VHA In-Person Care Declined Substantially More than Community Care During Pandemic – And Has Yet to Recover

BACKGROUND:
VA manages a nearly $100 billion per year integrated healthcare system for more than 9 million Veterans. Like other healthcare systems, VA has faced unprecedented challenges responding to the COVID-19 pandemic but was able to leverage its existing infrastructure and prior planning to rapidly scale virtual care services. This cross-sectional study sought to describe how VA care patterns shifted in response to the pandemic, including all forms of care either purchased (Community Care) or provided by VA. Using VA data, investigators identified all healthcare encounters paid or provided by VA from January 2019 to March 2021. During this time, VA provided or paid for 179.5 million health encounters for 6,737,274 Veterans. Encounters were categorized by type and location of care, as well as by epidemiological weeks. To estimate the total volume of missing visits in 2020, investigators performed local polynomial regression of total weekly visits prior to and during the pandemic.

FINDINGS:

• As expected, overall VA healthcare use dropped precipitously in March and April of 2020, while virtual care expanded swiftly. However, VA in-person care declined substantially more than Community Care, and total encounters have yet to recover to pre-pandemic levels.
  • The estimated total volume of missing encounters relative to the previous year (2019) was 16.5 million.
  • Virtual care in VA increased from 6% (n=454,399) in April 2019 to 44% (n=1,894,674) in April 2020 before falling to 29% (n=1,861,922) in December 2020.
  • As of December 2020, VA in-person care constituted just 30% of VA paid or provided care while non-acute community care accounted for 29% of all encounters.

IMPLICATIONS:

• VA likely adopted a more conservative reopening strategy compared to community providers, who have different financial incentives to resume in-person care and returned close to pre-pandemic patient volume by September 2020. In the wake of concerns about access, VA has steadily increased spending on Community Care, and study results indicate existing trends pushing VA toward being a mixed payer and provider may have accelerated.

LIMITATIONS:

• There is likely a lag in adjudication of more recent Community Care claims. However, this means that current estimates of Community Care encounters are an underestimate.

AUTHOR/FUNDING INFORMATION:
This study was funded by HSR&D (IIR 16-266). Drs. Rose and Tran are part of HSR&D’s Health Economics Resource Center (HERC). Drs. Asch and Vashi are with HSR&D’s Center for Innovation to Implementation (Ci2i). Both HERC and Ci2i are part of the VA Palo Alto Health Care System.

Rose L, Tran LD, Asch S, and Vashi A. Assessment of US Veterans Affairs System Care Delivery Methods Changes During the COVID-19 Pandemic. JAMA Network Open. October 2021;4(10): e2129139.