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FORUM - Translating research into quality health care for Veterans

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Director's Letter

David Atkins, MD, MPH, Director, HSR&D

It has been more than a decade since scandals over wait times in Phoenix (and more specifically, manipulation of wait time data) triggered a cascade of consequences that included the departure of a VA Secretary and Under Secretary for Health, and Congressional legislation allowing certain groups of Veterans to get care in the community at VA expense. The costs of providing community care under the Choice Act and then the MISSION Act have far exceeded what Congress anticipated, largely because providing community care for some Veterans had few offsetting savings within VA. A decade into this experiment, many questions remain about the challenges and tradeoffs involved in allowing Veterans more choice of providers. As indicated in this issue, HSR&D researchers have contributed a lot to answering those questions. While it is safe to say that some element of choice is here to stay in VA healthcare, several factors have influenced the debate over the right balance. First, research has documented many challenges in coordinating care in and outside VA, and possible quality concerns (e.g., Medical Care, 2021; Rose, 2021; Vashi, 2021; Vanneman, 2022). Second, VA leadership is worried that excessive referrals to community care can undermine remaining VA services. Third, the high and growing costs of community care are unsustainable. Finally, the increasing availability of virtual care provides options for Veterans who are far from the nearest VA clinic and, through new clinical resource hubs, for those who face long wait times for certain services.

Determining the right mix of VA and non-VA care will require answering a variety of questions, only some of which are clinical. How well can we determine the quality of clinicians in community networks? What is a reasonable standard for wait times for different services? How do Veterans feel about their experiences with community care? And when can virtual VA care meet their needs while preserving the advantages of continuity within a system of care? It has been gratifying to see how quickly our researchers responded to this major shift in VA care with important, influential research. They will have no shortage of work for the next decade.

David Atkins, MD, MPH, Director, HSR&D


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