Dramatic Increase in Veterans' Use of Non-VA Emergency Care

BACKGROUND:
Recent legislation, particularly the MISSION Act of 2018, significantly expanded options for Veterans to receive care in non-VA, or community settings. However, national trends in community emergency department (ED) use by Veterans are unknown. This study used VA data from more than 19 million ED visits during FY2016–2022 to examine national trends in the frequency and types of community ED visits, and to explore the association between VA facilities’ purchase of community care and facility and regional factors. Participants were Veterans who received ED care at VA facilities or ED care paid for by VA in the community. The primary outcome measures included community ED visit volume, reason for visit, disposition, and payments over time.

FINDINGS:

• Of 19,787,056 ED visits from FY2016-22, the majority (73%) occurred at VA facilities.
• The annual number of community ED visits increased 154% from FY2016 to 2022, while the number of unique users of community emergency care increased by 134%. The proportion of all ED visits that occurred in the community progressively increased from 18% in FY2016 to 37% in FY2022.
• Total community care ED payments, adjusted to 2021 dollars, were $1.18 billion in FY2016. By FY2022, VA paid approximately $6.15 billion for community ED care. 
• The most common reasons for community ED visits were chest pain (6%), abdominal pain (3%), and serious bloodstream infection (3%). The costliest conditions treated in community EDs during the study period were septicemia, acute myocardial infarction, and COVID-19. 
• The average proportion of ED visits purchased by a VA facility increased from 14% in FY2016 to 32% by FY2022.
• Low-complexity VA facilities were more likely to purchase community emergency care than their high-complexity counterparts.

IMPLICATIONS:

• Emergency care now encompasses over one-third of the total community care expenditure. This underscores the urgency of addressing the underlying factors contributing to this budgetary surge and seeking solutions for a potentially unsustainable trend.
• The pronounced shift toward community ED care highlights the need for policies that minimize fragmented patient experiences across care settings and navigate the complexities of providing and purchasing community emergency care.

LIMITATIONS:

• This analysis is based on administrative data, which includes the possibility of miscoding, variations in coding, and changing definitions.
• Researchers did not examine Veterans’ outcomes and whether receipt of community care, which may involve care across multiple healthcare systems, has affected outcomes.

AUTHOR/FUNDING INFORMATION:
Drs. Vashi, Urech, and Wu are with HSR’s Center for Innovation to Implementation (Ci2i). Dr. Tran is with HSR’s Health Economics Resource Center (HERC).

Vashi AA, Urech T, Wu S, Tran LD. Community Emergency Care Use by Veterans in an Era of Expanding Choice. JAMA Network Open. March 8, 2024;7(3):e241626.