Veterans Affairs health system faces significant challenges, studies find

The reports, done as part of a congressionally mandated examination of the delivery of health care to veterans in facilities owned and operated by the Department of Veterans Affairs, have been posted to the RAND website at http://www.rand.org/health/projects/VA-choice.html.

RAND conducted three of 12 mandated assessments, all of which were coordinated by the MITRE Corporation and required by the Veterans Access Choice and Accountability Act. The legislation was in response to reports that veterans faced long delays for care at some VA health facilities.

An assessment of demographic trends in the VA found that while the number of living veterans has been declining, the number of veterans using VA health care has increased substantially over the past two decades. This has resulted from expanded eligibility and higher reliance on VA health services by newer veterans.

The research showed that demand will continue to increase until the end of the decade. However, it will level off or even decline over the subsequent decade due to the end of the wars in Iraq and Afghanistan and the continuing decline in the size of the veteran population, unless there are changes in eligibility or another protracted military conflict.

The assessments also found that the nation's veterans on average are older than nonveterans and have elevated rates of many health conditions, when compared to nonveterans. Veterans who rely on the VA for health care are less healthy, with higher rates of chronic conditions and mental illness, than veterans who do not use the VA health system.

Based on VA data, RAND researchers found no widespread evidence of long waits across the VA health system. Most veterans have appointments within a few days of their preferred date for care -- the date on which their provider recommends the appointment should occur or the date on which the veteran would like to receive care. More than 90 percent of appointments for existing patients and 80 percent of appointments for new patients occur within 14 days of the preferred date.

However, waiting times are highly variable by location and type of care and some veterans in some facilities face very long wait times, such as almost 40 days for a primary care appointment at the extreme. In addition, surveys show that VA patients are less likely than private-sector patients to get appointments, care and information as soon as needed.

The RAND research also found that geographic access to care in the VA system is good for most veterans. Nearly 93 percent of enrolled veterans live within 40 miles of a VA medical facility, although veterans with specific health conditions may not live close to the type of care they need.

Veterans who live far from VA care also tend to live far from other health services. RAND research found that while 80 percent of enrolled veterans who live far from VA care have access to primary care in their community, less than 20 percent have access to specialty care, reflecting the challenges across the U.S. health care system of providing care in rural areas.

Other findings from the three reports include:

• The VA has long played a national leadership role in quality measurement and the quality of care provided by the VA health system generally was as good as or better than other health systems on most quality measures.
• The VA has significantly increased the amount of care provided through contracts with non-VA providers. The VA spent $5.6 billion -- 10 percent of the VA health care budget -- on purchased care during the 2014 fiscal year. However, RAND found that the VA lacks a strategy and coherent program for purchasing care.
• Over the next decade, the rates of some chronic conditions among veterans who use VA health care will increase, primarily a result of the group aging.

RAND researchers recommend that the federal government collect better information about veterans and their health care needs, which will aid planning for the future. This will require not only improved efforts by the VA and the Department of Defense, but also the U.S. Census Bureau.

To meet demands over the near term, the VA health system needs to substantially increase its capacity, according to RAND researchers. A mixed strategy will be needed to do this. It should include hiring more providers, granting VA advanced practice nurses full practice authority, expanding use of virtual care and making strategic use of purchased care.

Policymakers must make decisions about the future of the VA health care system as the size and demographics of the patient population change. According to RAND researchers, the president, Congress and VA will need to determine whether VA should continue to deliver care in its brick-and-mortar facilities or whether most or all care should be delivered by non-VA providers. Once there is a clear strategy, there may be implications for VA's authority to implement the strategy.

RAND Health is the nation's largest independent health policy research program, with a broad research portfolio that focuses on population health, health care costs, quality and public health systems, among other topics.