Reasons Why Women Veterans Leave or Stay in VA Healthcare

HSR&D’s monthly publication Veterans’ Perspectives highlights research conducted by HSR&D and/or QUERI investigators, showcasing the importance of research for Veterans – and the importance of Veterans for research.

In the May-June 2022 Issue:

• Introduction: This issue discusses concerns about the rate of women Veterans’ attrition from VA healthcare.
• The study: This study sought to characterize women Veterans’ decision-making related to leaving or continuing to use VA healthcare.
• Study participants: Participants included women Veterans from ten VA medical centers.
• Findings: Women Veterans discuss their personal experiences using VA healthcare, describing why they left or stayed.
• Implications: This information will help VA understand what motivates women Veterans’ decisions about their use of VA healthcare, which is critical to developing retention strategies.
• Partners: VA partners continue to collaborate on providing optimal care for women Veterans.

Introduction

Women Veterans new to VA are the fastest growing cohort of new VA users, but they remain a minority in VA care (about 8% of patients), which raises concerns about their rate of attrition, i.e., departure from VA. Further, there have been many changes in VA healthcare over the past decade, such as the shift to a patient-centered medical home model, the implementation of comprehensive women’s healthcare policy, and the expansion of VA-paid community-based care.

The study

Led by Alison Hamilton, PhD, MPH and Susan Frayne, MD, MPH – part of HSR&D’s Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP) and Center for Innovation to Implementation (Ci2i),– this study sought to characterize women Veterans’ decision-making related to leaving (attriting) or continuing to use VA, and to explore factors that help retain/attract women to the VA healthcare system. Attrition was defined as having no VA healthcare use (VA outpatient/inpatient or VA-purchased community care) during years two and three following the Veteran’s first 2011 visit (i.e., thru 2014). Semi-structured interviews were conducted with 51 women Veterans from 2017-2018. The qualitative team conducted a targeted analysis related to women’s decision-making, contexts, and recommendations related to healthcare use. Lead author and CSHIIP senior qualitative methodologist Joya G. Chrystal, MSW, LCSW led this foundational analysis of women’s decision-making related to VA use.

Study participants

The qualitative sampling frame was limited to women who had received care at one of ten of VA’s 138 Health Care Systems (HCSs) in the United States: six HCSs from the highest quartile in terms of attrition rate among new women Veterans and four from the lowest. The team drew random stratified samples of women Veterans based on their attrition status, oversampling attriters by a two to one ratio.

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Findings

Fifty-one women Veterans (25 attriters, 26 non-attriters) completed interviews. They described complex reasons why they left or continued using VA healthcare, with cost and affordability playing an important role even in considerations of returning to VA after a long hiatus.

“I go because it's free.”

Care experiences that influenced women’s decisions not to continue using VA care included:

• Strained patient-provider interactions (e.g., feelings of mistrust)

“It should be [about] healthcare making you better, but instead you feel like they don't have time for you and they don't even believe you anyway.”

• Disruptive provider turnover; service-connection compensation/pension claim challenges

“I had a really nice doctor, he was very, very nice, very knowledgeable, which was great, but then he left… And it just seemed like too big of a mountain to climb to have to find somebody and start going through this again.”

• Billing and care coordination disputes regarding VA-purchased care
• Burdensome access (i.e., clinic-initiated appointment cancellations and rescheduling problems)
• Inconvenient appointment times
• Travel distance to the main medical center

Additional results show:

• Personal experiences with VA care were regarded similarly by both attriters and non-attriters and considered greatly influential in their decision to use VA or not.

“VA is more comprehensive and inclusive, and you know, the VA has pretty much most of my medical history.”

“You get to be around more Veterans and you can share stories, things like that. So yeah, I kind of like the atmosphere as far as being around other Veterans.”

• More than one-third of women originally categorized as attriters described subsequently re-entering or planning to re-enter VA care.

“I'm going to continue to use [private care] as long as I can afford to, and I don't know how long that'll be. But right now, the only reason I would go back to the VA is because I couldn't afford my insurance premiums that I'm paying right now.”

• Suggestions to reduce attrition included increasing outreach, improving access, and continuing to tailor care delivery to women Veterans’ needs.

“I think a lot of female Veterans just don't know what's available for them. So, it would be really nice if they had an open house where you can invite [them]— “Yeah, even if you don't think you have benefits, come and visit us and we'll sit down and talk to you,” and make it in a safe environment where they feel like it's okay for them to talk.”

Implications

This information will help VA understand what motivates women Veterans’ decisions about their use of VA healthcare, which is critical for the development of strategies to improve retention of current patients and optimize health outcomes for Veterans.

Partners

Partners and collaborators in this study included VA’s Office of Women’s Health, and the VA HSR&D Women’s Health Practice-Based Research Network (PBRN), which is part of the VA Women’s Health Research Network (WHRN). Since 2010, WHRN has worked to transform VA’s capacity to examine and reduce gender disparities in health and healthcare – and to use research to increase the delivery of evidence-based care tailored to the needs of women Veterans.

* This study was supported by HSR&D (CRE 12-019)

Publication

Chrystal J, Frayne S, Dyer K, et al. Women Veterans' attrition from the VA health care system. Women’s Health Issues. March-April 2022;32(2):182-193.

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