Resistance to Switching Health Care Institution Among Veterans Referred for VA-Purchased Care
This research provides valuable insights into the factors influencing Veterans' resistance to switching between VA-direct and VA-purchased care, despite evidence suggesting that veterans often receive lower quality, less satisfying, less coordinated, and less timely care at non-VA facilities.
College of Health researcher(s)
Abstract
Background
Little is known about how Veterans choose between receiving Veterans Affairs (VA)–paid health care from VA-direct care (care provided in VA facilities) vs. non-VA facilities (VA-purchased care).
Objective
To evaluate Veterans’ resistance to switch their hypothetical choice of health care institution with reasonable alterations in quality and access using Discrete Choice Experiments (DCE).
Design
We conducted a nationwide survey among Veterans who had been offered a referral for VA-purchased care.
Participants
Of the 12,547 Veterans we approached, 1253 (10.0%) respondents had evaluable data.
Main Measures
We summarized DCE results. We evaluated the multi-variable adjusted association of travel time to the nearest VA facility (≤ 1 h vs. > 1 h) with resistance to switch health care institutions. We calculated predicted probabilities (PP) for resistance to switching and separately based on distrust in VA health care.
Key Results
When respondents imagined their local VA facility was 1 h farther away than their local VA-purchased care facility, more than 60% chose VA-direct care for every quality and access improvement scenario (e.g., VA had higher quality of care). However, when all factors of care in both institutions were equal, up to 60% of respondents who initially chose VA-purchased care would not switch to VA-direct care for any incremental improvement in access and quality of VA-direct care. Travel time was not associated with high resistance to switching health care location (adjusted OR 1.1, 95% CI 0.8–1.4; p = .70). Respondents who originally chose VA-purchased care and had high distrust in VA had the highest predicted probabilities of resistance to switch (≤ 1 h travel time: PP 36%, CI 28–43%; > 1 h travel time: PP 42%, CI 34–49%).
Conclusions
Interventions to increase Veterans choosing VA-direct care should improve Veterans’ understanding of VA and non-VA quality and access and also improve trust in VA.
Frequently Asked Questions about Veterans' Healthcare Choices
What was the primary goal of this study regarding Veterans' healthcare decisions?
The primary objective of this study was to understand Veterans' reluctance to switch their chosen healthcare institution (VA-direct care vs. VA-purchased care in non-VA facilities) when presented with hypothetical scenarios involving changes in quality and access. The researchers used Discrete Choice Experiments (DCE) to evaluate these preferences among Veterans who had been offered referrals for VA-purchased care.
What were the key findings regarding Veterans' willingness to switch between VA-direct and VA-purchased care?
The study found that while most Veterans would choose VA-direct care if it offered better quality or access, even if it meant traveling an hour further, a significant portion (up to 60%) of those who initially preferred VA-purchased care would not switch to VA-direct care, even with incremental improvements in the VA's quality or access. This suggests a strong resistance to switching among some Veterans who initially opt for community care.
How did travel time to the nearest VA facility influence Veterans' resistance to switching their healthcare institution?
Contrary to what might be expected, the study found no significant association between travel time to the nearest VA facility (≤ 1 hour vs. > 1 hour) and Veterans' resistance to switching their healthcare location. This implies that factors other than mere convenience, such as travel distance, play a more critical role in their decision-making process.
What role did distrust in the VA healthcare system play in Veterans' resistance to switching care locations?
Distrust in the VA healthcare system was identified as a significant factor influencing Veterans' resistance to switching. Those who initially chose VA-purchased care and had high distrust in the VA were the most resistant to switching to VA-direct care, particularly when travel times to VA facilities were longer. Conversely, Veterans who initially chose VA-direct care and had low distrust were also highly resistant to switching to VA-purchased care.
How did Veterans weigh improvements in quality or access at the VA against the convenience of VA-purchased care?
When presented with scenarios where the local VA facility was an hour farther away but offered higher quality of care, more thorough doctors, fewer complications, higher patient satisfaction, or earlier appointments, the majority of Veterans still chose VA-direct care. This indicates that many Veterans are willing to trade some convenience for perceived improvements in quality and access within the VA system.
Were there differences in resistance to switching based on the type of care (e.g., mental health, primary care, specialty care, surgical care)?
The study observed some differences in resistance to switching based on the authorized care type. Notably, respondents referred for mental health care were overall predicted to be the most resistant to changing their initial choice, regardless of whether they initially preferred VA-direct or VA-purchased care.
What implications do these findings have for the VA in terms of encouraging Veterans to choose VA-direct care?
The findings suggest that to encourage more Veterans to choose VA-direct care, the VA should focus on improving Veterans' understanding of the quality and access differences between VA and non-VA facilities. Additionally, efforts to build and improve trust in the VA healthcare system are crucial, especially for those currently preferring community care. Interventions should likely be multi-faceted, addressing various aspects of care and communicating these improvements effectively and individually to Veterans.
What were some of the limitations of this study that should be considered when interpreting the results?
Several limitations should be considered. The response rate to the survey was relatively low (10.0%), which might introduce some bias. The study relied on hypothetical scenarios in the DCE, and actual behavior might differ. The data was collected in 2019-2020, and changes in the MISSION Act implementation and VA-purchased care processes since then may have influenced Veterans' preferences. Finally, the study did not assess the satisfaction levels of participants who had actually used VA-purchased care.