we deliver care where the outcomes are not dependent on gender, race, sexual orientation, or anything else about an individual.

What does it mean to you to provide ‘equitable’ care?

The likelihood of you surviving a heart attack should not depend upon aspects of your identity. That’s what equitable care means to me. It’s aspirational right now. We know that these are deep-seated disparities in health care, not just at the VA but in the United States. We can’t solve all problems in all domains, but within our institution we can ensure that the care delivered is increasingly fair and just. It’s about justice, about delivering the care that these veterans have earned because of their service to this country.

Peter Groeneveld is a professor of medicine at the Perelman School of Medicine and a primary care physician at Philadelphia’s Corporal Michael J. Crescenz VA Medical Center. He is director of the VA Center for Health Equity Research and Promotion; founding director of Penn’s Cardiovascular Outcomes, Quality, and Evaluative Research Center; chair of the VA’s Research and Development Committee; and co-director of Penn’s Master of Science in Health Policy Research program.