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Research Highlight

Optimizing Veteran Decision-Making About Use of VA and Non-VA Healthcare

Recent policy developments such as the creation of health insurance exchanges, Medicaid expansions, and the VA MISSION Act have provided Veterans with unprecedented healthcare choices.¹ On one hand, this array of healthcare options provides opportunities for Veterans to make personalized decisions that could optimize the timeliness, affordability, quality, and patient-centeredness of their care. Yet for many Veterans, the process of navigating their healthcare options can be confusing, or can even lead to serious unintended consequences because Veterans receive little to no information to support their decision-making. Because of this lack of decision support, Veterans may miss opportunities to make choices that are optimal in meeting their preferences and needs, or may even make decisions that don’t consider the risks of healthcare fragmentation that can result when use of VA and non-VA providers is not well-coordinated. These risks could be of special concern among Veterans who have greater healthcare needs (e.g., because of multiple chronic conditions) or more difficulty with complex healthcare decisions (e.g., due to limited health literacy)^.2

Understanding healthcare use and decision-making among the 6 million Veterans who used VA healthcare in the last year and the 14 million Veterans who did not³ is critical to the success of national efforts to expand healthcare choices for Veterans. Such an understanding will also help achieve a VA healthcare system that is maximally responsive to Veterans’ needs. However, VA does not yet know how best to design and deliver decision support strategies to help Veterans make choices about their healthcare options to optimize their experiences and outcomes.

Through a VA HSR&D Merit Award (IIR 18-239), our team of researchers from the VA Ann Arbor Healthcare System and the VA Salt Lake City Healthcare System is using a multi-phase, mixed methods research plan that will culminate in novel strategies to support Veterans in their decisions to use VA and/or non-VA healthcare services. In this article, we summarize our progress to date and outline how each phase of our research is yielding key products to help inform the next phase. We also discuss plans to disseminate our research to both VA and non-VA stakeholders.

How Veterans Make Decisions About VA and Non-VA Healthcare

In the first phase of our research, we used qualitative methods to examine how Veterans make decisions about use of VA and non-VA healthcare and what information would help them make these decisions. In October of 2020 through March of 2021, we conducted semi-structured telephone interviews with 31 Veterans from across the United States. We distributed recruitment materials through email and social media, and with the help of Veterans Service Organizations. Sampling was stratified by use in the last 12 months of VA care only, non-VA care only, or both VA and non-VA care. Non-VA care included services covered by Medicare, Medicaid, private health insurance, or out-of-pocket. We classified VA-purchased community care as VA care because such services are only available to Veterans who are enrolled in VA healthcare.

Among the 31 participants, nine had used only VA healthcare, eight only non-VA healthcare, and 14 both VA and non-VA healthcare in the last 12 months. Some Veterans we interviewed felt they had a choice about where to receive their healthcare, but many others felt that VA healthcare constituted their only option due to financial and insurance constraints. Participants cited multiple factors that influenced their healthcare decision-making, including health insurance, previous healthcare experiences, convenience, and the ability to research qualifications of clinicians. Veterans used a variety of information sources in their decision-making, including word-of-mouth recommendations, Veterans organizations, websites and social media, and advice of VA and non-VA medical professionals. Many participants suggested that information about clinician qualifications (e.g., credentials, ratings, and reviews) and features of facilities (e.g., layout and care processes) would be helpful in their decision-making about VA and non-VA healthcare.

The Information that Veterans Say They Need and How They Want it Delivered

To build on the interview data from our first phase of research, we used Zoom.gov to conduct five focus groups with 22 Veterans from across the United States between August of 2021 and May of 2022. Three focus groups consisted of Veterans who in the last 12 months had used: only VA care (one group), only non-VA care (one group), and both VA and non-VA care (one group). Two additional focus groups consisted of a mix of Veterans from the above three categories. Across the five focus groups we identified six key themes. First, primary information needs include eligibility, available services, and out-of-pocket costs; transportation options; and a consistent point of contact. Second, most participants thought information about healthcare options would ideally be provided by VA, yet many questioned the feasibility of any single entity providing comprehensive, nationwide information about non-VA healthcare options. Third, participants generally trusted fellow Veterans to deliver information and to triage Veterans to professionals with specific VA or non-VA care expertise. However, focus group participants perceived the delivery of accurate and consistent information as more important than its source. Fourth, participants felt that those delivering information should be empathetic and have extensive knowledge of local VA and community resources. Fifth, participants felt that an informational support program would need to accommodate a range of Veteran needs, including the needs of those Veterans already in VA and moving to a new location, those being discharged from active duty, those not enrolled in VA, those with a negative perception of VA, Veterans living in a rural area, those enrolled in higher education, those willing and able to access technology, or those experiencing homelessness. Sixth, many Veterans may not be aware they are eligible for VA benefits; such Veterans would benefit from a multi-faceted outreach strategy tailored to local communities and Veteran subgroups.

Veterans’ Decision-making about VA and Non-VA Healthcare

In the second phase of our research, we used our qualitative findings to develop and refine new survey measures of: Veterans’ reasons for using VA care, non-VA care, or both; reasons for choosing the VA facility they use for most of their care; sources of information they used to choose between getting healthcare in VA or outside VA; and the importance of having particular types of information to facilitate that choice. We then combined these new measures with existing items into a survey that will measure Veterans’ use of and decision-making about VA and non-VA care; and perceptions of the timeliness, affordability, quality, and patient-centeredness of their healthcare.

In November 2022, we administered this survey to a nationally representative sample of 3,000 Veterans who are part of Ipsos KnowledgePanel®. In addition to the new survey measures we developed, products of this phase will soon include national estimates of factors associated with Veterans’ use of VA care, non-VA care, or both; reasons Veterans choose VA care, non-VA care, or both for different types of healthcare services; and Veterans’ views of different types of information to help them choose between getting healthcare inside or outside the VA system.

Partnering with Veterans and VA leaders to Translate Findings into Policy and Practice

In the third and final phase of our research, we will engage both Veterans and VA operational leaders to identify actionable strategies to inform Veterans’ decision-making and ways in which policies and programs could reflect Veterans’ preferences for and experiences with using VA and  non-VA healthcare. Using a combination of deliberation and design methods, we will share key qualitative and survey findings with separate virtual groups of Veterans and VA leaders from across the United States. We will then guide participants through a collaborative process in which they will identify, prioritize, and begin to design programs and policies that could support Veteran decision-making about use of VA and non-VA care. To maximize the benefits of VA and non-VA healthcare options, Veterans need information and support that they can trust, that they will value, and that will be useful to their healthcare decision-making. Our multiphase research will yield opportunities to better inform Veterans’ healthcare decisions to help them access the services they need and deserve.

References

1. Kullgren JT, Fagerlin A, Kerr EA. “Completing the MIS-SION: a Blueprint for Helping Veterans Make the Most of New Choices,” Journal of General Internal Medicine 2020; 35(5):1567-70.
2. West AN, Charlton ME, Vaughan-Sarrazin M. “Dual Use of VA and non-VA Hospitals by Veterans with Multiple Hospitalizations,” BMC Health Services Research 2015; 15(1):431.
3. The Veterans Community Care Program: Background and Early Effects | Congressional Budget Office. Published October 26, 2021. Accessed October 24, 2022. https://www.cbo.gov/publication/57583