Implications of Cross-System Use Among US Veterans With Advanced Kidney Disease in the Era of the MISSION Act: A Qualitative Study of Health Care Records.

Journal Article (Journal Article)

IMPORTANCE: Since 2014, when Congress passed the Veterans Access Choice and Accountability (Choice) Act (replaced in 2018 with the more comprehensive Maintaining Internal Systems and Strengthening Integrated Outside Networks [MISSION] Act), the Department of Veterans Affairs (VA) has been paying for US veterans to receive increasing amounts of care in the private sector (non-VA care or VA community care). However, little is known about the implications of these legislative changes for the VA system. OBJECTIVE: To describe the implications for the VA system of recent increases in VA-financed non-VA care. DESIGN, SETTING, AND PARTICIPANTS: This qualitative study was a thematic analysis of documentation in the electronic health records (EHRs) of a random sample of US veterans with advanced kidney disease between June 6, 2019, and February 5, 2021. EXPOSURES: Mentions of community care in participant EHRs. MAIN OUTCOMES AND MEASURES: Dominant themes pertaining to VA-financed non-VA care. RESULTS: Among 1000 study participants, the mean (SD) age was 73.8 (11.4) years, and 957 participants (95.7%) were male. Three interrelated themes pertaining to VA-financed non-VA care emerged from qualitative analysis of documentation in cohort member EHRs: (1) VA as mothership, which describes extensive care coordination by VA staff members and clinicians to facilitate care outside the VA and the tendency of veterans and their non-VA clinicians to rely on the VA to fill gaps in this care; (2) hidden work of veterans, which describes the efforts of veterans and their family members to navigate the referral process, and to serve as intermediaries between VA and non-VA clinicians; and (3) strain on the VA system, which describes a challenging referral process and the ways in which cross-system care has stretched the traditional roles of VA staff and clinicians and interfered with VA care processes. CONCLUSIONS AND RELEVANCE: The findings of this qualitative study describing VA-financed non-VA care for veterans with advanced kidney disease spotlight the substantial challenges of cross-system use and the strain placed on the VA system, VA staff and clinicians, and veterans and their families in recent years. These difficult-to-measure consequences of cross-system care should be considered when budgeting, evaluating, and planning the provision of VA-financed non-VA care in the private sector.

Full Text

Duke Authors

Cited Authors

  • O'Hare, AM; Butler, CR; Laundry, RJ; Showalter, W; Todd-Stenberg, J; Green, P; Hebert, PL; Wang, V; Taylor, JS; Van Eijk, M; Matthews, KL; Crowley, ST; Carey, E

Published Date

  • July 1, 2022

Published In

Volume / Issue

  • 182 / 7

Start / End Page

  • 710 - 719

PubMed ID

  • 35576068

Pubmed Central ID

  • PMC9112136

Electronic International Standard Serial Number (EISSN)

  • 2168-6114

Digital Object Identifier (DOI)

  • 10.1001/jamainternmed.2022.1379


  • eng

Conference Location

  • United States