Rae Woods (00:17):
From Advisory Board, we are bringing you a Radio Advisory, your weekly download on how to untangle healthcare's most pressing challenges. My name is Rachel Woods. You can call me Rae. Today is November 11th, 2025. It's Veterans Day in the United States. And look, normally radio advisory doesn't necessarily focus our episodes on federal holidays, but we're making the exception today, because healthcare business leaders may not realize that veterans represent a pretty significant portion of their patients.

(00:49):
Let me ground us with some numbers. There's around 15.8 million veterans in the US, but only about nine million receive some care at the VA. That means that about 40% of all veterans receive all of their care in the civilian healthcare system. So today, I want to talk about how we can better serve those who have served us. And I'm so excited to have Christi Kruse and Christine Erspamer from Optum Serve joining me today. Optum Serve is focused on improving care for veterans, service members, and their families. They completed new research this year that included over 200 in depth ethnographic interviews with service members and veterans, plus more than 50 interviews with healthcare providers and VA employees. That means they've learned a lot.

(01:39):
They understand the obstacles this population faces when seeking care. They understand their unique healthcare needs, and they've identified clear action steps that health leaders can take today to ensure that they can continue to reach out and provide high quality care for veterans. Christi, Christine, welcome to Radio Advisory.

Christine Erspamer (01:59):
Good morning.

Christi Kruse (02:00):
Hello.

Rae Woods (02:07):
You two are the experts here. And I want to admit from the start that I think I've been operating under an incorrect assumption about how veterans use and receive healthcare. I assume that most vets received pretty much all of their healthcare from the VA, but I actually think I'm wrong about that. Help me wrap my head around this. Where do veterans generally get their care?

Christi Kruse (02:35):
It is a common misconception that that is where veterans get their care. And one of the reasons why it is VA care isn't like a regular health plan the way that we, many people get their care through an employer or through Medicare. VA care is directly related to somebody's service because what the VA there is to do is to support veterans based upon the needs that they develop during service. Because of that, you get about 40% or so of veterans who have a disability rating below 50% and they're getting most of their care outside of the VA. Then you've got veterans who have maybe one foot in VA, they have some coverage for service connected disabilities and then get the rest of their care through some other kind of coverage.

(03:25):
For example, maybe they have a knee injury from a training exercise. Care related to that knee injury is going to be provided by VA, but the rest of their body and everything else is covered by their regular insurance, employer coverage or something else. And then, you've got those who do have 100% rating or other eligibility categories that make it so they get most or all of their care through VA. So it really is veterans centric, venture dependent.

Christine Erspamer (03:53):
Yes. Even for those that receive their care within the VA, they also have an option to receive care in the community through the VA Care Network program, which brings about 40% of veteran care into the community even when it's delivered and administered through the VA. So it really does extend into many different ways that veterans are being seen out in the commercial provider environment.

Rae Woods (04:16):
Make this real for me. How many people approximately are we talking about?

Christi Kruse (04:21):
So there are about 15 million veterans in the country and somewhere between nine million or so, are enrolled with VA. And on any given year, six to seven million get care through VA, some form of care. So you kind of do that math and can kind of say, "Well, five or six million get no care through VA because they're not enrolled." And then, you've got some that are in the "Some care" category and then others in the "All care" category.

Rae Woods (04:51):
So bottom line is that the folks that listen to this podcast, the traditional healthcare leaders, they're the ones who are actually caring for veterans.

Christi Kruse (04:59):
Yeah. Veteran care is everywhere. Everybody who is involved in the US healthcare system is involved in caring for veterans, just bottom line.

Rae Woods (05:08):
And when I speak to those healthcare leaders, I'm not sure that they make those connections, or even if they're thinking about caring for say high risk populations, I'm not sure that veterans are part of the group that float to the top of their priority list, right? They think about their polychronic population, those with complex medication management. Why is it important for healthcare providers to pay attention to this population outside of just the numbers that are out there?

Christi Kruse (05:35):
There's two reasons. First of all, if they don't know that a veteran is also getting care within VA, they may not realize that they're looking at an incomplete record of that veteran. And one of the places that is a real simple example of this is someone who is enrolled for VA can get their formulary medications for no out of-pocket costs. And many times these formulary medications are going to be those maintenance meds like a statin. And so, if you are a risk-taking provider or if you're in an MA plan and one of the quality measures that you're being graded on is statins for those with diabetes.

(06:15):
You're not going to have a statin in your medical record because that veteran is probably getting that statin from the VA, which means it's not that the veteran isn't getting the medications that they need, it's that you don't have a record of it.

Rae Woods (06:28):
That is one example of the business case for why health leaders need to not only understand that they're serving this population, but they also need to serve this population well. And it's hard to do that because of the complex, I'm going to use the word, siloed nature of some of our systems.

Christi Kruse (06:47):
Absolutely, yes, you've got it. Spot on. That's exactly the problem. But then there's also the personal side, and let me just tell you a personal story, something very close to my heart, which really made me interested in doing this research. My father-in-law was 62 and he got a cough and that cough just didn't go away. Then that cough generated into cardiomyopathy. And like a 62-year-old man who is very healthy, never had any problems. Why did he all of a sudden develop cardiomyopathy? And then turned out he had multiple myeloma. We had spent about a year going from doctor to doctor trying to figure out what was wrong with him and his health was deteriorating.

(07:30):
And then one day, one social worker at Mayo Clinic asked him a very simple question. She said, "Are you a veteran? Did you serve in Vietnam and were you exposed to Agent Orange?" And the answer was yes. This was most likely Agent Orange-induced multiple myeloma. And all of a sudden his treatment plan changed and what we were looking at changed. And had we understood that, had that question been asked a year prior, probably a lot of both suffering and costs that could have been avoided. And that was one of the things that crystallized in my mind that we need to better understand veteran health and we need to make sure that everybody who's caring for veterans, which as said before is everyone, has the ability to understand, and identify veterans in their practices so that they can give them the care they need.

Rae Woods (08:22):
Because veterans have specific health needs, in this case, can lay dormant. They might present differently. They might not present for years. And that clinical presentation is essential to being able to care for that individual and also, being able to care for the population, right?

Christi Kruse (08:40):
Yep, absolutely.

Christine Erspamer (08:42):
It's also true that things can present in different ways for veterans. They have different experiences. They lived some different conditions that can cause things to just show up in different ways. And so if providers aren't taking the time to ask some of the questions to understand their past and how it will impact the care needs that they have in the present, it's a potential that you might not have the complete picture that the provider might want to be able to deliver the right care.

Rae Woods (09:11):
We need to understand veterans' past and their care needs in the present. And the only way that we can actually understand those things is to understand veterans. And that's why you and your team have spent the last year talking to literally hundreds of military service members, talking to veterans, talking to their families, to really understand their healthcare experiences. What are the common challenges that your team learned when looking at this population?

Christi Kruse (09:41):
One thing too, we learned, and it was reiterated with every veteran that we spoke to, and that is every veteran's experience is different because veterans come to military service from all walks of life, have very different experiences and leave after service into a different environment. So what is important is to not paint all veterans with the same brush, but to be ready to identify and listen and understand. What we don't want to do is paint the picture that every veteran is dealing with PTSD and is going to be tricked by things and is a suicide risk. That is not true, but some are, but some aren't.

(10:19):
And so recognizing the complexity and individuality of the veterans that are in your practice, that you may encounter every day, the importance is to listen, then to understand and be ready to respond in a way that's based on what they need.

Rae Woods (10:37):
I appreciate that. And at the same time, in a civilian world, we talk about the patient journey. And I have to imagine there are patterns in the service member's journey where we need to understand where the traditional delivery system is falling short so that we can better serve them even as we think about serving the specific patient, in this case, the specific veteran that is in front of us.

Christi Kruse (10:57):
Yes. There are certain things that even though this may not be every veteran's experience, there's certain things that for a veteran after their service are going to happen earlier where you may need to look at sooner than you would if you were talking to a civilian. For example, you may be thinking about your patients in their 60s, mid 60s, early 70s who may be candidates for a hip replacement or a knee replacement. A veteran may be looking at that same thing in their late 40s, especially if you have a veteran who had a high impact role, somebody who regularly jumped out of airplanes is going to have a different profile on their body than somebody who's never jumped out of an airplane.

(11:39):
Somebody who has regularly carried very heavy packs and marched long distances, those people are going to have a different physical profile than others. And those are the kinds of things, be available and ready to ask those questions.

Christine Erspamer (11:54):
You also talked about the veteran journey, and I think that's so important. And it is what we heard loud and clear as we listened to the stories of service members, of veterans and really put the lens on ... from the researchers to what are their experiences and how does it impact their healthcare? And what we found is that there's some really important times of transition, moments of impact that they look to the healthcare system to react with them.

(12:19):
And if when they extend their hand, if they're met with someone who's able to listen to their experiences, to be able to help them to navigate through the care choices that they have and help to be able to develop that right care plan, it can make a lasting impact on not only their own care experiences, but that of their families as well. And it was just time and time again in the stories that we heard that that interaction is just so important. And that's true, whether it's through their commercial health plans or through care within the VA.

Rae Woods (12:51):
So what I'm hearing is that it's both. There are some patterns that will represent difficult moments in the veteran's journey, transitions, continuity of care, that's hard in the civilian population, even harder here. And then there are the specific needs of the individual service member. Were they the ones jumping out of planes? Are they going to need a knee replacement one, two decades before their counterparts in the civilian world? I have to admit, this is making me a little nervous.

(13:20):
Does this mean that the providers who are caring for populations who are doing complex care management need entirely new and different clinical models so that they can care for veterans in a way that is different than when they care for the polychronic population?

Christi Kruse (13:35):
I don't think it's different models. I think it's understanding a nuance. I think it's first of all, you just have to ask. You have to ask the question, did you serve? And you need to know what you're going to do once you get the answer yes or no. And so, understanding which service experiences are going to impact a veteran more than others. And the way that the shortcut for providers to augment their care plans is through, DOD and VA develop joint clinical practice guidelines in those areas where caring for service members and veterans varies from a commercial population and they publish those.

(14:18):
They're not secret. They are absolutely for all providers to be able to access, so that once you have identified a veteran in your population, you can simply augment the care plans that you would normally have.

Rae Woods (14:31):
So there are care pathways that can be embedded into the workflow of clinicians that we don't need to build ourselves that exist that we can implement to make it easy for clinicians to better serve this population.

Christi Kruse (14:45):
Yes, absolutely. That is exactly right. That is exactly right.

Rae Woods (14:49):
Can I actually link to those in the show notes?

Christi Kruse (14:51):
Yes, yes, you absolutely can.

Rae Woods (14:53):
Okay. We'll do that. And I have to admit that where my brain is going is straight into population health. I kind of nodded to this when I was talking about the difference between the high-risk veteran population and the high-risk civilian population. Care pathways is absolutely something that's essential in both worlds. That is a population health best practice.

(16:50):
Let me actually talk about patient activation for a moment, because one thing that's really difficult in pop health is making sure that you are engaging with patients when they are most active in their care. I have to admit, and I hope I'm not sharing a stereotype here, that I often worry that service members might be more likely to delay their care, might be more likely to think they'll experience risk to their job for seeking physical care, behavioral healthcare.

Christi Kruse (17:19):
Yeah.

Rae Woods (17:20):
What does patient activation look like in this population?

Christi Kruse (17:24):
You're not far off. And I think that one of the things that really was a foundational understanding that came out of the research was understanding the transformation that a person goes from civilian to service member. And this is early on in a service member's experience, and it's that transition from the I orientation to the we orientation, where you start to think about your unit first and the mission first, and that you want to make sure that you are never the weak link in that chain.

(17:59):
And you want to make sure that everybody gets what they need. That transformation from the I to the we is something that almost never goes back to an I, that even as a veteran, the orientation of thinking about others first and not wanting to take limited resources. So it's really important for those who are engaging with veterans to recognize that that reticence to speak up is not because they don't care, it's not because they don't want to be engaged, it's because the orientation is to think about others first.

(18:33):
So you may need to ask twice. You may need to reassure that they're not taking resources away from anybody else and that it's okay for them to raise their hand.

Rae Woods (18:43):
And this is a small difference in behavior that I think clinicians themselves need to hear because if we think about the civilian population, if a patient is not active in their care plan, they're not engaged with doing their medication management, focusing on their holistic needs, wraparound care support, you're not going to get them to do it. But what you're saying is this is slightly different. It's that you just need to ask again to make sure you're saying, "No, no, you can have care."

Christi Kruse (19:09):
Yes. And you're not taking it away from anybody else. And this is something that you have earned or this is something that you need. And once you break through that, then most likely you're going to have a very, very engaged patient because the veterans through their service journey understand that their health is, for lack of another term, a tactical weapon. Their ability to stay healthy, to stay sharp means that they can stay on mission. So you may have to ask twice, but once you get them engaged, they most likely would be very engaged.

(19:43):
And then you also have to make sure that you recognize that for many veterans, their care team is bigger than just you, because if they are dealing with VA as well, this is where really truly patient-centered care is so important, so that you recognize that their VA care team is also part of your care team, as you all are caring for that veteran.

Rae Woods (20:07):
So continuity of care becomes really important.

Christi Kruse (20:09):
Absolutely.

Rae Woods (20:09):
And continuity across, again, these parts of healthcare that are typically siloed. So not just continuity across service lines or specialties or across hospitals, but across whole parts of the healthcare sector.

Christi Kruse (20:21):
Yeah. And VA recognizes this. And I think one of the things that they have done over the last five years is really lean into interoperability and making sure that civilian providers as well as providers that are giving care in the community through the VA community care program, as well as their department providers can all share a view of that veteran through the VHIE, the Veterans Health Information Exchange. And activating that in your own practice will allow you to see not only the care that is being delivered within your practice, but also being able to view and retrieve records that have been delivered within VA and also within other community providers through VA.

Rae Woods (21:07):
It is not often that when a challenge is named on this podcast that the guests can say, no, no, there is an answer to this. There is somebody who is providing the care pathways that is helping with the interoperability, that's maybe helping with the risk stratification. It comes back to recognizing that this is a problem for a traditional business leader that they need to engage with. And good news is there are resources that can help them.

Christi Kruse (21:32):
Correct. And the first step is identifying that the person that you're talking to is a veteran.

Rae Woods (21:38):
Yes.

Christi Kruse (21:38):
And usually that means simply asking the question and making sure that the veteran knows that in answering that question, that's going to be a positive thing, that they're going to have better and more connected care by answering that, yes. Yes, I am a veteran. Yes, I did serve. And so making sure that not only do you ask, but that when you do ask, you have the ability to hold onto that answer. So have a place to put it in your medical record. So once someone says they're a veteran on one visit, you remember it on the next visit and that you then take that into account with the way that you care for that veteran.

Christine Erspamer (22:18):
And that was such an important aspect as well in some of the research that we heard. We heard over and over again that people wants to be heard, that they want to have an awareness of their experiences. And like Christi said, sometimes it's just as simple as being able to know that that was part of their experiences and that that may unlock an entirely different set of resources, of helping to navigate the care system in a new way. So just by asking the question, listening to the answer, you're not only addressing a core need that they have to be heard and to feel that that is being understood as part of who they are, but also helping to unlock ways that you can help to manage that patient in a more holistic way.

Rae Woods (23:06):
That's exactly where I wanted to go next. Managing that patient in a more holistic way. If I keep my population health hat squarely on, meeting the needs of vulnerable populations includes clinical support, it also includes non-clinical support. What does that look like for veterans? We talk about whole person care in the civilian world. What does whole veteran care look like?

Christi Kruse (23:32):
Whole veteran care is first of all, recognizing that every veteran, as I said, comes to service and leaves service in their own way. And once you've identified that somebody is a veteran and you ask the question, let's say, going through that conversation in your mind as a provider, you do not need to be an expert on veteran care in order to do one of two things. If someone says, "Yes, I am a veteran." And the follow-up question is, "Are you connected with VA for part of your care?" And if their answer is no, they're not, then the next step is simply to say ... for some of our practices, we developed a simple POM card.

(24:08):
And then also there's actually a brochure that VA creates that is intended to be put into civilian practices to show veterans how to reconnect the VA. But if they, on the other hand, say, yes, I am a veteran and I am also connected to VA is to then say, great, I will make sure that I connect our EHR to VAs so that we can see your full care.

Rae Woods (24:31):
Doing the strong handoff to community partners, right? That is another classic population health principle here. When it comes to the wraparound support that the VA can provide or even that traditional healthcare providers can provide, what are the kinds of non-clinical needs that often come up for this particular population?

Christi Kruse (24:50):
Some of the things that you may traditionally think about, which are behavioral health and other social determinants of health, many veterans who are experiencing homelessness for a couple of reasons, usually they involve both not necessarily being able to connect their military service to civilian employment. And so they kind of float on the fringes, not really finding their place. And then others may also be dealing with behavioral health issues, substance use issues that may be connected to their service that they're also not treating. So those two comorbidities have a huge impact on their health.

(25:29):
VA has a lot of resources to help veterans on that kind of vocational rehab and helping them find their place in the civilian world, as well as specific behavioral health resources, both to help perhaps with PTSD or other behavioral health issues, as well as substance use issues. And for many veterans, doing those kinds of services, especially behavioral health, many veterans want to do those services at VA because they don't have to reexplain to a civilian the things that they're dealing with.

Rae Woods (26:03):
They want to be seen and they deserve that, frankly.

Christi Kruse (26:05):
Correct. Correct.

Rae Woods (26:06):
Our listeners may not have realized that they are largely responsible for caring for veteran health. But the good news that I'm hearing from this conversation is that health leaders can actually draft off of the success of their existing population health programs to support veterans.

Christi Kruse (26:23):
Yes.

Rae Woods (26:24):
I wonder if it actually goes the other way too. If the lessons about caring for the very unique and differentiated needs of veterans can help them better support the civilian populations they serve, the complex needs of the traditional patient population. How can health leaders use this information, this amazing ethnographic research that you've done to be better population health managers for other vulnerable groups?

Christi Kruse (26:51):
They can. And I think that the thing about veteran care, as we said, they're going to be experiencing, many veterans will be experiencing things earlier than civilians, but they're not necessarily different than what a civilian is dealing with. And there are many civilians who also deal with complex behavioral health issues that are trauma-informed. And you're going to get that with lots of populations.

Rae Woods (27:16):
Yes.

Christi Kruse (27:16):
First responders, especially firefighters, EMTs, and police officers.

Rae Woods (27:21):
Doctors themselves, nurses themselves.

Christi Kruse (27:24):
Exactly. Secondary trauma, these are all things that are very, very simple. So some of those clinical practice guidelines that are about trauma-informed care that DOD and VA have created for veterans are also absolutely applicable in other areas. So incorporating those into care pathways when you're dealing with your civilian population could be just as beneficial.

Rae Woods (27:46):
I actually really appreciate that you're calling out trauma-informed populations here. I think there are a lot of lessons that health leaders can take and apply to their own clinical population. You talked about the I versus we mentality. That's exactly how clinicians operate.

Christi Kruse (28:02):
Yes, they do.

Rae Woods (28:03):
We do struggle with getting doctors and nurses and clinical team members to engage in their own care. There's a lot that can be applied just to your own clinicians, let alone your patient populations as well.

Christi Kruse (28:15):
Absolutely. And many first responders, and you know what? The overlap of first responders to veterans is also very high, that Venn diagram of overlaps. So if you have a lot of first responders in your own patient population, you're going to probably dealing with that same I to we, and that same need to reinforce that, yes, these are for you and you are not taking care away from others and you need this because it's going to help you be better in what you're doing.

Christine Erspamer (28:42):
We also saw the importance of community, and I think that comes through in all of these population groups. Being able to understand and find the benefit of navigating through care with your peer group, to be able to see the importance of connection that happens not just in the provider's office, but with other people that may be going through similar experiences. Often, that's how veterans or folks are trying to navigate their care. They're asking their friends, they're asking their buddies, they're asking the people that they served with as to how they're navigating.

(29:13):
And so I think some of those same concepts come through around the need to consider the emphasis of community, of that peer group to help to be able to drive those holistic care practices that we want to see, and that ultimately helps to achieve better outcomes.

Rae Woods (29:31):
In order to better serve veterans, we have to understand veterans, and it's because of you, Christi, you, Christine, the entire team at Optum Serve that we have this incredible body of research to understand how service members, veterans, and their families access healthcare, what their unique challenges are, what their unique needs are. I want you to take all that knowledge you have and channel it to our listeners for a moment. What's one action step that you want health leaders to take today as they work to flex their population health muscles and provide the right high quality care for veterans. Christi, let's start with you.

Christi Kruse (30:14):
Number one is to recognize the veterans in their practices. Recognize that they're already participating in veteran care. So the first thing is recognize. And the way that you recognize is you make it simple and safe for veterans to self-identify. So we've had practices where we've given lapel pins that says, thank you for your service. We put maps on the wall with push pins to allow veterans to say where they served. And giving those signals that this is a place that recognizes and celebrates service and wants to be a part of that. So that's number one.

(30:53):
Recognize that you're already caring for those veterans and then participate in veteran care through participating in the VHIE so that you are able to share interoperably with VA. And third is to incorporate those DOD VA clinical practice guidelines into your care pathways. So essentially, recognize and participate. That's really what it's all about.

Rae Woods (31:20):
Christine?

Christine Erspamer (31:21):
So the only thing that I would add, and it's really just compounding on the participation that Christi mentioned, is just taking the time to use your whole care team. We talked about the fact that they're navigating through maybe getting care through the VA, through different health plan options, through different provider experiences. And so use that whole care team. It comes with available resources. It comes with understanding all of the background that comes when the way that the care is delivered. So I would just say recognize the way that they navigate through the system and use the whole team.

Rae Woods (31:57):
Yeah. Well, Christi, Christine, thank you truly for all of the work that you've done. And thank you for coming on Radio Advisory.

Christi Kruse (32:06):
Thank you so much for having us.

Rae Woods (32:08):
Happy Veterans Day.

Christi Kruse (32:09):
Happy Veterans Day.

Christine Erspamer (32:11):
Thank you to all those who have served. We're honored to be able to help to serve them any way we can.

Ed Weinberg (32:21):
Hi, I'm Ed Weinberg, CEO of Optum Serve and a proud 23-year US Army veteran. I hope you found this conversation enlightening, not just because of the insights shared by Christi and Christine, but because the content truly reflects the heart of our mission at Optum Serve. The insights from our ethnographic research on veteran and military families doesn't just boil down to data. It's about understanding the lived experiences of those who have served. It's about recognizing the moment a veteran walks into your exam room, not just on Veterans Day, but every day.

(33:00):
And it's about equipping our clinical providers with the tools to respond with knowledge, consistency, and compassion. To our listeners who are on the front lines delivering care to our military and veteran populations, I ask you to ground yourself in the dozens of clinical practice guidelines designed to elevate clinical decision-making, to engage with the interoperability efforts within the VA, and to leverage Optum Serve's expertise in the fields of policy research, data management, and service optimization.

(33:37):
I've asked Rae to add these links for all these things in the show notes, because as she says, we're here to help. Serving together, honored to serve. It's not just a motto. It's a commitment, one we're honored to uphold.

Rae Woods (34:21):
If you like Radio Advisory, please share it with your networks. Subscribe wherever you get your podcasts and leave a rating and a review. Radio Advisory is a production of Advisory Board. This episode was produced by me, Rae Woods, as well as Abby Burns, Chloe Bakst, and Atticus Raasch. The episode was edited by Katy Anderson with technical support provided by Dan Tayag, Chris Phelps, and Joe Shrum. Additional support was provided by Leanne Elston and Erin Collins. We'll see you next week.