Abstract

Background: The VA Maintaining Systems and Strengthening Integrated Outside Networks (MISSION) Act of 2018 increased Veterans’ ability to seek care in their communities, at VA expense, if they meet certain appointment wait or drive time criteria. Since the MISSION Act was implemented, millions of Veterans have been authorized to receive community care. Critically, no research has examined the frequency or costs of referrals to community care where Veterans experienced worse access compared to the VA system. As a VA health services researcher with substantial experience developing measures of Veterans’ access to care, I am uniquely well-positioned to conduct this research. This proposal will provide key trainings in qualitative and mixed research methods, VA cost data, and user experience design. These experiences will directly support my goal of becoming an independent mixed-methods HSR&D investigator with expertise in comparative analyses of VA versus community care and interventions to improve Veterans’ access to care. Significance/Impact: The number of Veterans receiving community care and associated costs have grown considerably over time. The community care program is expected to consume $41 billion in FY2025, nearly half of the VA’s budget for direct medical care. It is crucial to determine the proportion of community care referrals and related spending that fail to enhance access to care. I will also develop a novel informational intervention that encourages Veterans to seek care in the setting that maximizes timeliness of care. Our research will inform VA clinicians and Veterans as they engage in shared decision-making about whether to remain in the VA system or seek a referral to community care. Innovation: To our knowledge, there has been no published research that examines how often Veterans would have experienced better access to care if they had remained in the VA system versus community care. We will estimate the financial costs of referrals to community care that did not result in improved access for Veterans, focusing on five high-volume specialties. We will also be the first to develop and pilot an informational intervention that presents Veterans with comparative wait and drive time estimates for both VA and community care specialists, supporting Veteran autonomy and informed decision-making. Specific Aims: Aim 1) Estimate the frequency & costs of referrals to community-based specialists that did not improve Veterans’ access to care. Aim 2) Evaluate the validity of our wait & drive time estimates using chart review and Veteran satisfaction surveys. Aim 3) Implement and pilot an informational intervention providing estimated wait and drive times for referrals to community-based specialists. Methodology: In Aim 1, I will use coarsened exact matching to examine differences in wait/drive times for Veterans referred to VA or community specialists in five high-volume specialties: ophthalmology, orthopedics, urology, gastroenterology, and cardiology. For Veterans referred due to excessive drive times, drive times will be compared from their home addresses to the nearest VA medical center offering each specialty and their chosen community care provider. In Aim 2, I will conduct chart reviews and retrospective analyses to validate my estimated wait and drive times and associate them with Veteran perceptions of healthcare access. In Aim 3, I will develop and pilot an informational intervention to inform Veterans of estimated wait/drive times for VA and community care specialists and assess its effects on access, referral patterns, and satisfaction. Next Steps/Implementation: These proposed aims will inform the ongoing debate regarding the MISSION Act’s effectiveness in improving specialty care access and develop a novel intervention that could enable Veterans and clinicians to make informed choices regarding whether to seek care within the VA or community. This CDA will prepare me with the appropriate training and necessary data to submit IIRs to assess the effects of VA community care network breadth on care access and a nationwide trial of my informational intervention.

NIH Reporter Project Information: https://reporter.nih.gov/project-details/11243454


PUBLICATIONS:
None at this time.