The effects of the Veterans Health Administration's Referral Coordination Initiative on referral patterns and waiting times for specialty care.

OBJECTIVE: To investigate whether the Veterans Health Administration's (VA) 2019 Referral Coordination Initiative (RCI) was associated with changes in the proportion of VA specialty referrals completed by community-based care (CC) providers and mean appointment waiting times for VA and CC providers. DATA SOURCES/STUDY SETTINGS: Monthly facility level VA data for 3,097,366 specialty care referrals for eight high-volume specialties (cardiology, dermatology, gastroenterology, neurology, ophthalmology, orthopedics, physical therapy, and podiatry) from October 1, 2019 to May 30, 2022. STUDY DESIGN: We employed a staggered difference-in-differences approach to evaluate RCI's effects on referral patterns and wait times. Our unit of analysis was facility-month. We dichotomized facilities into high and low RCI use based on the proportion of total referrals for a specialty. We stratified our analysis by specialty and the staffing model that high RCI users adopted: centralized, decentralized, and hybrid. DATA COLLECTION/EXTRACTION METHODS: Administrative data on referrals and waiting times were extracted from the VA's corporate data warehouse. Data on staffing models were provided by the VA's Office of Integrated Veteran Care. PRINCIPAL FINDINGS: We did not reject the null hypotheses that high RCI use do not change CC referral rates or waiting times in any of the care settings for most specialties. For example, high RCI use for physical therapy-the highest volume specialty studied-was associated with -0.054 (95% confidence interval [CI]: -0.114 to 0.006) and 2.0 days (95% CI: -4.8 to 8.8) change in CC referral rate and waiting time at CC providers, respectively, among centralized staffing model adopters. CONCLUSIONS: In the initial years of the RCI program, RCI does not have a measurable effect on waiting times or CC referral rates. Our findings do not support concerns that RCI might be impeding Veterans' access to CC providers. Future evaluations should examine whether RCI facilitates Veterans' ability to receive care in their preferred setting.

Geographic Variation in Appointment Wait Times for US Military Veterans.

Importance: Timely access to medical care is an important determinant of health and well-being. The US Congress passed the Veterans Access, Choice, and Accountability Act in 2014 and the VA MISSION (Maintaining Systems and Strengthening Integrated Outside Networks) Act in 2018, both of which allow veterans to access care from community-based clinicians, but geographic variation in appointment wait times after the passage of these acts have not been studied. Objective: To describe geographic variation in wait times experienced by veterans for primary care, mental health, and other specialties. Design, Setting, and Participants: This is a cross-sectional study using data from the Veterans Health Administration (VHA) Corporate Data Warehouse. Participants include veterans who sought medical care from January 1, 2018, to June 30, 2021. Data analysis was performed from February to June 2022. Exposures: Referral to either VHA or community-based clinicians. Main Outcomes and Measures: Total appointment wait times (in days) for 3 care categories: primary care, mental health, and all other specialties. VHA medical centers are organized into regions called Veterans Integrated Services Networks (VISNs); wait times were aggregated to the VISN level. Results: The final sample included 22 632 918 million appointments for 4 846 892 unique veterans (77.3% male; mean [SD] age, 61.6 [15.5] years). Among non-VHA appointments, mean (SD) VISN-level appointment wait times were 38.9 (8.2) days for primary care, 43.9 (9.0) days for mental health, and 41.9 (5.9) days for all other specialties. Among VHA appointments, mean (SD) VISN-level appointment wait times were 29.0 (5.5) days for primary care, 33.6 (4.6) days for mental health, and 35.4 (2.7) days for all other specialties. There was substantial geographic variation in appointment wait times. Among non-VHA appointments, VISN-level appointment wait times ranged from 25.4 to 52.4 days for primary care, from 29.3 to 65.7 days for mental health, and from 34.7 to 54.8 days for all other specialties. Among VHA appointments, wait times ranged from 22.4 to 43.4 days for primary care, from 24.7 to 42.0 days for mental health, and from 30.3 to 41.9 days for all other specialties. There was a correlation between wait times across care categories and setting (VHA vs community care). Conclusions and Relevance: This cross-sectional study found substantial variation in wait times across care type and geography, and VHA wait times in a majority of VISNs were lower than those for community-based clinicians, even after controlling for differences in specialty mix. These findings suggest that liberalized access to community care under the Veterans Access, Choice, and Accountability Act and the VA MISSION Act may not result in lower wait times within these regions.