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Noteworthy Publications

Veterans Choice Program analyzed


Dr. Walid Gellad is with VA's Center for Health Equity Research and Promotion, and the University of Pittsburgh.
Dr. Walid Gellad is with VA's Center for Health Equity Research and Promotion, and the University of Pittsburgh. (Photo by Glenn Hangard)

Dr. Walid Gellad is with VA's Center for Health Equity Research and Promotion, and the University of Pittsburgh. (Photo by Glenn Hangard)

The Veterans Choice Program, administered by VA, allows Veterans already enrolled in VA health care to get care from non-VA doctors, instead of waiting for a VA appointment or traveling to a VA facility.

Veterans are eligible for this type of care if they have been, or will be, waiting for more than 30 days for VA medical care, or if they live more than 40 miles away from a VA medical care facility or face excessive travel burdens.

In an Aug. 20 editorial in the Journal of General Internal Medicine, Dr. Walid Gellad of the VA Pittsburgh Healthcare System and the University of Pittsburgh reviews the history of the program, which was formally enacted in 2014. Gellad also discusses problems associated with dual care use and care fragmentation, and offers some ideas for ensuring its safe and effective implementation.

Gellad notes that while the effects of any care fragmentation as a result of the Choice Program are not yet known, "prior work has documented convincing evidence that dual use of Medicare and VA services comes with inherent risks related to care fragmentation and duplication of services." These included higher risks of hospitalization for ambulatory care-sensitive conditions, higher cost and worse outcomes in cancer, and higher rates of rehospitalization.

He also mentions that care received outside VA cannot be seamlessly integrated into VA's electronic medical record and can lead to risk of duplication of services, errors, and inefficient care.

To avoid these issues as the Veterans Choice program is implemented, Gellad suggests that the risks of care fragmentation be brought to the fore in any discussions about the program and how it is to be administered.

He also believes that an early, robust, and informed evaluation of the care Veterans receive under the program be conducted in order to understand the nature and extent of care fragmentation under the program. "If the Choice Program increases access without leading to unacceptably frequent duplicative testing, dangerous drug-drug interactions, unsustainable costs, or poorer quality, then the program may be considered a success"—but that these evaluations cannot be rushed "to fit political timelines."

Finally, Gellad recommends VA ensure that medical records from Choice services, including physician visits, imaging tests, and surgical records, be easily accessible to VA physicians who may still be treating those Veterans, or who will be treating them in a few years when authorization for the program ends. "Ultimately," he writes, "if dual healthcare system use is to become the norm within VA, then improving medical data sharing has to become a priority."

The investigator concludes that the rush to improve access does not mean quality can be ignored, and care fragmentation is not compatible with the highest quality care. He suggests that these risks to Veterans' care be "acknowledged and addressed" alongside the benefits of improving access and instituting choice.


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