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Open Access 09-05-2024 | Original Research

Growth of Community Outpatient Care in the Veterans Affairs System After the MISSION Act

Authors: Jean Yoon, PhD, MHS, Kritee Gujral, PhD, Clara Dismuke-Greer, PhD, Jennifer Y. Scott, MS, Hao Jiang, MS

Published in: Journal of General Internal Medicine

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Abstract

Background

The Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act of 2018 authorized a major expansion of purchased care in the community for Veterans experiencing access barriers in the Veterans Affairs (VA) health care system.

Objective

To estimate changes in primary care, mental health, and emergency/urgent care visits in the VA and community fiscal years (FY) 2018–2021 and differences between rural and urban clinics.

Design

A national, longitudinal study of VA clinics and outpatient utilization. Clinic-level analysis was conducted to estimate changes in number and proportion of clinic visits provided in the community associated with the MISSION Act adjusting for clinic characteristics and underlying time trends.

Participants

In total, 1050 VA clinics and 6.6 million Veterans assigned to primary care.

Main Measures

Number of primary care, mental health, and emergency/urgent care visits provided in the VA and community and the proportion provided in the community.

Key Results

Nationally, community primary care visits increased by 107% (50,611 to 104,923), community mental health visits increased by 167% (100,701 to 268,976), and community emergency/urgent care visits increased by 129% (142,262 to 325,407) from the first quarter of 2018 to last quarter of 2021. In adjusted analysis, after MISSION Act implementation, there was an increase in community visits as a proportion of total clinic visits for emergency/urgent care and mental health but not primary care. Rural clinics had larger increases in the proportion of community visits for primary care and emergency/urgent care than urban clinics.

Conclusions

After the MISSION Act, more outpatient care shifted to the community for emergency/urgent care and mental health care but not primary care. Community care utilization increased more in rural compared to urban clinics for primary care and emergency/urgent care. These findings highlight the challenges and importance of maintaining provider networks in rural areas to ensure access to care.
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Literature
1.
go back to reference Shiner B, Gottlieb D, Rice K, Forehand JA, Snitkin M, Watts BV. Evaluating policies to improve access to mental health services in rural areas. J Rural Health. 2022;38(4):805-816.CrossRefPubMed Shiner B, Gottlieb D, Rice K, Forehand JA, Snitkin M, Watts BV. Evaluating policies to improve access to mental health services in rural areas. J Rural Health. 2022;38(4):805-816.CrossRefPubMed
2.
go back to reference Vanneman ME, Rosen AK, Wagner TH, et al. Differences between VHA-delivered and VHA-purchased behavioral health care in service and patient characteristics. Psychiatr Serv. 2023;74(2):148-157.CrossRefPubMed Vanneman ME, Rosen AK, Wagner TH, et al. Differences between VHA-delivered and VHA-purchased behavioral health care in service and patient characteristics. Psychiatr Serv. 2023;74(2):148-157.CrossRefPubMed
3.
go back to reference Rose L, Aouad M, Graham L, Schoemaker L, Wagner T. Association of expanded health care networks with utilization among Veterans Affairs enrollees. JAMA Netw Open. 2021;4(10):e2131141-e2131141.CrossRefPubMedPubMedCentral Rose L, Aouad M, Graham L, Schoemaker L, Wagner T. Association of expanded health care networks with utilization among Veterans Affairs enrollees. JAMA Netw Open. 2021;4(10):e2131141-e2131141.CrossRefPubMedPubMedCentral
4.
go back to reference Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act, Pub. L. No. 115–182, 132 Stat 1393. 2018. Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act, Pub. L. No. 115–182, 132 Stat 1393. 2018.
5.
go back to reference Whaley CM, Pera MF, Cantor J, et al. Changes in health services use among commercially insured US populations during the COVID-19 pandemic. JAMA Netw Open. 2020;3(11):e2024984-e2024984.CrossRefPubMedPubMedCentral Whaley CM, Pera MF, Cantor J, et al. Changes in health services use among commercially insured US populations during the COVID-19 pandemic. JAMA Netw Open. 2020;3(11):e2024984-e2024984.CrossRefPubMedPubMedCentral
6.
go back to reference Eck CS, Jiang C, Petersen LA. Veterans Health Administration enrollees' choice of care setting relates to the expansion of care options: Evidence from screening colonoscopies before and after the MISSION Act. Health Serv Res. 2024;59(1):e14241.CrossRefPubMed Eck CS, Jiang C, Petersen LA. Veterans Health Administration enrollees' choice of care setting relates to the expansion of care options: Evidence from screening colonoscopies before and after the MISSION Act. Health Serv Res. 2024;59(1):e14241.CrossRefPubMed
7.
8.
go back to reference Vashi AA, Urech T, Wu S, et al. Community urgent care use following implementation of the veterans affairs maintaining internal systems and strengthening integrated outside networks act. Medical Care. 2021;59:S314-S321.CrossRefPubMedPubMedCentral Vashi AA, Urech T, Wu S, et al. Community urgent care use following implementation of the veterans affairs maintaining internal systems and strengthening integrated outside networks act. Medical Care. 2021;59:S314-S321.CrossRefPubMedPubMedCentral
10.
go back to reference Ohl ME, Carrell M, Thurman A, et al. Availability of healthcare providers for rural veterans eligible for purchased care under the veterans choice act. BMC Health Serv Res. 2018;18(1):1-7.CrossRef Ohl ME, Carrell M, Thurman A, et al. Availability of healthcare providers for rural veterans eligible for purchased care under the veterans choice act. BMC Health Serv Res. 2018;18(1):1-7.CrossRef
13.
go back to reference Heyworth L, Kirsh S, Zulman D, Ferguson JM, Kizer KW. Expanding access through virtual care: The VA’s early experience with Covid-19. NEJM Catal Innov Care Deliv. 2020;1(4) Heyworth L, Kirsh S, Zulman D, Ferguson JM, Kizer KW. Expanding access through virtual care: The VA’s early experience with Covid-19. NEJM Catal Innov Care Deliv. 2020;1(4)
14.
go back to reference Burgess Jr JF, Maciejewski ML, Bryson CL, et al. Importance of health system context for evaluating utilization patterns across systems. Health Econ. 2011;20(2):239-251.CrossRefPubMed Burgess Jr JF, Maciejewski ML, Bryson CL, et al. Importance of health system context for evaluating utilization patterns across systems. Health Econ. 2011;20(2):239-251.CrossRefPubMed
15.
go back to reference Gordon SH, Beilstein-Wedel E, Rosen AK, et al. County-level predictors of growth in community-based primary care use among veterans. Medical Care. 2021;59(6 Suppl 3):S301.CrossRefPubMedPubMedCentral Gordon SH, Beilstein-Wedel E, Rosen AK, et al. County-level predictors of growth in community-based primary care use among veterans. Medical Care. 2021;59(6 Suppl 3):S301.CrossRefPubMedPubMedCentral
16.
go back to reference Fortney JC, Maciejewski ML, Warren JJ, Burgess Jr JF. Does improving geographic access to VA primary care services impact patients' patterns of utilization and costs? Inquiry. 2005;42(1):29-42.CrossRefPubMed Fortney JC, Maciejewski ML, Warren JJ, Burgess Jr JF. Does improving geographic access to VA primary care services impact patients' patterns of utilization and costs? Inquiry. 2005;42(1):29-42.CrossRefPubMed
17.
go back to reference Gao J, Moran E, Woolhandler S, Toporek A, Wilper AP, Himmelstein DU. Primary Care’s Effects on Costs in the US Veterans Health Administration, 2016–2019: an Observational Cohort Study. J Gen Intern Med. 37, 3289–3294 (2022). Gao J, Moran E, Woolhandler S, Toporek A, Wilper AP, Himmelstein DU. Primary Care’s Effects on Costs in the US Veterans Health Administration, 2016–2019: an Observational Cohort Study. J Gen Intern Med. 37, 3289–3294 (2022).
18.
go back to reference Yano EM, Simon BF, Lanto AB, Rubenstein LV. The evolution of changes in primary care delivery underlying the Veterans Health Administration’s quality transformation. Am J Public Health. 2007;97(12):2151-2159.CrossRefPubMedPubMedCentral Yano EM, Simon BF, Lanto AB, Rubenstein LV. The evolution of changes in primary care delivery underlying the Veterans Health Administration’s quality transformation. Am J Public Health. 2007;97(12):2151-2159.CrossRefPubMedPubMedCentral
19.
go back to reference Gujral K, Scott JY, Dismuke-Greer CE, Jiang H, Wong E, Yoon J. The Clinical Resource Hub telehealth program and use of primary care, emergency, and inpatient care during the COVID-19 Pandemic. J Gen Intern Med. (Suppl 1), 118–126 (2024). Gujral K, Scott JY, Dismuke-Greer CE, Jiang H, Wong E, Yoon J. The Clinical Resource Hub telehealth program and use of primary care, emergency, and inpatient care during the COVID-19 Pandemic. J Gen Intern Med. (Suppl 1), 118–126 (2024).
20.
go back to reference Burnett K, Stockdale SE, Yoon J, et al. The Clinical Resource Hub initiative: first-year implementation of the veterans health administration regional telehealth contingency staffing program. J Ambul Care Manag. 2023;46(3):228-239.CrossRef Burnett K, Stockdale SE, Yoon J, et al. The Clinical Resource Hub initiative: first-year implementation of the veterans health administration regional telehealth contingency staffing program. J Ambul Care Manag. 2023;46(3):228-239.CrossRef
Metadata
Title
Growth of Community Outpatient Care in the Veterans Affairs System After the MISSION Act
Authors
Jean Yoon, PhD, MHS
Kritee Gujral, PhD
Clara Dismuke-Greer, PhD
Jennifer Y. Scott, MS
Hao Jiang, MS
Publication date
09-05-2024
Publisher
Springer International Publishing
Published in
Journal of General Internal Medicine
Print ISSN: 0884-8734
Electronic ISSN: 1525-1497
DOI
https://doi.org/10.1007/s11606-024-08787-7
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