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

Abstract

AbstractObjectiveTo 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 SettingSecondary data were collected on VHA‐enrolled Veterans from FY2017–FY2021.Study DesignThis 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 ExtractionData were extracted for VHA enrollees (n = 773,766) who underwent a screening colonoscopy either performed or purchased by the VHA from FY2017–FY2021.Principal FindingsIn 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.ConclusionsThe 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.