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

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. St...

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Published in:Health services research 2024-02, Vol.59 (1), p.e14241-n/a
Main Authors: Eck, Chase S., Jiang, Cheng, Petersen, Laura A.
Format: Article
Language:English
Subjects:
access/demand/utilization of services
Beliefs, opinions and attitudes
Cancer
Cancer screening
Change agents
Colonoscopy
Colorectal cancer
Colorectal carcinoma
Confidence intervals
COVID-19
Cross-Sectional Studies
Diagnosis
Extraction
health policy/politics/law/regulation
health promotion/prevention/screening
Humans
Medical screening
Methods
Military hospitals
Oncology, Experimental
Pandemics
Patients
Retrospective Studies
Statistical analysis
United States
United States Department of Veterans Affairs
VA health care system
Veterans
Veterans Health
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Summary: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.
ISSN:0017-9124
1475-6773
DOI:10.1111/1475-6773.14241