The healthcare landscape for new Veterans, especially those who served in Operations Enduring Freedom, Iraqi Freedom, and New Dawn (OEF/OIF/OND), has changed over the past two decades. Access to Veterans Health Administration (VHA) healthcare services was expanded to Reserve Component (National Guard and Reserve) members for 5 years after demobilization (Public Law 110-181). Additionally, more options are available for non-VHA health care through the Patient Protection and Affordable Care Act ("ACA) and more recently through the Veterans Access, Choice and Accountability Act's (VACAA) Veterans Choice Program (VCP).
Under VCP, which went into effect in November 2014, eligible VHA enrollees are able to receive care from non-VHA providers that is paid for by VA. Eligibility requirements include having to wait more than 30 days from the clinically indicated date for an appointment, living over 40 miles driving distance from the closest VHA, or experiencing hardship (living 40 miles or less from the nearest VHA, but only being able to access that VHA by boat or plane, or face other excessive travel burdens, such as heavy traffic, geographic barriers, hazardous weather, or medical challenges).
We have limited knowledge about the impact of VCP. The goal of this project was to develop methods for using VHA data to evaluate the impact of VCP for primary and specialty care. Delays in data access and sample size limitations required that we focus on understanding the effect on primary care - which has been particularly difficulty to identify in administrative data.
We investigated whether we could use administrative data to identify primary care utilization for purchased care, including VCP. We examined VHA and traditional Fee primary care utilization for three years prior to VCP (fiscal years (FY) 2012-2014), and VCP primary care utilization during the first year of VCP (FY2015).
We conducted a descriptive study to examine OEF/OIF/OND Veterans' use of VHA and non-VHA primary care before and after implementation of VCP. The study cohort consisted of all Veterans included in the OEF/OIF/OND Roster who used VCP services in FY2015. The OEF/OIF/OND Roster identified Veterans involved in the OEF/OIF/OND conflicts who have a connection to VHA -- i.e., enrolled in VHA and/or have utilized services at VHA; our study was limited to those enrolled in VHA as they had to be eligible for VCP. The OEF/OIF/OND Roster contains demographic and deployment information for these Veterans from FY2002 to present; we received the Roster in August 2015.
We included data for primary care visits between FY2012-2015. Although ninety percent of claims for non-VA care are typically processed within 30 days of receipt, there can be delays in the processing of some claims. In addition, authorized claims may be submitted within six years of the date of service. So missing data are possible, but not likely.
To understand Veterans' use of VHA and purchased care, we linked Veterans in the OEF/OIF/OND Roster to VHA and Fee Basis data in the Corporate Data Warehouse (CDW). For VHA-provided care we used data from the Managerial Cost Accounting (MCA) National Data Extracts in CDW. The MCA National Data Extracts are records compiled from multiple sources to create encounter data. We pulled data from the Outpatient and Treating Specialty Extracts. We linked our cohort to MCA data using scrambled social security number. For purchased care, we pulled data from CDW Fee Domain tables. The Fee domain contains data for VA-paid medical care performed by non-VA providers.
To determine whether an outpatient visit was primary care, we collapsed data from the "Category of Care" variable in the Fee Basis Claims System (FBCS). Less than 1% of VCP visits were missing a value for category-of-care. Approximately 15% of traditional Fee visits were missing a value for category-of-care. When Veterans enrolled in VA mid-FY, we assumed their utilization pattern was the same for the full year. If the Veteran died mid-FY, we assumed zero utilization after death.
In FY2015, approximately 215,000 OEF/OIF/OND Veterans were eligible to use VCP services. However, as expressed by VHA leadership, actual utilization of VCP was lower than expected.
The number of primary care users in VHA increased over time in our cohort. This coincided with a decrease in the average number of VHA primary care visits per user. The declines were similar for the wait-list group and the mileage/hardship group. As expected, Veterans in the wait-time category utilized more VHA primary care services per user than Veterans who fell into the mileage and/or hardship category - where it would be difficult to get to a VHA facility. Furthermore, as hypothesized, Veterans in the mileage/hardship group had more VCP primary care visits per capita (1.4) than those in the wait-time group (1.3) in FY2015. There was not a clear increase or decrease pattern with traditional Fee care.
Results from this Quality Enhancement Research Initiative (QUERI) project were necessary in order to pursue our long-term goal of understanding the impact of VCP on OEF/OIF/OND Veterans with mental health conditions. VHA is likely to become an increasingly important purchaser of care through VCP and any subsequent programs that might expand care provided in the community. Understanding when and why Veterans pick VHA or not is essential to best provide care to Veterans and key to VHA's survival as an institution.
External Links for this Project
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