2023 HSR&D/QUERI National Conference

1019 — The Impact of the MISSION Act on VA-based and Community Outpatient Care Delivered to Veterans with Type 2 Diabetes

Lead/Presenter: Mark Zocchi
All Authors: Zocchi MS (Center for Healthcare, Organization, and Implementation Research, Bedford & The Heller School, Brandeis University), Adams RS (Boston University School of Public Health & VHA Rocky Mountain Mental Illness Research Education and Clinical Center for Suicide Prevention, Aurora, CO), Charns MP (Center for Healthcare, Organization, and Implementation Research, Boston & Boston University School of Public Health), Hodgkin D (The Heller School, Brandeis University), Vimalananda VG (Center for Healthcare, Organization, and Implementation Research, Bedford & Boston University School of Medicine).

To examine how the Maintaining Internal Systems and Strengthening Integrated Outside Networks Act (MISSION Act) affected use of outpatient services in the Veterans Health Administration (VA) and in the Community Care program (CC) among Veterans with type 2 diabetes. Additionally, to compare characteristics of Veterans with diabetes using CC for the first time under the MISSION Act to those with prior use of CC under the Veterans Choice Program.

A regression analysis was conducted using VA administrative and CC claims data, prior to and immediately following implementation of the MISSION Act (June 2019). Fixed-effect linear regression models at the facility-level were used to compare rates of VA-based and CC diabetes-related outpatient utilization (primary, mental health, specialty, and surgical care) during the first nine months of the MISSION Act to the same months a year prior. In addition, multivariable logistic regression compared demographic, clinical, and geographic characteristics of first-time users of CC under the MISSION Act (N = 71,669) to those with prior use of CC under Choice (N = 400,589).

Following implementation of the MISSION Act, CC outpatient care grew by 16% (95% CI 6% to 25%), while overall use of VA-based outpatient care did not change (95% CI -1% to 4%). Relative to pre-MISSION Act trends, CC mental health care increased by 31%, CC specialty care increased by 18%, and CC surgical care increased by 25%. CC primary care did not change. MISSION Act Veterans in CC were similar demographically and in health status to Choice Act Veterans in CC; however, were more likely to have a drug or alcohol dependence diagnosis (Adjusted Odds Ratio [AOR] = 1.30, 95% CI 1.25 to 1.35), live in highly rural areas (AOR = 2.7, 95% CI 2.2 – 3.2), and live >60 minutes from VA specialty care (AOR = 1.3, 95% CI 1.1 – 1.4).

Among Veterans with type 2 diabetes, the MISSION Act was associated with higher levels of CC outpatient care, but not with changes in VA-based outpatient care. CC mental health care grew the most under the MISSION Act. First-time users of CC under the MISSION Act were more likely to have a drug or alcohol dependence diagnosis than those using CC during the Choice Act. These MISSION Act Veterans also had higher levels of rurality and longer drive times to VA specialty care.

As CC utilization grows under the MISSION Act, the question of whether CC serves as a supplement or substitute for VA-based care will be important to better understand – especially for patients with complex chronic diseases who require coordinated care with numerous outpatient providers. Our analysis shows that the MISSION Act had a significant impact on utilization of CC outpatient services, particularly for mental health care and among Veterans with a drug or alcohol dependence diagnosis. We did not find evidence of changes in utilization of VA-based outpatient services, suggesting CC may be serving to supplement VA-based services. We also found that a larger proportion of MISSION Act Veterans were from highly rural areas, who may face additional care coordination challenges.