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

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.