Complex administrative bureaucracy and rural locales have made it difficult for the Veterans Affairs in Montana to fill a glut of vacant positions at its clinics.
Turnover within the VA in Montana in the past year has left 14 of 40 primary care provider positions without a replacement.
"Frustrations with a heavy administrative burden, Choice (the Choice Care program) and the advent of same-day access resulted in a few providers leaving the VA," said Mike Garcia, a spokesman for the Montana VA.
He added, "However, many of our vacancies were due to more routine circumstances like retirement, illness or pursuing school, research or other employment opportunities in and out of state."
James Gordon, an Army veteran who is 30 percent disabled, receives his care through the VA clinic in Billings. He acknowledged the process of trying to get care can be frustrating. He spoke of friends who simply seek providers on their own and pay out of pocket for the services.
"It's ridiculous trying to get in," he said.
Part of that frustration comes from getting connected with a care provider only to have the appointment canceled because that care provider has left the VA.
However, Gordon said that once a veteran gets into the system, it's not bad.
"I'm able to see my doctor pretty easily," he said.
One of the bigger hurdles the VA faces in recruiting is for new doctors in Eastern Montana.
"Despite our best efforts to recruit primary care providers, there has been very little interest among applicants to live in the more remote eastern areas of the state," Garcia said.
The problem is compounded when trying to fill vacancies created by specialists who leave the system. Practicing in the rural corners of the state leaves specialists without the ability to conduct research and it limits their opportunities to treat more complex medical issues, Garcia said.
John Kominsky, an ER doctor in Billings, said he understands the VA's turnover problem.
"A lot of doctors go to the VA because it's pretty posh," he said.
However, they often quickly burn out because of the complex administrative bureaucracy built into the system. Kominsky, who's not a veteran, said his frustration with the VA stems from what he sees in the emergency room.
He said the veterans he treats don't always need urgent care; rather they show up because the VA has instructed them to go to the hospital.
"Because the VA can't get them with a doctor," he said. "Veterans deserve a hell of a lot better than they're getting."
Garcia explained that veterans are sometimes referred to their local hospital ER for a number of reasons, including that an emergency room visit may be the level of care they need.
He said it's also possible that the services they need, be it specialty care or surgery, might be available only at the local hospital. The VA uses its "Nurse Triage Advice Line" where veterans can speak with a registered nurse who can help them determine what level of care they need.
"They use a similar approach," Garcia said. The nurses "determine the clinical urgency and find the nearest availability for VA services or refer to scheduling for a future appointment or recommend going to the ER."
Both the state and the national VA have detailed their efforts to recruit care providers and fill vacancies within the Montana VA. It includes working with job recruiters from the Veterans Integrated Service Networks and pulling from other regional VAs.
Montana has also expanded its "fee-based primary care providers," which connects veterans with other health care providers in the community outside the VA system.
Montana VA is working to expand its telemedicine programs, which allows patients in rural areas to video chat with doctors and specialists at other VAs.
"For several months, we have been aggressively pursuing a wide array of options to recruit highly qualified primary care providers to serve Montana's veterans," Garcia said.