Alex Woodruff is a Policy Analyst at Boston University School of Public Health. He tweets at @aewoodru.
The Veterans Access, Choice and Accountability Act (known as the 2014 Choice Act) expanded Veterans’ ability to seek medical care outside of Veterans Health Administration (VHA) if they met certain criteria. Prior to this legislation, concerns over wait times, especially for specialty care, showed long delays in Veterans’ access to VHA care. Since the implementation of the Choice Act, VHA wait times have decreased; at the same time, Veterans have increasingly taken advantage of their ability to utilize community-based care. Between 2014 and 2018, over 2 million Veterans received care from community providers — that’s roughly 25% of the Veteran enrollee population. This trend is likely to increase with further infrastructure developments and expansion of the program under the 2018 MISSION Act.
Little is known, however, about how VHA care compares to the care Veterans receive in the community through VA-purchased care. Understanding Veterans’ experience with community care is important. Health care experiences can drive patients’ care-seeking behavior; for example, positive experiences are often a marker for safe and effective health care services. New research has taken one of the first rigorous looks at patient experiences with both VHA and non-VHA care.
New Research on Veterans Experiences with Community Care versus VHA Care
Vanneman et al (2020) take a look over time at patients’ reported care experiences following implementation of the Choice Act. This study was conducted by researchers from the Department of Veterans Affairs, with affiliations to the University of Utah School of Medicine, Stanford University School of Medicine, and Boston University’s School of Medicine and Health, Policy, and Law Department.
Using data from the VA Survey of Health Experiences of Patients, they evaluated Veterans’ experiences with both VHA and non-VHA care. This routine survey captures patients’ overall rating of their provider and experiences with access to care, communication with their provider, and care coordination. Using a score for provider rating and composite scores across access, communication, and coordination domains, the researchers assessed each type of outpatient care — specialty care (i.e. cardiology, orthopedics), primary care, and mental health care. Completed surveys administered between 2016 and 2017 were included, totaling over 412,000 responses for specialty care, 430,000 for primary care, and 29,000 for mental health care. The researchers examined multiple covariates in their models including education level, perceived health status, and perceived mental health status.
This study tested four hypotheses:
- VHA outpatient care would rank higher than community-based care in patients’ reported experiences.
- VHA would score better in mental health and primary care access than community-based care, but worse in specialty care access.
- Over time, Veterans’ experiences with outpatient care would improve for both VHA and community-based care due to increased focus on patient-centered care.
- Differences in Veterans’ experience between VHA and community-based care would lessen over time as the Choice program was more firmly established and community providers gained experience treating Veterans.
Previous studies attempted to draw conclusions between VHA and non-VHA data, but these studies either did not compare results over time or were limited by single-measure designs or comparisons to non-Veteran populations. This is the first study to directly compare VHA and non-VHA Veteran care experiences over time and to be conducted after the community care program has seen a significant uptake.
Findings
Using a series of multivariate regression models to adjust for covariates, researchers found that scores on provider ratings, communication, and coordination of care were all better for VHA care compared to non-VHA care, confirming their first hypothesis. There are multiple possible reasons for this, including that patients familiar with the VHA may find community-based care challenging to access and that providers at VHA facilities are better in tune with the social and medical challenges Veterans face. Additionally, providing care to veterans in both the community and VHA systems has substantial challenges in terms of communication and care coordination that may impact patient satisfaction.
The second hypothesis was also supported, with patients reporting a better experience accessing specialty care in the community than in VHA and no difference between primary and mental health access experience. Only specialty care experience scores increased across all four experience domains, which is a mixed result for the third hypothesis that speculated all outpatient care would increase. And finally, the fourth hypothesis was unsupported as the gaps between VHA and non-VHA care experiences remained stable over the study period.
Discussion
This study gives valuable insight into the success and future of VHA’s efforts to expand care options for Veterans to community-based providers. Understanding care experiences among Veterans is an important factor in both care and policy decisions. Vanneman et al (2020) provide strong evidence to support the quality of VHA care when compared to community-based care. Overall, patients found outpatient care at VHA facilities to be high quality. Specialty care access was the only domain in which Veterans reported a better experience in the community, aligning with the study’s hypotheses as well as the driving forces behind offering community care to Veterans in the first place. These results provide context for Veterans, policymakers, and VHA providers around when it is best to facilitate community care.
The study also calls attention to the need to accurately track Veterans’ experiences regardless of where they receive care, whether within VHA or in the community. For example, VHA facilities that have large numbers of patients receiving community care may choose to study why and what modifications could be made to improve Veterans’ VHA experiences. As community-based care utilization increases, VHA has the opportunity to expand its infrastructure to measure patient experiences in response to these changes. This knowledge will improve how VHA cares for its Veterans, ensuring a patient-centered experience in the most appropriate setting possible.
