Trends in Outpatient Specialty Care Referrals and Specialty Clinic Wait Times in the Veterans Affairs Health System Before and After VA Community Care Expansion.

Abstract

The MISSION Act of 2018 expanded Veteran eligibility to seek care through community providers at VA expense ("VA community care") with the goal of improving access to care, particularly for specialty services. Understanding trends in specialty referral volumes and the proportion of care outsourced to the community following MISSION implementation is critical to understanding where and how Veterans are accessing specialty care and whether MISSION is achieving its core policy goals. Describe changes in specialty referral volumes and the proportion of referrals outsourced to VA community care from FY 2019 to 2024, and concurrent changes in mean wait times. National, retrospective cohort study examining monthly referrals to 24 unique specialties. Veterans Health Administration (VA). VA-enrolled Veterans referred for outpatient specialty care. Monthly volume of specialty referrals in total and by category (medical, surgical, ancillary). Proportion of specialty care referred to VA community care in total, by category, and by individual specialty. Mean new patient wait time. The total monthly volume of specialty referrals increased from 1,163,172 to 1,657,504 (42.5% relative increase) from 10/2018 to 9/2024. The proportion of this care referred to the community increased from 16.1% to 21.5% (33.6% relative increase). All categories of specialty care were referred to the community at similar rates at the beginning of the study period (range: medical 15.7% to surgical 17.1%). However, the proportion of medical and surgical care referred to community settings rose post-MISSION (medical 15.7% to 21.2%; surgical: 17.1% to 26.4%), while ancillary referrals remained stable (16.1% to 16.7%). Mean wait times for new patient visits increased, rather than decreased. Specialty care referrals outsourced to VA community care increased substantially following MISSION Act implementation without concurrent improvement in specialty wait times. Policymakers should consider other strategies to improve timely access to care.