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Publication Briefs

Study Suggests Expanded Provider Options are Associated with Increased Healthcare Utilization among Veterans

Narrow health insurance networks have been offered as a source of potential savings for runaway healthcare costs in the US. When faced with an option to join a narrow network with lower premiums, however, many individuals are willing to pay higher premiums to maintain continuity with their provider. Research has focused on estimating the effect of narrowing networks, but examining expansions also can tell us about the impacts of insurance network changes on an individual’s healthcare decisions and outcomes. This study sought to determine the association of expanded healthcare options with Veterans’ healthcare choices and outcomes, particularly as they relate to the introduction of the Choice Act (2014), which expanded coverage to more Veterans for non-VA care. Thus, investigators compared healthcare use and mortality for Veterans eligible for the Choice Act to those who were not eligible, including more than 2.7 million VA enrollees between 2015 and 2018, who lived between 20-60 miles from a VA facility. Healthcare utilization was examined separately by outpatient and inpatient visits. Using VA data, investigators also assessed patient demographics and mortality.


  • Expanding provider options among more than 2.7 million Veterans with VA care was associated with higher outpatient use, as well as increased lab visits, prescriptions, and psychotherapy visits.
  • Outpatient use was 3% higher among Veterans with an expanded provider network. Lab testing also increased by 3%, while medications only increased by 1%. In contrast, individual and group psychotherapy increased substantially, with an 8% increase overall and an 8% increase for Veterans with more comorbidities.
  • Increased outpatient use was most concentrated among Veterans with more service-connected disabilities – and among younger Veterans without service-connected disabilities.
  • There was no evidence of changes to inpatient use or mortality.


  • Findings suggest that larger provider networks are associated with more intensive healthcare use by affected patients. Therefore, without larger budgets VA may struggle to sustain its current internal infrastructure while also providing more community care. This is especially pressing given that the MISSION Act (2019) further expanded access to community care.


  • Investigators could not elicit the exact reasons VA patients decided to use community care nor could they determine the medical necessity for visits.

This study was funded by HSR&D (IIR 19-421), and Dr. Wagner is supported by an HSR&D Research Career Scientist Award. Drs. Rose, Graham, Schoemaker, and Wagner (Director) are part of HSR&D’s Health Economics Resource Center (HERC), Palo Alto, CA.

Rose L, Aouad M, Graham L, Schoemaker L, and Wagner T. Association of Expanded Health Care Networks with Utilization among Veterans Affairs Enrollees. JAMA Network Open. October 26, 2021;4(10):e2131141.

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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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