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Research Highlight

Our results demonstrated that understanding the impact of Choice providers requires a specialty specific understanding of network adequacy.

In response to concerns about inadequate access to health care services for Veterans, Congress passed the Veterans Access, Choice and Accountability Act (Choice) of 2014, thereby expanding VA health care networks with the addition of community care providers. This expansion affected rural Veterans especially, since 97 percent of U.S. rural counties lack a VA medical facility.1 In this article, we review the results of a recently completed operations evaluation of approved Choice providers and discuss how VA can optimize future health care network expansion.

The key dimensions of an adequate health care network are wait times to see the provider, travel distance to the provider, and specialty of the provider. An adequate health care network must have the appropriate specialist within a reasonable drive distance from a Veteran's home with availability in a reasonable time frame. For example, if a Veteran lives 10 miles away from a VA medical center, but the wait time for an appointment is 35 days, the network is inadequate. If a Veteran lives 15 miles from a clinic offering primary care, but 100 miles away from a VA cardiologist, the network is inadequate. Optimizing network adequacy therefore requires recognizing the distribution of resources across wait time, location, and specialty.

Evaluating the Impact of Initial Choice Providers

The Choice Act sought to increase Veterans' access to health care by adding community care providers to the VA health care network. Community care providers have the potential to positively impact VA health care network adequacy if they are located in geographic areas where there are inadequate VA resources. Therefore, we sought to assess the impact of approved Choice providers on VA network adequacy by identifying what proportion of these providers were located in areas of low VA network adequacy.

We examined primary care and cardiology Choice providers in a primarily rural network (VISN 19) and a primarily urban network (VISN 10). We identified 3,362 unique Choice provider practice locations as of September 1, 2015. We performed a provider-level analysis by assessing if each Choice provider was located outside of existing service areas (i.e., an area of low network adequacy). We implemented two definitions for low network adequacy areas. Consistent with the Choice Act, we first defined network adequacy areas by generating 40 mile drive-time service areas around all VA clinics and medical centers. We next identified which clinics and medical centers had active cardiology and primary care clinics based on completed appointments data. We then generated 40 mile service areas around the sites with active primary care and cardiology clinics. For each Choice provider, we then examined two possible results. First, is this Choice provider located within 40 miles driving distance of an existing VA clinic? Second, is this Choice provider located within 40 miles driving distance of a VA clinic with the same specialty available?

In VISN 10, an urban network, we found that the first definition of network adequacy based on the 40 mile service area of all VA sites essentially covered the entire geographic space in the VISN. Therefore, very few Choice providers were located outside of existing service areas (1 percent of primary care and none of the cardiology Choice providers). However, when we changed the definition of service areas to be specific to VA sites with cardiologists, we found that 36 percent of the cardiology Choice community providers were located outside of existing service areas.

In VISN 19, a rural network, results were substantially different. After applying the first definition of network adequacy based on the 40 mile service areas of all VA sites, a large amount of geographic space was located outside of the service areas. Despite this, we found only 15 percent of primary care and 9 percent of cardiology Choice providers were located outside of existing service areas. After applying the second definition using only VA sites with cardiologists to generate service areas, we found that 56 percent of the cardiology Choice providers were located outside of existing service areas.

Optimizing Future Community Care Networks

Our results demonstrated that understanding the impact of Choice providers requires a specialty specific understanding of network adequacy. As VA continues to commit resources to the growth of community care networks, optimizing the allocation of these resources is critical. The highest value of external care providers will be those located where the current VA network has low adequacy. A Veteran-level, geospatial analysis using current data on clinic activity and wait times will allow VA to identify locations of low network adequacy. In many rural areas, locations of low VA network adequacy may also be health care shortage areas. These rural areas can be targeted for technologybased health care program expansion. Optimizing internal VA care, community care, and technology-based care is vital to meeting the future health care needs of rural Veterans.

  1. Doyle JM, Streeter RA. "Veterans' Location in Health Professional Shortage Areas: Implications for Access to Care and Workforce Supply," Health Services Research 2017; 52 Suppl 1:459-80.

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