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Publication Briefs

Potential Problems and Suggested Solutions for VA as Veterans Take Advantage of Dual Use Care via the "Choice Act"

The Veterans Access, Choice and Accountability Act (Choice Act) of 2014 includes a number of provisions to improve care for Veterans, including increasing healthcare staffing. However, the most well-known, and perhaps controversial, provision is the Choice Program, which established a mechanism for eligible Veterans to receive care outside VA for three years. Veterans unable to schedule an appointment within 30 days of their preferred date – or who live more than 40 miles from a VA healthcare facility – are now eligible to receive care from non-VA providers. Many of these Veterans will also continue to use VA services, and this 'dual use' of healthcare systems may lead to care fragmentation that results in adverse consequences. This Commentary describes the problems of dual use and care fragmentation, the complexity of the Choice Program, and offers suggestions for ensuring its safe and effective implementation.


  • The author writes in this commentary that the Presidential Commission on Care, established through the Choice Act, should expand its current mandate to evaluate Veterans' access to healthcare to also include an assessment of fragmentation and quality of care. Moreover, an early, robust, and informed evaluation of healthcare for Veterans under the Choice Program is needed to understand the nature and extent of fragmentation. With the right data, this evaluation can be done in concert with multiple ongoing evaluations of prior insurance expansions that have led to increasing dual use among Veterans (e.g., Medicare Part D).
  • The author also recommends that medical records from Choice services, whether physician visits, imaging tests, surgeries, etc., be easily accessible to VA physicians who may still be treating those Veterans, or who will treat them when authorization for the Choice Program ends. A more effective way to integrate non-VA data for VA providers must be developed, perhaps by requiring laboratory, imaging, and provider notes from outside VA to be embedded with VA data within the electronic medical record, rather than scanned into a separate section.
  • Likewise, VA must broaden its efforts to identify the optimal strategy for sharing VA data with non-VA providers if dual use of care is to become the norm.

Veterans being seen in two different health systems, with different electronic records and different policies and procedures, face risks from dual system healthcare use that should not be ignored. The author notes that one cannot understand the impact of the Choice Program by focusing only on access – one must also look at care fragmentation and quality of care. Moving forward, these risks must be acknowledged and addressed alongside the benefits of improving access and instituting 'Choice.'

Dr. Gellad is part of HSR&D's Center for Health Equity Research & Promotion in Pittsburgh, PA.

PubMed Logo Gellad WF. The Veterans Choice Act and Dual Health System Use. Journal of General Internal Medicine, Commentary. August 20 2015; 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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