A patient’s access to quality health care is a critical social determinant of health, impacting overall health outcomes and mortality rates. Barriers to access may include geographic limitations, the availability of various services, and the timeliness of care provision.
Veterans Health Administration (VHA) operates over 170 medical facilities and clinics in the United States, serving millions of Veterans. As one of the largest health systems in the country with significant patient demand, waiting to access care has been a crucial policy issue.
In response to documented access challenges, Congress enacted the Choice Act in 2014 and the MISSION Act in 2018. VHA then created wait time access standards for each specialty (e.g., 20 days for primary care and mental health care and 28 days for specialty care), meaning no Veteran should wait longer than the standard for an appointment in that specialty in VHA. These laws and policies may reduce wait times by enabling Veterans to receive care with private sector providers (i.e., community care) if VHA cannot meet the access standard.
Despite these initiatives, timely access to VHA care remains an inherent challenge for many Veterans, and monitoring wait times is important to understand the Veteran experience.
New Research
In October 2022, researchers at the Partnered Evidence-based Policy Resource Center (PEPReC) published a new paper titled “Geographic Variation in Appointment Wait Times for U.S. Military Veterans.” PEPReC researchers conducted the first national comparison of appointment wait times across both VHA and community care settings and all specialties.
Methods
This cross-sectional study included over 22 million appointments for about five million Veterans from January 2018 to June 2021. Appointments were categorized into primary care, mental health care, and all other specialties. The VHA enrollees in the sample were: 65.0% White, 77.3% male, 80.7% non-Hispanic, 49.3% married, and an average of 61.6 years old. VHA medical centers were organized by geographical regions called VISNs.
Data analysis comprised of four steps, including estimating mean and median wait times, estimating multivariate linear regression models to account for regional variations in the specialty mix (direct standardization), comparing and ranking VISNs across specialties, and lastly comparing appointment wait times between VHA and community care clinicians using 2-sided t tests.
Findings
PEPReC researchers found that community care appointments had longer mean wait times than VHA appointments for primary care, mental health care, and all other specialties (see table below). This was also true at a regional level in almost every VISN. Geographic variations in wait times were substantial, showing both a smaller range of and shorter wait times for all care categories (e.g., 22.4-43.4 days vs. 25.4-52.4 days in primary care) for VHA care compared to community care at the VISN level. Across all categories, less than 50% of community care appointments met their respective in-house VHA access standards.
Table 1: Average Appointment Wait Times (in days) for Each Care Category
|
Mean Appointment Wait Times (SD) in days |
||
| Community Care (non-VHA) | VHA | |
| Primary Care | 38.9 (8.2) | 29.0 (5.5) |
| Mental Health Care | 43.9 (9.0) | 33.6 (4.6) |
| Other Specialties | 41.9 (5.9) | 35.4 (2.7) |
Conclusion:
The study had some noteworthy limitations. First, it exclusively focused on VHA data and the experiences of enrolled Veterans, so the findings may not be generalizable to a non-Veteran or an unenrolled Veteran population. Since the data lacked clinician identifiers for community care providers, it may not be representative of community care clinicians more broadly. Additionally, the results did not indicate the sources of geographic variation in wait times or whether those wait times were clinically appropriate.
Despite significant geographic variations in wait times, no distinct VISN meets the wait time access standards for any care category. Furthermore, community care appointments were found to be less likely to meet VHA’s in-house wait time access standards compared to VHA appointments. This implies that policies aimed to increasing Veteran access to community care clinicians may not necessarily result in shorter wait times in those regions. Moreover, it suggests that policies intended to improve Veterans’ access to community care may be insufficient in reducing wait times in many regions. However, certain strategies, such as increased telehealth usage, physician relocation incentives, or mobile deployment units, still hold the potential to improve in-house access for Veterans in underserved areas.
In summary, this study provides valuable insight into wait times across specialties and care settings for Veterans in the United States as access to care remains a pressing policy priority.
