Concerns about veterans getting access to quality healthcare in a timely fashion led to the Veterans Choice Act in 2014 followed by the VA MISSION Act in 2019. These programs provide veterans with the opportunity to receive healthcare in the community that is paid for by the Veterans Health Administration (VHA).
The initial Veterans Choice Act was available to veterans if they lived more than 40 miles from a VA facility or could not be scheduled for an appointment within the VHA wait time goals (usually less than 30 days). The MISSION Act expanded eligibility criteria to include:
- Service not available at a VA, or veteran lives in a state without a full-service VA
- Drive time: >30 minutes for primary care; >60 minutes for specialty care; >40 miles to a VA providing specified care
- Appointment wait time: >20 days for primary care; >28 days for specialty care
- Community care in the veteran’s best medical interest as determined by patient and clinician
- Quality of care provided by the VA for the veteran’s specific condition fails to meet its own quality standards
Even before the expansion of services triggered by the MISSION Act, the VA provided non-VA, community-based healthcare for more than 25% of veterans. The 2022 VHA budget requested $23 billion in discretionary funding for community care that represents an increase of 26.5% from the 2021 budget and makes up nearly one-fourth of the total medical care appropriations. In 2021, the more than 4.75 million veterans received community care referrals, of which approximately 34,000 (less than 1%) were referred for vascular surgery care. The most common reason for vascular surgery referrals was distance (50%) followed by unavailable service (33%).
The MISSION Act aims to provide veterans with timely access to high-quality healthcare that is geographically accessible. However, meeting these ambitious goals may require a more nuanced solution than simply increasing referrals to community care providers. Challenges include how to evaluate the outcomes of community services, helping veterans make informed decisions about community care, maintaining open communication between the community and the VA, evaluating the cost effectiveness of community services, and determining when geographic proximity increases quality. Recognizing and addressing each of these areas will be important in the future success of VA-sponsored community care.
For many veterans, travel to a large VA medical center represents a hardship, and the MISSION Act attempts to address this by allowing for community care that is geographically closer. However, community care, regardless of its convenience, does not always translate into faster or better-quality service. Remote areas rarely offer surgical specialty care, and veterans requiring these services may be best served by staying within the VA.
Quality studies comparing the VA and community services have shown that the VA has the same or lower rates of surgical morbidity and mortality compared to the general community. Wait times for specialty care also may not be uniformly shorter in the community compared to the VA. Ensuring that veterans benefit from the MISSION Act will require close evaluation and monitoring of the availability and timeliness of community services.
To achieve the goals set by the MISSION Act, veterans and their VA caregivers will have to make informed decisions regarding community care. Ideally, quality metrics from the community and the VA will be available for comparison so the veteran can make an informed choice. The access and sharing of these quality measures requires active participation by the VA. Raising awareness of the VA’s quality measures and performance among veterans and VA providers represents half of this equation. The other half should focus on setting up incentives for community health systems to track and share quality measures with VA providers and patients.
The VA’s healthcare system centralizes patient data and facilitates communication between VA providers. This system promotes quality care and reduces cost by decreasing the risk of duplicated therapy and coordinating care programs for veterans with medical and mental health concerns.
As community care expands, the VA will need to develop an effective communication system in order to promote sharing information between the VA, community providers, and veterans. Opening and maintaining these communication channels will foster efficient care, and possibly lead to a comparative evaluation of community and VA outcomes and patient experience.
Telehealth may allow the VA to provide more timely and efficient care by meeting veterans where they are. In addition to routine follow-up appointments, which can occur in the veterans’ home, telehealth can also support more detailed, specialty-specific evaluations. Telehealth visits conducted in community-based outpatient centers (CBOCs), or local wound clinics, can employ licensed nursing staff to perform a basic vascular exam. These telehealth encounters shorten wait times and eliminate the barrier of long travel distances. Maximizing the use of telehealth could help decrease the number of community care referrals placed for “distance.” An expanded role for telehealth will also bring new challenges unique to a technology-reliant healthcare system. Rural areas often lack broadband availability to support telehealth encounters. Ensuring that veterans have access and technologic support will play a role in determining how much telehealth can provide for more timely and convenient care.
Non-VA providers play an extremely important but potentially overlooked role in the VA’s community care program. The rapid increase in community care requests triggered by the MISSION Act has undoubtedly taxed the entire referral system. Non-VA providers who have the expertise and capacity to care for referred veterans often experience difficulty in gathering information from the VA and in getting authorizations for follow-up visits.
Bureaucratic inefficiencies and delays in receiving compensation can discourage non-VA providers from accepting future referrals. Long-term success for the MISSION Act hinges on the VA’s effort to engage non- VA providers. Creating a user-friendly referral system that maintains continuity of care and provides prompt and appropriate compensation for non-VA providers will help foster a network of high-quality care. The VA stands alone as an effective and committed provider for the nation’s largest integrated healthcare system. With the MISSION Act, the VA steps into a more prominent role as a healthcare payor. Ensuring that veterans continue to receive timely and high-quality care will require sustained cooperation and coordination between the VA and community providers.
Efforts that promote sharing and comparing quality measures, open communication, cost containment, and the innovative use of telehealth, will be be central to ensuring that community care plays a vital role within the VA health system.
References
- Kullgren JT, Fagerlin A, Kerr EA. Completing the MISSION: A blueprint for helping veterans make the most of new choices. J Gen Intern Med 2019;35:1567-70.
- Massarweh NN, Itani KM, Morris MS. The VA MISSION Act and the future of veterans’ access to quality healthcare. JAMA 2020;324:343-4.
- Schlosser J, Kollisch D, Johnson D, Perkins T, Olson A. VA-Community dual care: Veteran and clinician perspectives. J Community Health 2020;45:795-802.
- Stroupe KT, Martinez R, Hogan TP, Gordon EJ, Gonzalez B, Kale I, Osteen C, Tarlov E, Weaver FM, Hynes, DM, Smith BM. Experiences with the Veterans’ Choice Program. J Gen Intern Med 2019;34:2141-9.
Michael Costanza, MD, and Vivienne Halpern, MD, are members of the SVS VA Vascular Surgeons Committee.
