MISSION Act Associated with Higher Risk of Adverse Outcomes Among Veterans Receiving Major Cardiovascular Procedures in Non-VA Facilities
BACKGROUND:
The MISSION Act expanded opportunities for Veterans to obtain care outside VA. However, the impact on healthcare outcomes has been uncertain. This study aimed to measure the MISSION Act's impact on Veterans' travel times and outcomes for major cardiovascular procedures. Investigators examined the outcomes of Veterans who received non-VA care under the MISSION Act (lived >60 minutes from a VAMC, i.e., "far") vs. Veterans who received VA care (lived ≤ 60 minutes from a VAMC, i.e., "near") for non-urgent percutaneous coronary intervention (PCI; n=43,000), coronary artery bypass grafting (CABG; n=23,301), or aortic valve replacement (AVR; n=14,682) between October 2016 and September 2022. The main outcomes were the mean travel time to the procedure, and major adverse cardiovascular events (MACE; defined as cardiovascular-cause rehospitalization or mortality within 30 days of the procedure).
FINDINGS:
- MISSION Act implementation was associated with decreased VA hospital use and travel time among “far” Veterans and increased MACE rates among “far” Veterans receiving PCI or CABG.
- After MISSION Act implementation, mean travel times decreased by 29 minutes for “far” Veterans receiving PCI, 18 minutes for “far” Veterans receiving CABG, and 23 minutes for “far” Veterans receiving AVR.
- After MISSION Act implementation, mean MACE rates increased by 2.3 percentage points for “far” Veterans receiving PCI and by 1.6 percentage points for “far” Veterans receiving CABG. AVR MACE rates increased for both “near” and “far” groups but were not statistically different.
- After MISSION Act implementation, compared to “near” Veterans, “far” Veterans were less likely to choose VA hospitals and more likely to obtain CABG at hospitals with worse quality metrics.
IMPLICATIONS:
- Some “far” Veterans likely unknowingly chose lower-quality non-VA hospitals rather than higher-quality VAMCs where, prior to the MISSION Act, they would have received care. Addressing this critical information gap at the point of hospital choice is essential to optimize decision making and promote better clinical outcomes.
- Rural Veterans may be at greater risk of adverse outcomes both by being far from VAMCs and having fewer high-quality non-VA hospitals from which to choose.
LIMITATIONS:
- It is possible that Veterans who received non-VA care after MISSION Act implementation had unrecorded comorbidities that would have explained their worsened clinical outcomes.
- Comparable data on hospital quality between VA and non-VA hospitals were limited.
AUTHOR/FUNDING INFORMATION:
This study was funded by HSR (IIR 20-270). Drs. Kanter and Groeneveld, and Ms. Wu are with HSR’s Center for Healthcare Evaluation, Research, and Promotion (CHERP). Dr. Wagner is director of HSR’s Health Economics Resource Center (HERC)
Wu J, Kanter GP, Wagner TH, et al., and Groeneveld PW. Impact of the MISSION Act on Quality and Outcomes of Major Cardiovascular Procedures Among Veterans. JAMA. July 31, 2025; online ahead of print.
