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

Authors

Chase S Eck
Cheng Jiang
Laura A Petersen

Publication Date

2-1-2024

Journal

Health Services Research

DOI

10.1111/1475-6773.14241

PMID

37750415

PMCID

PMC10771906

PubMedCentral® Posted Date

9-26-2023

PubMedCentral® Full Text Version

Post-print

Published Open-Access

yes

Keywords

United States, Humans, Veterans Health, Veterans, United States Department of Veterans Affairs, Retrospective Studies, Cross-Sectional Studies, Pandemics, Colonoscopy, access/demand/utilization of services, health policy/politics/law/regulation, health promotion/prevention/screening, VA health care system

Abstract

Objective: To estimate whether those enrolled in the Veterans Health Administration (VHA) were less likely to use VHA-delivered colorectal cancer screening colonoscopies after the MISSION Act.

Data sources and study setting: Secondary data were collected on VHA-enrolled Veterans from FY2017-FY2021.

Study design: This retrospective cross-sectional study measured the volume and share of screening colonoscopies that were VHA-delivered over time and by drive time eligibility-defined as living more than 60 min away from the nearest VHA specialty-care clinic. We used a multivariable logistic regression to adjust for patient and facility factors.

Data extraction: Data were extracted for VHA enrollees (n = 773,766) who underwent a screening colonoscopy either performed or purchased by the VHA from FY2017-FY2021.

Principal findings: In the 9 months after the implementation of the MISSION Act, and before the onset of the Covid-19 pandemic, the average monthly VHA-share of screening colonoscopies decreased by 3 percentage points (pp; 95% confidence interval [CI] = [-4 to -2 pp]) for the non-drive time eligible group and it decreased by 16 pp (95% CI = [-22 to -9 pp]) for the drive time eligible group. The total number of screening colonoscopies did not significantly change in either group during this time period. After adjusting for patient characteristics, a linear time trend, and parent facility fixed effects, implementation of the MISSION Act was associated with a reduction in the probability of a VHA-delivered screening colonoscopy (average marginal effect [AME]: -2.5 pp; 95% CI = [-5.1 to 0.0 pp]) for the non-drive time eligible group. The drive time eligible group (AME: -9.4 pp; 95% CI = [-13.2 to -5.5 pp]) experienced a larger change.

Conclusions: The VHA-share of screening colonoscopies among VHA enrollees fell in the 9 months immediately after the passage of the MISSION Act. This decline was larger for VHA enrollees who were targeted for eligibility due to a longer drive time. These results suggest that the MISSION Act led to more VHA-purchased care among targeted VHA enrollees, though it is unclear whether total utilization increased.