- JGIM Special Issue on Improving Access to VA Care
This special issue of the Journal of General Internal Medicine titled “Veterans’
Access to Care” highlights recent advancements in access-related research and illustrates how VA has evolved in its ongoing journey to be a high-reliability organization using a learning healthcare system framework to improve
access to care.
Date: July 1, 2023
- VA Surgical Care Comparable or Better than Non-VA Surgical Care
Investigators conducted a systematic review to compare VA and non-VA care for surgical conditions across domains of quality and safety, access, patient experience, and comparative cost/efficiency using studies published between 2015 and 2021 – following implementation of the Choice and MISSION Acts. Findings showed that in all but two studies, VA care had comparable or better quality and safety outcomes than non-VA care. For
access to care, neither VA nor non-VA care was found to be consistently better. Studies of patient experience were too limited to draw conclusions, and the few studies of cost and efficiency outcomes favored non-VA care. Findings suggest that expanding eligibility for Veterans to receive care in the community may not provide benefits in terms of increasing access to surgical procedures or result in better quality, but may reduce inpatient length of stay and cost.
Date: May 8, 2023
- Giving Veterans an Active Voice in Creating a Veteran-Centered Chronic Pain Research Agenda
Veterans Action League (VAL) 2.0 was a two-year community engagement project (2019–2021) that sought to develop a national Veteran-centered chronic pain research agenda that includes Veteran-generated recommendations for chronic pain management and chronic pain research priorities. Findings showed that Veterans’ most frequently cited need for chronic pain management and treatment was better
access to care, with easier appointment booking and shorter wait times. Veterans also requested improved coordination among providers, and more thorough, holistic assessments for identifying contributors to their chronic pain. Some Veterans perceived that many providers overprescribed opioids as a “quick fix,” while other Veterans warned that the anti-opioid pendulum had swung too far. Veterans across states strongly agreed that they wanted to be offered choices for chronic pain management, with their options clearly outlined and their preferences sought. Veterans’ preferred approaches for managing chronic pain were diverse and included acupuncture, an anti-inflammatory diet, and epidural injections. Many Veterans voiced that they would like to see more studies on the efficacy of non-traditional therapies, including cannabis, chiropractic treatments, and therapeutic massage.
Date: March 23, 2023
- Early Expansion of Benefits under Choice Act Increased Community Hospital Use but Did Not Change Mortality
This study examined changes in VA enrollees’ use of VA and non-VA hospitals from 2012-2017, as well as mortality associated with policies intended to increase
access to care, such as the Choice Act. Findings showed that over the five-year study period, Veterans increased their use of community hospitals paid by VA and Medicaid and decreased their use of VA hospitals when access to non-VA care expanded. This shift in hospitalizations from VA to the community was not associated with changes in mortality rates, however, other outcomes need to be assessed to understand how changes in hospital use affected the quality of care for Veterans. Shifting inpatient care to non-VA hospitals poses significant challenges for care coordination across providers and healthcare systems and requires that outcomes be closely monitored. The VA MISSION Act of 2018 further expanded Veterans’ access to community care and is expected to amplify the trends observed in this study.
Date: June 10, 2022
- Referral Coordination Team Improves Timeliness of VA Specialty Care Delivery and Patient Experience
In 2018, the Office of Veterans
Access to Care (OVAC) partnered with local providers at the VA Puget Sound Medical Center to pilot a referral coordination team to manage new referrals in sleep medicine. Investigators then compared the referral coordination team and the traditional specialist-led referral method in terms of timeliness and community care referrals. Findings showed that the referral coordination team was linked to improved timeliness of specialist appointments, reduced reliance on community care services, and greater patient satisfaction, with favorable impacts on cost. Patients whose consults had been completed by the referral coordination team were much more likely to have appointment dates within 28 days after referral than matched peers in the traditional system (33% vs. 12%) and to have these appointments scheduled within 7 days (35% vs. 7%). Each year, VA Puget Sound receives approximately 6,000 sleep medicine consults. Investigators estimate that the referral coordination team could allow VA Puget Sound to accommodate 4,800 additional visits, valued at $420,368. Although referrals to community care were low among patients in both groups, patients whose consults had been managed by the referral coordination team were slightly less likely to be referred outside of VA to community care, consistent with more timely service delivery. Informed by these results, national VA partners, including OVAC and the Office of Specialty Care, are working to disseminate referral coordination to other specialties nationwide.
Date: February 1, 2021
- VA’s Primary Care-Mental Health Integration Affects Access Differently for Women and Men Veterans
This study of 5.4 million Veterans (including 448,455 women), who received care at one of 396 VA primary care clinics between FY2013 and FY2016, set out to answer the following question: Did VA’s national Primary Care-Mental Health Integration (PC-MHI) initiative improve
access to care equally among men and women Veterans? Findings showed that PC-MHI was associated with greater use of all outpatient services among men but with lower use of services (except primary care visits) among women. Both men and women had more primary care visits (+22% and +40%, respectively) and total costs over time, but women had 74% fewer hospitalizations (versus +2% in men) related to mental health integration. Each percentage point increase in the proportion of Veterans who saw an integrated specialist was associated with 38% fewer mental health visits per year for women, but 39% more visits for men. Women Veterans had twice the rates of depression and anxiety and used more mental health and primary care services than men. Also, women Veterans were more likely than men to receive care in hospital-based (vs. community-based) clinics, where average PC-MHI penetration rates are higher and where women-only treatment settings are more commonly located.
Date: October 20, 2020
- VA Policies to Establish National Dialysis Contracts Reduce Reimbursement Without Compromising Access or Survival
This study examined whether changes in VA reimbursement and contracting policies were associated with VA spending on dialysis, Veterans’ access to dialysis care, and mortality. Findings showed that VA policies to standardize payment and establish national dialysis contracts increased the value of community dialysis care by reducing costs without compromising
access to care or survival. Over the time period that payment reforms went into effect, there was an estimated 44% reduction in average treatment prices for VA-financed community-based dialysis care. Over the same time period, there was an increase in the number of community dialysis facilities contracting with VA to deliver care to Veterans with end-stage kidney disease from 19 to 37 facilities (per VAMC), and there were no changes in either the quality of community dialysis facilities or in the 1-year mortality rate of Veterans (12% vs. 11%). Standardization of payments to community dialysis providers did not appear to have unintended adverse effects on
access to care or mortality, suggesting that national price setting may be a feasible approach for VA to improve the value of community care more broadly.
Date: September 22, 2020
- Nurse Practitioners as Primary Care Providers May Be a High-Value Solution to Increasing
Access to Care for All Veterans
Investigators in this study assessed patient outcomes between primary care nurse practitioners (NPs) and MDs, including utilization, costs, and quality of care – one year after patient reassignment to a new primary care provider (due to a Veteran’s prior MD PCP leaving VA). Findings showed that compared to Veterans newly assigned to MDs, those newly assigned to NPs were less likely to use primary care and specialty care services – and incurred fewer hospitalizations. Further, Veterans assigned to NPs achieved similar quality of care in the management of chronic disease compared to those assigned to MDs. Differences in costs, clinical outcomes, and the receipt of diagnostic tests between NP and MD groups were not statistically significant. Findings suggest that the general use of nurse practitioners as primary care providers may be a high-value solution to increasing
access to care for all Veterans. Also, comparable or better outcomes achieved at similar costs for patients across differing levels of comorbidity suggest NPs as primary care providers need not be limited to less complex patients.
Date: April 1, 2020
- Social Stressors Strongly Associated with Suicide Ideation and Attempt among Veterans
This study examined documented social stressors in VA’s electronic health record (EHR) and how these stressors were associated with suicidal ideation and suicide attempt. Seven types of social stressors were included: 1) experiences of violence, 2) housing instability, 3) employment or financial problems, 4) legal problems, 5) social or familial problems, 6) lack of
access to care or transportation, and 7) non-specific psychological needs. Findings showed that social stressors were strongly associated with suicidal ideation and suicide attempt. For example, compared with Veterans who had no social stressors, those with one social stressor had nearly 2.5 times the odds of suicidal ideation, two social stressors had over four times the odds, three social stressors had nearly five times the odds, and four or more social stressors had over eight times the odds – after adjusting for numerous socio-demographic factors and mental illness diagnoses. Social stressors are as relevant as biological factors (e.g., depression) for suicide prevention and treatment. Systematic assessment of a more complete set of these stressors may improve the ability to identify patients at highest risk of suicide.
Date: November 19, 2019
- Lack of Awareness among VA Providers about Risk Associated with Prescribing Inhaled Corticosteroids to Veterans with COPD
More than 50% of patients with mild-to-moderate COPD in the U.S. are prescribed inhaled corticosteroids despite recommendations to restrict use to patients with frequent breathing exacerbations. This study explored VA primary care providers’ experiences prescribing inhaled corticosteroids among Veterans with mild-to-moderate COPD. Of the Veterans with COPD in this study cohort, 15% were prescribed an inhaled corticosteroid. However, 61% of these prescriptions were not clinically indicated. Providers reported being unaware of current evidence and recommendations for prescribing inhaled corticosteroids; e.g., 46% of providers reported they were unaware of the risk of pneumonia. Providers also reported they are generally unable to keep up with the current literature due to the broad scope of primary care practice. Some providers expressed reluctance to change or stop prescribing if their patient was doing well. However, 52% of providers reported they would make an effort to reduce the use of inhaled corticosteroids, and 50% reported that they would make an effort to make greater use of alternative guideline-recommended medications. Study results corroborate prior findings that lack of awareness of current evidence-based guidelines is likely an important part of medical overuse. Efforts to expand
access to care by increasing the number of prescribing providers a patient sees could make it more difficult to de-implement harmful prescriptions.
Date: August 8, 2019
- Mental Health Integration in VA Primary Care Settings Increased
Access to Care – and Costs
This study examined the effect of the Primary Care-Mental Health Integration Program (PC-MHI) on healthcare use and cost patterns among 5.4 million primary care patients in 396 VA clinics (FY2014-FY2016), while also accounting for the implementation of VA’s Patient Aligned Care Team (PACT) model of care. Investigators assessed VA outpatient and inpatient care and total cost of VA care as a function of attending a clinic with a high vs. low PC-MHI penetration rate. Findings showed that Veterans treated in clinics with higher proportions of primary care patients seen by PC-MHI providers received more outpatient care than those treated in clinics with lower PC-MHI penetration, but at a higher total cost. Each percentage-point increase in the proportion of clinic patients seen by PC-MHI providers was associated with 11% more mental health and 40% more primary care visits, but also 9% higher average total costs per patient per year. Among patients with serious mental illness, increasing PC-MHI penetration was associated with greater use of specialty-based mental health and all other healthcare visits. Among patients seen in hospital-based clinics, increasing PC-MHI penetration was associated with fewer emergency visits per person per year.
Date: August 1, 2019
- Veterans Eligible for VA Purchased Healthcare Based on Distance from VA Facilities Face Shortage of Non-VA Providers
This study examined the potential impacts of reforms to improve
access to care for Veterans living in rural areas on these Veterans and healthcare providers. Findings showed that initiatives to purchase care for Veterans living more than 40 miles from VA facilities may not significantly improve their
access to care, as these areas are underserved by non-VA providers. For example, about 16% of these Veterans lived in areas where there was a shortage of primary care providers, while 70% lived in areas where there was a shortage of mental healthcare providers; the majority of VA users eligible for purchased care lived in counties with no psychiatrists, cardiologists, pulmonologists, neurologists, PM&R specialists, or community mental health centers; and nearly half of these Veterans (47%) lived in counties with no community health center. Veterans eligible for purchased care based on distance were much more likely than the general population to live in counties with a median household income < $40,000 per year (40% vs. 11%) and very poor population health status (28% vs. 10%). VA should continue to develop telehealth programs and other strategies to deliver care to Veterans in rural areas underserved by both community and VA providers. Such programs are a necessary complement to initiatives to purchase in-person care from community providers.
Date: May 29, 2018
- Racial/Ethnic and Gender Variations in Veteran Satisfaction with VA Healthcare
This study of Veterans’ satisfaction with outpatient, inpatient, and specialist care in a diverse sample of Veterans from predominantly minority-serving VAMCs sought to better understand racial/ethnic and gender variations in healthcare satisfaction. Findings showed generally high levels of healthcare satisfaction across 16 domains, with 83% of respondents somewhat or very satisfied with VA healthcare overall. The highest satisfaction ratings were reported for costs, outpatient facilities, and pharmacy services (74% to 76% were very satisfied); the lowest ratings were reported for
access to care, pain management, and mental healthcare (21% to 24% were less than satisfied). Contrary to previous studies, there was little evidence of racial, ethnic, or gender disparities in satisfaction with care at minority serving VAMCs.
Date: March 1, 2018
- Racial and Ethnic Differences in Primary Care Experiences for Veterans with Mental Health and Substance Use Disorders
This study examined racial and ethnic differences in positive and negative experiences in VA Patient-Centered Medical Home (PCMH) settings among Veterans with mental health or substance use disorders (MHSUDs) who completed VA’s 2013 PCMH Survey of Healthcare Experiences of Patients. Findings showed that positive experiences were reported least often for access. Negative experiences were reported most often for self-management support and comprehensiveness, defined as provider attention to MHSUD concerns. One or more racial/ethnic minority groups reported more negative and/or fewer positive experiences than Whites in the following 4 domains: access, communication, office staff helpfulness/courtesy, and comprehensiveness. Solutions are needed to improve
access to care for all Veterans with MHSUDs, with additional attention on improving access for Black, Hispanic, and AI/AN Veterans.
Date: June 20, 2016
- VA Maintains
Access to Care as Need for Substance Use Treatment Grows
VA has enhanced funding of mental health programs and substance use disorder (SUD)-specific treatment and also has directed approximately $152 million toward hiring additional SUD staff. This study examined the relationship between dedicated SUD funding and SUD performance measures from 2005 and 2010 for VA medical centers. Findings showed that, overall, access and quality of care kept pace with the demand for SUD services in the VA healthcare system. There was a statistically significant and generally positive correlation between additional, dedicated SUD resources and access and treatment intensity. The number of VA patients with an SUD diagnosis grew from about 310,000 in 2005 to 439,000 in 2010 – an increase of 42%. Average dedicated SUD funding per facility grew from $65,870 in 2005 to $324,416 in 2007, falling to $147,151 in 2009 and 2010. However, not all VAMCs received funding in each year.
Date: March 12, 2015
- JGIM Special Supplement Highlights Access to VA Healthcare
The JGIM Supplement includes both the white papers commissioned as background for the September 2010 state-of-the-art (SOTA) conference on “Improving Access to VA Care” and manuscripts submitted in response to a post-SOTA solicitation for original research and reviews pertaining to improving access to VA care. Articles focus on a myriad of topics related to improving
access to care for Veterans, including: eHealth technologies (e.g., Care Coordination Home Telehealth program, and My HealtheVet personal electronic health record); measuring the impact of access on healthcare utilization, quality, and outcomes; and redefining access for 21st century healthcare.
Date: November 1, 2011
- Disparities in Healthcare Coverage and Access among American Indian/Alaska Native Veterans
American Indian/Alaska Native (AIAN) Veterans have considerable disparities in healthcare coverage and
access to care compared to non-Hispanic white Veterans. For example, AIAN Veterans are nearly twice as likely to be uninsured, even after adjusting for sociodemographic and economic characteristics. AIAN Veterans are significantly less likely to report private coverage and significantly more likely to report public coverage, military coverage, and be uninsured. Regarding barriers to healthcare, AIAN Veterans were significantly more likely to delay healthcare due to not getting timely appointments, not getting through on the telephone, and having transportation problems.
Date: June 1, 2010
- Teledermatology – Promising Technique for Improving
Access to Care
In this study, teledermatology demonstrated good performance in comparison to clinic-based consultation for diagnostic agreement and diagnostic accuracy. Regarding diagnosis, teledermatologists agreed with each other and with clinic-based dermatologists at a rate comparable to group agreement among clinic dermatologists. Regarding accuracy, when compared to the gold standard of histology, rates ranged from 30% to 92% for clinic dermatologists and from 19% to 95% for teledermatologists.
Date: April 1, 2009
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