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. 2023 Mar;38(4):889-897.
doi: 10.1007/s11606-022-07800-1. Epub 2022 Oct 28.

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

Diana J Govier  1   2 , Alex Hickok  1 , Samuel T Edwards  1   3 , Frances M Weaver  4   5 , Howard Gordon  4   6   7 , Meike Niederhausen  1   2   3 , Denise M Hynes  8   9   10
Affiliations

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

Diana J Govier et al. J Gen Intern Med. 2023 Mar.

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.

Keywords: Veterans; care; health; outcomes; primary.

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Conflict of interest statement

Drs. Govier, Hynes, Edwards, Weaver, and Gordon, and Mr. Hickok are VA employees and otherwise have no conflicts of interest to report. Dr. Niederhausen was supported, in part, by a US VA HSR&D Center of Innovation (CIN) grant (CIN 13-404) during the conduct of this study (PI Steve Dobscha).

Figures

Figure 1
Figure 1
Unadjusted mean wait times for community primary care appointments by CCN status and months since CCN implementation (N = 54,358 appointments), overall and by rural/urban status and primary care HPSA status. Notes: The vertical line in each plot delineates the pre- and post-CCN periods. Due to the assignment of CCN contracting dates for comparison sites, comparison sites had a maximum of 3 months of post-CCN period data, whereas CCN sites had a maximum of 5 months of post-CCN period data. Months with unstable mean wait time estimates due to small group-specific cell size (n > 20 appointments) were excluded from plots. Abbreviations: CCN, Community Care Network; HPSA, health professional shortage area.
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References

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