Does a non-VA emergency department visit lead to more non-VA care for Veterans?

The Department of Veterans Affairs (VA) operates one of the largest health systems in the United States, providing care to millions of Veterans each year. With the passage of the Choice Act in 2014 and the MISSION Act in 2018, Veterans who are unable to receive VA care because of distance, wait times, or availability of services are allowed to receive care in the community from non-VA providers.

While this improves access to care, it’s unclear if it improves care quality or coordination. In fact, studies have established that VA care is of exceptional quality and that using out-of-network providers can lead to care fragmentation. A better understanding of how the use of non-VA care affects future use of both VA and non-VA care will help VA leadership focus on providing high quality, cost-effective care to Veterans.

New Evidence

Evaluators at the Partnered Evidence-based Policy Resource Center (PEPReC) recently published a paper in Academic Emergency Medicine titled: “Community care emergency room use and specialty care leakage from Veterans Health Administration hospitals.” The goal of this paper was to add to the conversation about care leakage – when care is provided outside a health system – and its implications by studying whether non-VA emergency care utilization led to more subsequent non-VA specialty care utilization than VA emergency care utilization did.


The authors used a retrospective cohort study design to assess the impact of non-VA emergency care utilization on subsequent non-VA specialty care utilization. They gathered VA administrative and claims data from the VA Corporate Data Warehouse. The study period was January 2021 to July 2021. They included Veterans who had at least one emergency department (ED) visit – VA or non-VA – in the first three months of the study period. After employing certain exclusion criteria, 330,547 Veterans were included in the sample.

They used Current Procedural Terminology (CPT) codes and provider taxonomies to identify to which specialties subsequent-to-ED-care visits belonged. In order to focus on specialty care that could likely be brought back in-house, the authors excluded visits in primary care, mental health care, inpatient settings, and various rehabilitation and extended stay specialties.

To estimate effects and conduct sensitivity analyses, the authors used two-stage least-square models, an instrumental variables approach, and ordinary least-square models. They controlled for a variety of factors, such as Veteran age, gender, VA priority status, comorbid conditions, race and ethnicity, rurality, drive time to closest VA medical center, VA medical center complexity, and VA medical center fixed effects.


Having a non-VA ED visit was associated with more subsequent non-VA specialty care visits within all timeframes studied (30, 60, 90, and 120 days) compared to a VA ED visit. The 30-day timeframe showed the biggest difference (45 percentage points higher).

For Veterans living within 60 minutes of VA specialty care, having a non-VA ED visit was associated with more subsequent non-VA specialty care. The average drive time to both primary and specialty care was higher for Veterans with a non-VA ED visit than those with a VA ED visit. The proportions of non-Hispanic White Veterans and rural Veterans were higher among those with a non-VA ED visit than a VA ED visit as well.

Lastly, the authors found that an increase in VA ED physician capacity was associated with a decreased likelihood that a Veteran would seek care at a non-VA ED.


One notable limitation of this study is the differences between VA and non-VA care systems. There are different data-generating processes and financial incentives for providers, making comparisons challenging.

Given how much VA spends on non-VA each year, policy changes that could reduce that financial footprint are important. For example, the authors found that shifting five percentage points of VA ED care to non-VA ED could result in a $769 million increase in non-VA care spending. One could assume that the same-sized shift in the opposite direction could result in $769 million in savings.

As such, the findings of this study shed light on how receiving care at a non-VA ED increases the likelihood that a Veteran will then also receive specialty care in a non-VA setting. Understanding care pathways provides VA policymakers with new ways to reduce spending. For example, if VA could provide more ED care in-house, it’s likely VA could save a significant amount of money on both ED care and specialty care follow-up visits. VA care is known to be both high quality and preferred by Veterans, so the incentives are strong to minimize unnecessary non-VA ED and specialty care. Not only will this produce financial savings, it will also leave more non-VA care available for Veterans for whom VA care is simply not an option.

PEPReC, within the Veterans Health Administration and funded in large part by the Quality Enhancement Research Initiative (QUERI), is a team of health economists, health services and public health researchers, statistical programmers, and policy analysts who engage policymakers to improve Veterans’ lives through evidence-driven innovations using advanced quantitative methods.

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