Early Impact of VA MISSION Act Implementation on Primary Care Appointment Wait Time

Abstract

Background Through Community Care Networks (CCNs) implemented with the VA MISSION Act, VA expanded provider contracting and instituted network adequacy standards for Veterans’ community care. Objective To determine whether early CCN implementation impacted community primary care (PC) appointment wait times overall, and by rural/urban and PC shortage area (HPSA) status. Design Using VA administrative data from February 2019 through February 2020 and a difference-in-differences approach, we compared wait times before and after CCN implementation for appointments scheduled by VA facilities that did (CCN appointments) and did not (comparison appointments) implement CCNs. We ran regression models with all appointments, and stratified by rural/urban and PC HPSA status. All models adjusted for Veteran characteristics and VA facility–level clustering. Appointments 13,720 CCN and 40,638 comparison appointments. Main Measures Wait time, measured as number of days from authorization to use community PC to a Veteran’s first corresponding appointment. Key Results Overall, unadjusted wait times increased by 35.7 days ([34.4, 37.1] 95% CI) after CCN implementation. In adjusted analysis, comparison wait times increased on average 33.7 days ([26.3, 41.2] 95% CI, p < 0.001) after CCN implementation; there was no significant difference for CCN wait times (across-group mean difference: 5.4 days, [−3.8, 14.6] 95% CI, p = 0.25). In stratified analyses, comparison wait time increases ranged from 29.6 days ([20.8, 38.4] 95% CI, p < 0.001) to 42.1 days ([32.9, 51.3] 95% CI, p > 0.001) after CCN implementation, while additional differences for CCN appointments ranged from 13.4 days ([3.5, 23.4] 95% CI, p = 0.008) to −15.1 days ([−30.1, −0.1] 95% CI, p = 0.05) for urban and PC HPSA appointments, respectively. Conclusions After early CCN implementation, community PC wait times increased sharply at VA facilities that did and did not implement CCNs, regardless of rural/urban or PC HPSA status, suggesting community care demand likely overwhelmed VA resources such that CCNs had limited impact.

Racial and Ethnic and Rural Variations in Access to Primary Care for Veterans Following the MISSION Act

“…9,11 Despite the comparatively modest percentage increases in veterans' utilization of VA, the much larger number of veterans using VA vs CC for primary care during the MISSION Act period indicated that reliance on VA for primary care continued to remain strong, mitigating concerns that the MISSION Act would contribute to privatization of VA care. 5,6,9 we found some interesting differences in utilization among race and ethnicity categories. Although Black and Hispanic veterans had higher percentage increases in CC utilization Abbreviation: ARR, adjusted risk ratio.…”

“…[18][19][20][21] Third, as expected, CC unadjusted mean wait times decreased substantially during the MISSION Act period for all veterans; however, CC unadjusted mean wait times remained consistently longer than those in VA, which was similar to findings from other studies and other outpatient care services. 6,12,17 VA and CC unadjusted mean wait times exceeded the 20-day wait time standards established in the MISSION Act. 35 Because primary care plays a key role in providing preventive care and managing and coordinating veterans' health care, 9,10,36 reducing wait times is essential for optimizing veterans' overall health and well-being.…”

“…Although veterans have historically relied on VA for primary care, utilization of CC for primary care steadily increased throughout the Choice Act period (FY 2015-FY 2018). Increases were associated with long delays in obtaining VA primary care, particularly among rural veterans who resided far from their local VA facility and/or who lived in areas with limited clinician supply . Sociodemographic characteristics (eg, Hispanic ethnicity, having additional health insurance, or lower disease burden) were also associated with utilization of CC for primary care .…”

“…Despite this potential benefit, concerns were raised about the unintended consequences of additional outsourcing (eg, fragmenting coordination of care and increasing attrition from VA care). [2][3][4][5][6][7] Although veterans have historically relied on VA for primary care, utilization of CC for primary care steadily increased throughout the Choice Act period (FY 2015-FY 2018. Increases were associated with long delays in obtaining VA primary care, particularly among rural veterans who resided far from their local VA facility and/or who lived in areas with limited clinician supply.…”

“…Although the Choice Act was intended as a short-term policy to address VA’s access crisis, the MISSION Act established a permanent CC program, requiring VA to build a network of CC clinicians to improve care access for veterans. Despite this potential benefit, concerns were raised about the unintended consequences of additional outsourcing (eg, fragmenting coordination of care and increasing attrition from VA care) …”