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Publication Briefs

Use of Community Outpatient Providers During the Choice Program was Associated with Less Attrition from VA Care

Despite considerable evidence that VA healthcare quality is comparable to privately run systems, there has been a greater move toward privatizing care so that Veterans rely more on private healthcare providers. This has been mainly due to concerns about timely access to care. In late 2014, VA began implementing the Veterans’ Choice Program to reduce access barriers by increasing the provision of care from community providers paid for by VA. This study examined the characteristics of patients and practices that used Choice outpatient care in the first year of implementation – and whether using Choice outpatient care was associated with attrition from VA primary care over a two-year period. Investigators analyzed data on a national cohort of non-elderly (younger than age 65) Veterans, with at least one chronic condition, who used VA primary care in one of 858 practices at baseline in FY2015, the first full year of Choice program implementation. Using VA administrative data, investigators assessed patient sociodemographics, healthcare use, and costs. Distance from VA primary care providers, rurality, and geographic region also were examined, as well as waiting time for new patient appointments. In this study cohort, 93,710 (7%) patients used some Choice outpatient care while 1,346,780 (93%) patients used only VA outpatient care during FY2015.


  • Overall, the attrition rate from VA primary care was low (4.4%), and Veterans who used Choice outpatient care were less likely to leave VA primary care than VA-only users.
  • Compared to Veterans who used only VA outpatient care, those using Choice care were more likely to be female, white or Hispanic, to live in the Continental or Pacific region, to have a higher service-connected disability rating, to have longer driving distances to all VA care, to not have a mental health condition, and to have greater primary care and total healthcare costs at baseline.
  • Practices that sent more patients out for Choice care had lower mean scores for patient-centered medical home implementation, especially regarding access, and longer mean waiting times for appointments.


  • Findings suggest that the use of community care more often supplements rather than replaces VA primary care, especially for practices that experience more difficulty in providing timely patient-centered primary care. However, because eligibility for community care has expanded since the Choice Program, it is important to continue to track Veterans' attrition from VA primary care.


  • This study examined attrition from VA primary care after the Choice program was implemented but did not look at trends in attrition prior to the Choice program in order to compare these rates.
  • The study did not control for potential confounders such as variation in site adoption of Choice Act referral processes.

Dr. Yoon is part of HSR&D’s Health Economics Resource Center (HERC), VA Palo Alto Health Care System, and Dr. Leung is part of HSR&D’s Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), Los Angeles, CA.

Yoon J, Leung L, Rubenstein L, et al. Use of the Veterans’ Choice Program and Attrition from Veterans Health Administration Primary Care. Medical Care. September 10, 2020; Epub ahead of print.

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What are HSR Publication Briefs?

HSR requires notification by HSR-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR published articles. Visit the HSR citations database for a complete listing of HSR articles and presentations.

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