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2019 HSR&D/QUERI National Conference Abstract

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4117 — Rural Veteran's Use of the Veterans Health Administration (VHA) and VHA-Purchased Care in Health Professional Shortage Areas: Implications for Policy

Lead/Presenter: Michelle Mengeling,  COIN - Iowa City
All Authors: Mengeling MA (Office of Rural Health, Veterans Rural Health Resource Center - Iowa City; Center for Access & Delivery Research and Evaluation, Iowa City), Wu, C (Center for Access & Delivery Research and Evaluation, Iowa City), McCoy, KD (Center for Access & Delivery Research and Evaluation, Iowa City) Sadler, AG (Center for Access & Delivery Research and Evaluation, Iowa City)

Objectives:
Rural Veterans, compared to urban Veterans, have greater reliance on Veterans Health Administration (VHA), are more likely to live in health professional shortage areas, and if they live more than 40 miles from their nearest VHA facility, are eligible to seek care from community providers under the Veterans Choice Program (Choice). Therefore, our objective was to describe rural Veterans' use of outpatient VHA-purchased care (i.e., community care) by Veteran characteristics, health professional shortage areas, and Choice eligibility.

Methods:
We identified VA-enrolled rural Veterans who had used outpatient VHA-provided and/or VHA-purchased community care between Oct. 1, 2015 - March 31, 2017 (1.9 million). Veteran characteristics included living in a Primary Care Health Professional Shortage Area (PC-HPSA) and Choice eligibility (mileage/hardship, wait-time). VHA-purchased care use (Choice and/or Fee) was examined for all care types combined and specifically for primary care.

Results:
Among rural VHA-outpatient users, 23% were Choice mileage-eligible, 88% resided in a PC-HPSA, 39% used VHA-purchased outpatient care. Characteristics associated with greater outpatient VA-purchased care use included sex (women 55%; men 38%), rurality (isolated rural 45%; rural 38%), VA priority (Priorities 1-4: 45%; 6-8: 26%) and mileage-eligibility (yes: 48%; no: 3%). Eight percent used VHA-purchased primary care (5% Fee, 3% Choice, < 1% Fee and Choice). VHA-purchased primary care was greatest among those living in complete PC-HPSAs compared to partial or no primary care HPSAs (28%, 8%, and 7%, respectively) and greatest among those with mileage and wait-time eligibility, compared to mileage only, or no eligibility (14%, 7%, and 8%, respectively). Notably, 87% of those who used VHA-purchased primary care also received primary care at a VHA facility.

Implications:
Rural Veteran VHA-purchased primary care use appears to be driven primarily by wait-time eligibility as this group had the greatest use compared to those with only Choice mileage-eligibility and no mileage-eligibility. Veterans appear to be using VHA-provided and VHA-purchased primary care, not switching to VHA-purchased community care.

Impacts:
Because Veterans who use VHA-purchased primary care are also using VHA-provided primary care, additional research is needed to understand how rural Veterans are making decisions about what care to get where, whether care is redundant/needed, as well as rural Veteran's driving distances for VHA-purchased care.