key: cord-0798753-y50tft3d authors: Rose, L.; Tran, L. D.; Asch, S. M.; Vashi, A. title: The COVID-19 pandemic shifted the Veterans Affairs System toward being a payer and virtual care provider: is it sustainable? date: 2021-06-01 journal: nan DOI: 10.1101/2021.05.31.21258031 sha: caa23315be81a085575272ae59f26ea8030fb60b doc_id: 798753 cord_uid: y50tft3d Objective: To examine how VA shifted care delivery methods one year into the pandemic. Study Setting: All encounters paid or provided by VA between January 1, 2019 and February 27, 2021. Study Design: We aggregated all VA paid or provided encounters and classified them into community (non-VA) acute and non-acute visits, VA acute and non-acute visits, and VA virtual visits. We then compared the number of encounters by week over time to pre-pandemic levels. Data Extraction Methods: Aggregation of administrative VA claims and health records. Principal Findings: VA has experienced a dramatic and persistent shift to providing virtual care and purchasing care from non-VA providers. Before the pandemic, a majority (63%) of VA care was provided in-person at a VA facility. One year into the pandemic, in-person care at VA's constituted just 33% of all visits. Most of the difference made up by large expansions of virtual care; total VA provided visits (in person and virtual) declined (4.9 million to 4.2 million) while total visits of all types declined only 3.5%. Community provided visits exceeded prepandemic levels (2.3 million to 2.9 million, +26%). Conclusion: Unlike private health care, VA has resumed in-person care slowly at its own facilities, and more rapidly in purchased care with different financial incentives a likely driver. The very large expansion of virtual care nearly made up the difference. With a widespread physical presence across the U.S., this has important implications for access to care and future allocation of medical personnel, facilities, and resources. The Veterans Health Administration (VA) manages a nearly $100 billion per year integrated health care system for over 9 million enrollees. 1 This makes it the third largest federal outlay on healthcare behind Medicare and Medicaid. VA facilities span every state (as well as Puerto Rico, the Virgin Islands, Guam, American Samoa, and the Philippines). In addition, in the wake of concerns about access, the VA has increased the amount of care it purchases from community providers. A multitude of factors make it difficult to predict veterans' health care needs and ensure access meets demand. First, veteran demographics are changing. Despite a threedecade long decline in the size of the veteran population, the number of VA patients has been increasing. 1 Policy and eligibility changes also impact the number veterans eligible for VA health care benefits. Moreover, many veterans who are eligible for VA health care have other insurance coverage and may only rely on VA to meet some of their health care needs. This reliance on VA can fluctuate based on economic conditions, U.S. health care policy changes, and location. To provide Veterans with more flexibility, the VA has increased spending on community care. From 2014 to 2018, the community care budget increased 82% and comprised nearly 20% of VA's health care budget. 2 Like other systems, VA has faced unprecedented challenges responding to the COVID-19 pandemic. While VA's large size, diverse operating environments, and geographically dispersed patient population make it difficult to pivot nimbly, VA was able All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. To capture all health care encounters in VA and those paid for by VA in the community, distinct VA and Community Care encounters from January 2019 to February 2021 were extracted from national VA administrative databases housed in the VA Corporate Data Warehouse. Encounters were then classified into mutually exclusive categories by the type and location of care delivered. VA acute encounters included VA emergency department (ED) and urgent care (UC) visits and acute inpatient hospital days. For inpatient stays lasting multiple days, a visit was counted for each day of the stay. Multiple ED visits on the same day were only counted once. Community acute care visits included ED and acute inpatient hospital days provided in community settings. Remaining VA encounters (outpatient care, rehabilitation care, ancillary and diagnostic encounters) were further All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 1, 2021. ; https://doi.org/10.1101/2021.05.31.21258031 doi: medRxiv preprint categorized as in-person care or virtual care (telephone or video-based, not including secure messaging). Similarly, remaining Community Care visits included all non-acute encounters. However, Community Care visits were not further categorized as in-patient or virtual but both types were included in totals, as virtual community encounters were less than 0.1% of all non-acute community encounters. Limitations of this study include that there is likely a lag in processing, reporting, and adjudication of more recent community care claims. However, this means that current estimates of Community Care encounters are an underestimate. Also, due to a limitation in available claims data, we were unable to reliably categorize Community Care as in-person or virtual. All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 1, 2021. ; https://doi.org/10.1101/2021.05.31.21258031 doi: medRxiv preprint VA provided or paid for 188.3 million encounters between January 2019 and February 2021. Figure 1 provides the volume of encounters over time by type and location. As expected, overall utilization dropped precipitously in March and April of 2020, coinciding with the start of the COVID-19 pandemic. However, virtual care in VA expanded swiftly. Strikingly, total encounters have yet to recover to either 2019 or early 2020 prepandemic levels, with 2019 levels shown with a dashed line. The estimated total volume of missing encounters relative to 2019 is 13.2 million. Note that this is a conservative estimate given strong yearly growth in encounter volume prior to the pandemic. Figure 2 shows these same data in proportions to better illustrate the change in the distribution of care categories over time. This analysis demonstrates how utilization patterns changed for VA enrollees during the COVID-19 pandemic. Like other systems, VA experienced large reductions in care early All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 1, 2021. ; https://doi.org/10.1101/2021.05.31.21258031 doi: medRxiv preprint in the pandemic. However, VA was well-positioned to quickly transition to providing large amounts of virtual care. 5 More surprisingly, however, VA in-person care declined much more than Community Care and has not yet recovered. As of December 2020, VA virtual care and Community Care made up 67% of total VA paid and provided care. Our results likely reflect several trends. First, our findings indicate that VA has likely adopted a more conservative reopening strategy, compared to community providers who have different financial incentives to resume in-person care. We found that Community Care paid for by VA returned to pre-pandemic levels by September 2020. This is consistent with private health care systems that have reported to have recovered within 5% of pre-pandemic inpatient and outpatient volume by September 2020. 6, 7 It may be that as VA continues to reopen, the share of in-person VA encounters will steadily rebound over a longer period. However, it is possible that in the interim, the shift toward Community Care may be preferred by veterans and thus semi-permanent. reflecting uncertainty about the extent to which policymakers wish to preserve VA's primary function as a health care provider or allow VA to provide more care through the community. In either scenario, a substantial reallocation of VA resources and All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 1, 2021. ; https://doi.org/10.1101/2021.05.31.21258031 doi: medRxiv preprint capabilities will be needed to meet the near-term demand for health services among veterans. What is clear is that the COVID-19 pandemic has resulted in substantial and persistent shifts in care patterns in the VA health care system that warrant continued monitoring as VA resumes normal operations. Telehealth adoption has been widespread, but existing trends pushing VA toward being a mixed payer and provider seem to have accelerated. VA should be prepared to reallocate resources to care for veterans and will need to articulate a clear strategy for how purchased care should be used and how it fits into VA's broader health care mission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted June 1, 2021. ; https://doi.org/10.1101/2021.05.31.21258031 doi: medRxiv preprint Department of Veterans Affairs -FY2021 Budget Submission Government Accountability Office. VA Health Care: Estimating Resources Expanding Access through Virtual Care: The VA's Early Experience with Covid-19. NEJM Catalyst Innovations in Care Delivery Reduced In-Person and Increased Telehealth Outpatient Visits During the COVID-19 Pandemic The Impact of COVID-19 on Outpatient Visits in 2020: Visits Remained Stable, Despite a Late Surge in Cases. Commonwealth Fund issue-brief/trends-in-overall-and-non-covid-19-hospital-admissions/ All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder