Evaluating the Veterans Choice Program: Lessons for Developing a High-performing Integrated Network

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As the largest integrated health care system in the country, the Veterans Health Administration (VHA) delivers care to >8 million Veterans each year at over 1700 sites of care across all 50 states. In addition to providing services within VHA facilities, VHA provides community care by partnering with federal and private providers, clinics, and hospitals to care for Veterans. In August 2014, Congress enacted the Veterans Access, Choice and Accountability Act (Choice Act), which required VHA to establish the Veterans Choice Program (VCP). The VCP allowed VHA to expand the availability of community care for eligible Veterans and became an additional avenue for VHA to deliver community care. Approximately 23% of all VHA community care appointments are delivered using the VCP.
The VCP has grown exponentially since its inception. Between November 2014 and January 2017, 1,478,039 Veterans have received care through VCP. This represents approximately 17% of all users of VHA care. In addition, the number of VCP appointments has grown from just over a million VCP appointments in 2015 to more than 5.6 million appointments in 2016. Nearly half a million private providers have joined the VCP network since 2014, an increase of 138% since the inception of VCP. Overall, 73% of respondents were either “satisfied” or “very satisfied” with their experience with the VCP, an increase of over 5% between March and September 2016. VHA has made great progress providing Veterans expanded access to health care through VCP and has improved the program since its implementation to better meet the needs of Veterans. However, there is still ample opportunity to improve VCP through needed legislation and removal of the expiration date, which is rapidly approaching.
As one of its 3 core missions alongside clinical care and education, the VHA research program plays a critical role in evaluating Veterans’ health care outcomes, costs, and utilization. In this issue of Medical Care, Kilbourne et al1 describes how VHA’s Quality Enhancement Research Initiative (QUERI), which funds studies that promote more rapid implementation of research into clinical practice, evolved to meet the changing needs of Veterans with the passage of the Choice Act. Notably, QUERI updated its proposal review criteria to ensure its Centers focus on cross-cutting VHA priorities, and promoted the application of implementation strategies to enhance uptake of effective practices. QUERI also increased funding for scientific evaluations of VCP, which will help inform the design and implementation of the next evolution of VCP.
In this supplement, 12 articles highlight some of important findings from early research evaluating VCP implementation. Several articles in this supplement are dedicated to understanding the impact of VCP on specific medical conditions. In a study examining Veterans seeking Hepatitis C virus treatment through VCP, Tsai et al2 found that many Veterans experienced difficulty accessing treatment through the Choice program, due to limited availability of VCP providers and fragmented care coordination between VHA and VCP providers. Similarly, in a retrospective cohort study of Veterans hospitalized for chronic obstructive pulmonary disease at VHA hospitals, Rinne et al3 found that prior use of non-VHA outpatient care was associated with an increased risk of 30-day readmissions for chronic obstructive pulmonary disease, though non-VHA care was not associated with an increased risk of all-cause readmissions.
Several investigators also focused on the use of prescriptions under VCP. Gellad and colleagues found that 5% of prescriptions, but 90% of prescription cost, in the first year of VCP went toward Hepatitis C medications.
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