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

Key Points

Question  What themes pertaining to cross-system use emerge from review of the Veterans Affairs (VA) health system records of patients with advanced kidney disease?

Findings  In this qualitative study of electronic health records of 1000 US veterans with advanced kidney disease, 3 dominant themes pertaining to VA-financed care outside the VA were identified. Themes described the VA as mothership, the hidden work of veterans, and strain on the VA system.

Meaning  Findings of this qualitative analysis highlight the substantial strain on the VA system, VA staff and clinicians, and veterans and their families of cross-system use.

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.

The Department of Veterans Affairs (VA) Health Care System is the largest publicly financed integrated national health care system in the US. While many veterans receive care outside the VA (eg, under Medicare, Medicaid, military and private health insurance)¹ and the VA has long outsourced some aspects of veteran care to non-VA health systems and clinicians (eg, dialysis, specialized procedures), most VA-financed care for eligible veterans has traditionally been provided within VA facilities.² However, beginning in 2014, amid widespread public concern about prolonged VA wait times,^3,4 Congress embarked on a series of legislative changes that would increase veteran access to VA-financed health care outside the VA system.⁵

In 2014, Congress passed the Veterans Access Choice and Accountability (Choice) Act, which led to the establishment of a temporary program (the Veterans’ Choice Program) to pay for care outside the VA when this care could not be provided in a timely fashion within the VA.⁶ The Choice Act also authorized allocation of funds to support additional VA staffing and resources to reduce wait times within VA facilities. Preexisting programs and mechanisms for providing VA-financed care outside the VA continued to operate in parallel with the Choice Program. In 2018, the Choice Act was replaced by the more comprehensive Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act.^5,7-10 Under the MISSION Act, established mechanisms and programs for financing non-VA care (eg, Fee Basis program) were consolidated under the Veterans Community Care Program (VCCP). The MISSION Act was explicit in conferring on the VA responsibility for both financing and coordinating care with non-VA clinicians and health systems to ensure timely scheduling of medical appointments and continuity of care and services.

Eligibility for VA-financed non-VA care under the VCCP varies depending on whether services are available within the VA, whether there is a full-service VA facility within a veterans’ home state, and other considerations such as travel distance, wait time, and clinical need. Access-based eligibility criteria for care under the VCCP are generally more liberal than they were under the 2014 Choice Program, leading to substantial increases in VA-financed non-VA care.¹¹ Between 2014 and 2021, VA spending on non-VA care more than doubled from $7.9 billion (approximately 12% of the Veterans Health Administration budget) to $17.6 billion (20% of the Veterans Health Administration budget).¹¹ Increasing VA engagement with non-VA clinicians and health systems and responsibility for coordinating much of this care offers a potentially useful model for studying the implications of cross-system use for integrated health systems. Understanding the internal implications of cross-system use for the VA system and enrolled veterans could be relevant to other types of dual system use common in the veteran population (eg, Medicare) and to other health systems.

To date, studies based on interviews with key stakeholders have identified substantial challenges associated with medical record sharing, care fragmentation, timely bill payment, and engagement of non-VA clinicians under the Choice and MISSION Acts.^12-17 To further the understanding of the internal challenges of cross-system use to the VA system and enrolled veterans, we conducted a qualitative analysis of documentation in the VA-wide electronic health record (EHR) pertaining to VA-financed non-VA care in the era of the MISSION Act using an approach that several authors of this study have used to assess other complex care processes.^18-21 Analysis of documents and other forms of unobtrusive observation can be helpful in characterizing system-level constructs that might not emerge from interpersonal interviews or fieldwork observations.^22,23 Because of their traditionally high levels of care complexity and reliance on non-VA clinicians and health systems, our analysis focuses on the medical records of a national sample of US veterans with advanced kidney disease.

We used VA administrative and clinical data to identify a national cohort of veterans alive on June 6, 2019 (starting date for MISSION Act implementation and establishment of the VCCP) with evidence of advanced kidney disease defined as having at least 2 estimated glomerular filtration rate measures below 30 mL/min/1.73 m² at least 3 months apart during the preceding year. We then selected a random sample of 1000 of these veterans for detailed EHR review (Table 1). Information on demographic and clinical characteristics, vital status, and health care use during follow-up were obtained from the VA Corporate Data Warehouse, a comprehensive national repository of information on episodes of care occurring both within (inpatient and outpatient VA encounters) and outside the VA. Specifically, information on non-VA claims was obtained from Patient Integrity Tool data supplemented with information on contract dialysis from the VA Fee Basis files. Race data were reported as recorded in the VA Vital Status file. The project was approved by the institutional review board at the VA Puget Sound Health Care System. Permission to abstract and report deidentified text from cohort member EHRs was approved by the VA Puget Sound Health Care System with a waiver of the requirement for informed patient consent. This study followed the relevant portions of the Consolidated Criteria for Reporting Qualitative Research (COREQ) reporting guideline for qualitative studies.

We used a Lucene-based search tool (Apache Lucene, version 8.11; Apache Software Foundation) developed by a member of our group (R.J.L.)^18-20 to search text in the VA-wide EHRs of cohort members stored as text integration utilities notes in the VA Corporate Data Warehouse. Because care provided outside the VA under the VCCP (as distinct from other forms of non-VA care not paid for by the VA) is generally referred to within the VA as community care, we searched for mentions of this term in cohort member EHRs between June 6, 2019, and February 5, 2021, after applying a filter to exclude uninformative mentions (eg, boilerplate text).

We analyzed text in the VA-wide EHR identified by the search using inductive content analysis,^24-26 a systematic approach to describing phenomena with the goal of providing new knowledge, fresh insights, and/or identifying opportunities for intervention.^24-26 Using the search tool, 1 coauthor (A.M.O.) reviewed all notes containing mentions identified in our search, abstracting and coding potentially informative text using the constant comparative method.^27,28 Because veterans can also receive non-VA care that is not financed by the VA, we analyzed only text that clearly pertained to VA-financed non-VA care based on careful review of surrounding text in the EHR (eg, documentation of a referral or authorization). Two other coauthors (C.R.B. and W.S.) independently coded abstracted phrases until reaching thematic saturation. The 3 coauthors (A.M.O., C.R.B., and W.S.) then worked together to develop the thematic schema, identify subthemes, and select exemplar quotations, returning to abstracted phrases and/or the EHR as needed to reconcile any differences in interpretation, clarify meaning, and ensure that emerging themes were grounded in the data.

The mean (SD) age of the 1000 cohort members was 73.8 (11.4) years. Most (957 [95.7%]) were male, 691 (69.1%) were White, 215 (21.5%) were Black or African American, 30 (3.0%) were from other racial groups (American Indian or Alaskan Native, Asian, Native Hawaiian or other Pacific Islander), and information on race was missing for 64 participants (6.4%). Overall, 607 (60.7%) cohort members had at least 1 active or paid claim for VA-financed non-VA care during follow-up (Table 1). Among the 1000 cohort members, the search identified 583 with at least 1 mention (and a total of 2792 mentions) of the term community care in clinical notes between June 6, 2019, and February 5, 2021. Three overlapping and interrelated themes pertaining to VA-financed non-VA care emerged from qualitative analysis of documentation in patients’ VA-wide EHR (Figure). The themes were (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.

Documentation in the EHRs of cohort patients indicated that designated VA staff members (eg, staff within the Offices of Community Care or Access Centers at individual VA medical centers) were engaged in an extensive process of systematic coordination of non-VA care (Table 2). This process involved a range of different tasks including directing requests from non-VA clinicians and health systems to the relevant VA clinicians for authorization, furnishing non-VA clinicians with medical records for referred patients, coordinating between VA and non-VA clinicians to facilitate care, monitoring the care of veterans hospitalized outside the VA and coordinating transfers to the VA when needed, retrieving health records from non-VA health systems, checking on the status and maintaining the momentum of non-VA referrals, and keeping patients’ VA clinicians informed about the care they were receiving outside the VA.

Other VA staff members and clinicians not officially tasked with coordinating non-VA care were also engaged in less systematic efforts to support this care (Table 2). This support included helping veterans to access services both within and outside the VA that had been recommended by their non-VA clinicians, encouraging veterans to keep non-VA care appointments, and helping to set up travel to non-VA appointments. Veterans Affairs staff and clinicians also sometimes coached veterans on how to interact with non-VA contractors and clinicians. Medical teams routinely relayed information, questions, and concerns (eg, unexpected medical bills) about non-VA care to VA Community Care staff members.

The work of VA staff and clinicians to support VA-financed non-VA care was in part prompted by the tendency of veterans to turn to the VA for assistance with referrals for non-VA care and filling administrative and clinical gaps in the care they were receiving (or wished to receive) outside the VA (Table 2). There were also instances of veterans seeking the care of trusted VA clinicians to supplement or replace VA-financed care they were receiving outside the VA. Incidentally, we found examples of veterans turning to the VA for bridging care while waiting for an appointment with a non-VA clinician, and of VA clinicians encouraging patients to return to the VA if specific services were needed. Documentation in veterans’ EHRs suggested that non-VA clinicians also sometimes helped or encouraged veterans to access VA services and resources to fill gaps in the care they were receiving outside the VA.

Despite the efforts of VA staff and clinicians, procurement of VA-financed non-VA care demanded substantial time and effort on the part of veterans and their families (Table 3). Documentation in the VA EHR suggested that veterans did not always find it easy to engage with the VCCP referral process in ways expected of them. We found examples of referrals that had been stalled or canceled due to the veteran not answering their phone or not responding to (or being confused by) calls they had received about their non-VA care. Veterans were expected to be proactive in initiating and maintaining the momentum of referrals, and many were. However, they also struggled with the referral process and had difficulty accessing needed care, which could be time-consuming and anxiety-provoking. There were also examples of veterans receiving bills for care they had received outside the VA, either in error or when care had not been preauthorized by the VA. Documentation in the EHR suggested that the reality or prospect of being billed for non-VA services weighed heavily on veterans and their families.

The records and treatment recommendations of non-VA clinicians were frequently not available to VA clinicians in a timely fashion, requiring that veterans (and/or their family members) serve as informants and messengers between their VA and non-VA clinicians (Table 3). We found examples of veterans requesting initiation, continuation, and/or expansion of coverage for particular services at the behest of their non-VA clinicians and conveying messages about treatment recommendations across systems. Veterans and/or their family members also provided VA clinicians with important contextual information about the care they were receiving (or had received) outside the VA.

There were multiple references in medical documentation to the time-consuming and inefficient nature of the community care referral process (Table 4). By design, VA referrals for care outside the VA were time limited, the scope of services covered by each referral was prespecified, and referrals were intentionally canceled when veterans did not respond to telephone calls. Requests for continuation of services had to be authorized by VA clinicians as did any changes to, or expansion of, authorized services, and canceled consultations had to be resubmitted. Veterans Affairs staff and clinicians appeared to have limited control and understanding of the referral process after submitting the consultation and were often uncertain about the status of particular referrals. Clinicians were also sometimes unsure who to turn to for support and assistance with tracking referrals and confirming that needed non-VA care had in fact been (or would be) provided.

The high level of VA clinician oversight required by the referral process meant that VA Community Care and other support staff routinely routed referral requests to physicians for approval, bureaucratizing their clinical role (Table 4). Efforts to accommodate the needs of veterans receiving care outside the VA also stretched the traditional roles of other VA clinical staff members. This was especially true for internal VA clinical social workers who often served as the point of contact for veterans and their non-VA clinicians seeking assistance with the referral process. Because those seeking such assistance were usually not familiar with the inner workings of the VA system or the VCCP, these requests were often misdirected, and VA staff and clinicians were not always accommodating.

Referring veterans to outside clinicians and health systems could also interact and conflict with VA care processes (Table 4). We found examples of VA clinicians rearranging VA appointments to accommodate veteran appointments outside the VA. Changes or delays in the provision of non-VA care limited the ability of the VA to help coordinate or otherwise support this care (eg, arranging transportation). Lack of information about care delivered outside the VA or the status of particular referrals led to duplication of services and increased the work of VA clinicians while limiting the quality and timeliness of the care they were able to provide. Clinicians also routinely made contingency plans (eg, placeholder appointments) to accommodate uncertainty about whether and when non-VA services would be initiated.

This qualitative study of documentation in the VA-wide EHR among a national random sample of 1000 US veterans with advanced kidney disease offers an internal window on the challenges of coordinating care across health systems. Specifically, our findings spotlight the substantial work of VA staff and clinicians and veterans and their families to arrange and coordinate VA-financed care outside the VA, and the strain that this can place on VA care processes. Although some of our findings pertain specifically to the VCCP in the era of the MISSION Act, most speak to the broader challenges of caring for patients receiving care in different health systems and thus bear relevance to other kinds of cross-system use among VA users (eg, VA-Medicare dual use) and to other health systems.

Since the VA waitlist crisis of 2014, there have been major changes to the types and volume of veteran care referred to non-VA clinicians and health systems. According to a recent Congressional Budget Office report, the number of veterans authorized to receive VA-financed care outside the VA almost doubled between 2014 and 2020 from 1.3 to 2.3 million.¹¹ In 2021 alone, the VA made more than 6 million referrals for non-VA care for eligible veterans.²⁹ It is thus perhaps not surprising that, similar to earlier interview studies of VA cross-system use under the Veterans’ Choice Program,^12-16 our results echo familiar refrains about health care fragmentation and complexity including surprise medical billing,³⁰ the work involved in being a patient,^31-34 and the invisible work of family members to support patient care.^31,32,35 The official responsibility of the VA for coordinating VA-financed care in the community along with several of the dynamics that emerged from our analysis of the VA EHR (ie, the mothership theme outlining the work of designated VA Community Care staff to coordinate non-VA care under the VCCP, the informal work of nondesignated VA staff and clinicians to support this care, and the tendency of veterans to turn to the VA to fill gaps in non-VA care) may well have increased the visibility of these somewhat hidden and difficult-to-measure consequences of cross-system use. Together with earlier interview-based studies,^12-16,36-38 our results highlight the importance of finding ways to account for the many intangible consequences of cross-system use when budgeting, evaluating, and planning the delivery of VA-financed care outside the VA.

Although many of our findings speak to the general challenges of cross-system use, they also have specific relevance to the VA health care system. In the wake of the Choice and MISSION Acts, the VA has been required to interact on an unprecedented scale with private health systems, many of which do not share its programmatic strengths or mission and culture of providing lifelong care to the veteran population.^2,39 It is thus perhaps not surprising that our description of the work of VA staff and clinicians to support veterans to receive VA-financed care outside the VA is consistent with the work of Lamphere⁴⁰ on Medicaid reform in New Mexico in the late 1990s, which described the substantial hidden work that public safety net institutions and clinicians undertook to try to smooth client interactions with other health systems when their care was shifted to the private sector.⁴⁰ Our findings also show consistency with the work of Van Eijk⁴¹ describing the mission-based approach of staff in an inner-city transgender clinic to supporting client interactions with insurance companies and other elements of the health system. Although the Choice and MISSION Acts were intended to improve the timeliness of veteran care by increasing access to non-VA clinicians, it is presently unclear whether the substantial VA investment in non-VA care in recent years has accomplished this goal,^42,43 at least in sufficient measure to justify the increased demands placed on the VA system, VA staff and clinicians, and veterans and their families.

While we describe dominant themes pertaining to the provision of VA-financed non-VA care as documented in the VA-wide EHR, our findings may not speak to the overall strengths and limitations of the VCCP for the following reasons: (1) the VA EHR does not directly or completely capture the experiences or perspectives of veterans, family members, or VA staff and clinicians; (2) we did not evaluate veteran interactions with private health systems and clinicians or capture the experiences of non-VA staff and clinicians; (3) we may not have adequately described the care of veterans who interacted infrequently with the VA system during the observation period; (4) our study focused on veterans with advanced kidney disease because of their high levels of care complexity and cross-system use, which may limit the transferability of our findings to veterans with other health conditions; (5) we described the early rollout of the VCCP and thus our results do not provide meaningful information on program evolution; and (6) our analyses were not designed to distinguish between particular non-VA contractors, clinicians, or types of care and thus may not address important differences across these domains.

In this qualitative study of documentation in the VA-wide EHRs of US veterans with advanced kidney disease pertaining to VA-financed care outside the VA, some of the challenges of cross-system use and specifically the strain this can place on health systems, clinical personnel, patients, and families were highlighted. These difficult-to-measure consequences associated with cross-system use warrant consideration when budgeting, evaluating, and planning for the provision of VA-financed non-VA care for the US veteran population.

Accepted for Publication: March 13, 2022.

Published Online: May 16, 2022. doi:10.1001/jamainternmed.2022.1379

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 O’Hare AM et al. JAMA Internal Medicine.

Corresponding Author: Ann M. O’Hare, MD, MA, Department of Medicine, VA Puget Sound Health Care System, 1660 S Columbian Way, Seattle, WA 98108 (ann.ohare@va.gov).

Author Contributions: Dr O’Hare had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: O'Hare, Hebert, Wang, Crowley, Carey.

Acquisition, analysis, or interpretation of data: O'Hare, Butler, Laundry, Showalter, Todd-Stenberg, Green, Wang, Taylor, Van Eijk, Matthews, Carey.

Drafting of the manuscript: O'Hare, Butler, Taylor, Van Eijk, Carey.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Butler, Laundry, Green, Hebert, Carey.

Obtained funding: O'Hare, Wang.

Administrative, technical, or material support: O'Hare, Laundry, Showalter, Todd-Stenberg, Wang, Matthews.

Supervision: Todd-Stenberg.

Conflict of Interest Disclosures: Drs O’Hare, Hebert, Wang, and Carey reported receiving grant support from Veterans Affairs (VA), and Drs O’Hare, Butler, Ms Showalter, Mr Todd-Stenberg, Drs Green, Hebert, Wang, Matthews, Crowley, and Carey reported being employed by the VA during the conduct of the study. Mr Laundry reported being a contractor for the VA during the conduct of this study. No other disclosures were reported.

Funding/Support: This work was funded by the VA Health Services Research and Development Service (VA IIR- IIR 18-032, PI O’Hare).

Role of the Funder/Sponsor: The funding organization had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: Dr O’Hare serves on the Editorial Board of JAMA Internal Medicine, but she was not involved in any of the decisions regarding review of the manuscript or its acceptance.

Additional Contributions: We thank the manuscript editors and reviewers for their thoughtful input on earlier drafts of this manuscript.