INTRODUCTION

Many Americans want to make their own healthcare decisions including choosing their provider(s),1and enhancing patient choice has been proposed to improve patient-centeredness and quality of care.2, 3 In choosing providers, patients often consider provider education, experience, qualifications, and certification;4–7 logistical factors like location, appointment wait time, insurance acceptance, and costs;4–6, 8 and other patients’ perceptions of providers and their care.4, 9, 10

With passage of the Veterans Access, Choice, and Accountability Act (Choice Act; Public Law 113–146)11 in 2014 and VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act (MISSION Act; Public Law 115–182)12 in 2018, many Veterans now have more options about where they receive care. These Acts require the Veterans Health Administration (VA) to pay for care delivered by community providers (“VA-purchased care”) if VA cannot provide standard-concordant care at its own facilities. Under the MISSION Act, Veterans are eligible for VA-purchased care if appointment wait time, travel distance or hardship, or quality of VA-delivered services do not meet VA’s standards. Veterans are also eligible if there are no VA facilities in their state or if they used VA-purchased care under the Choice Act. Since implementation of the MISSION Act, VA has referred > 2.7 of the estimated 3.7 million eligible Veterans (approximately one-third of all VA-enrolled Veterans) to VA-purchased care,13, 14 and many more Veterans are now using both VA-delivered and VA-purchased care.15–20

While these changes may improve access to care for some Veterans, concerns about potential adverse impacts of multi health system use have surfaced. For example, evidence suggests Veterans who use multiple systems of care experience more healthcare “hassles” (e.g., inadequate information about referrals, treatment options),and worse care coordination and continuity, and some non-VA providers may lack training in Veteran-specific clinical and cultural competencies—an important aspect of caring for Veterans.21–29 Yet, some Veterans report important benefits of VA-purchased care including being part of a familiar medical community, developing long-term relationships with local providers, fewer travel issues, improved access to and timeliness of care, and greater ability to have family accompany them to appointments.28, 30

With national policy changes resulting in growth in Veterans’ use of VA-purchased care,31 VA is increasing efforts to optimize where and from whom Veterans receive care.32 Importantly, incorporating Veterans’ preferences, values, and needs into these care decisions is a crucial aspect of providing patient-centered care. Further, while Veterans’ experience-scores for communication, coordination, and provider ratings for VA-delivered care have out-performed VA-purchased care previously,33 greater understanding about how these and other factors influence patient decision-making under more recent policy initiatives is needed. Drawing on interviews with Veterans who were eligible for VA-delivered and VA-purchased care, we sought to understand Veterans’ care preferences including factors and information they consider when making decisions about whether to use VA-delivered or VA-purchased care.

METHODS

We conducted semi-structured interviews with Veterans from August 2020 to August 2021 as part of a mixed-methods, cross-sectional study about decisions around where to receive care. All participants completed informed consent using IRB-approved documents (VA Portland Health Care System/Oregon Health & Science University IRB#20,861).

Sample

Veterans were recruited from May 2020 to August 2021. To identify eligible Veterans, we found those with an authorization for VA-purchased outpatient care from 2019 through mid-2020. We used the category of care from the most recent authorization to assign Veterans to Standard Episodes of Care (SEOC): mental health, primary care, specialty care, and surgical care. The research information sheet attached to the survey indicated that participants who responded to the survey also assented to be called by study staff to assess their interest in participating in an interview. Of the 1662 participants who responded to the survey, we randomly selected participants in each SEOC group. Due to low response rates among mental health SEOC participants, we oversampled for this group. In total, 146 were contacted and invited via phone to participate; 28 agreed to participate and completed interviews. We stopped recruiting for interviews once thematic saturation was reached.

Data Collection and Analysis

We used a semi-structured interview guide to elicit participants’ perceptions of VA-delivered and VA-purchased healthcare and to understand their information needs, values, and preferences. Questions included knowledge of the VA MISSION Act, what factors are important when deciding where to receive care (probes included providers, distance, wait times, cost), what quality of care means to them, experiences and perceptions using VA-delivered and VA-purchased care (including referral processes), and decision-making processes and information needs. Two qualitative methodologists (SEG and ML) conducted the interviews via phone, which were digitally recorded and transcribed verbatim. Interviews ranged from 18 to 70 min.

We conducted an integrated approach of deductive and inductive analysis based on transcript summaries and coding. We first utilized a deductive approach—rapid analysis—to develop summaries of key points from each interview. After reading through three to four transcripts, ML created a transcript summary template, organized by domains in the interview guide (e.g., VA care, values and preferences, referral process, information needs). These templates were tested for usability among co-authors (ML, SEG, ND, DJG) who summarized four of the same interviews, refining the template to ensure consistency in capturing key points across interviews. All transcripts were then summarized by the same co-authors. Transcript summaries were combined into a matrix to aid in identifying patterns and emergent themes across participants while keeping individual narratives intact.

We then used an inductive approach to create a codebook based on emergent findings and themes from the rapid analysis. Coding allowed us to identify themes that did not fit into predetermined domains, such as environment of care. Three co-authors (ML, SEG, ND) tested the codes on transcripts, refining the codes until consensus was reached and coding was consistent across coders. We then coded all the transcripts using Atlas.ti v9. The rapid analysis matrix and code reports were discussed among co-authors to ensure ongoing agreement of the findings. Both rapid analysis and coding generated the findings presented in this paper.

RESULTS

More than half of participants (pseudonyms provided for ease of identification) lived in rural areas, 21 were men, and 25 were > 50 years old (Table 1). Participants were eligible for both VA-delivered and VA-purchased care, often having been referred to VA-purchased care for specialty care unavailable at their VA facility, or for routine physical or mental health therapy appointments closer to their homes.

Table 1 Participant Characteristics
Full size table

Four themes emerged from the interviews. We found the most important factors to participants in choosing where to receive care included (1) high-quality relationships with providers, and (2) the environment, or “eco-system of care.” We discovered corresponding findings related to information needs. Participants cited the need for more (3) transparent and accessible information about available providers and services, and (4) adequate information around care coordination and referrals to make informed care decisions.

High-Quality Relationships with Providers

Most participants discussed how high-quality relationships with providers are central to their decision-making around where to receive care and provided examples of developing and maintaining quality patient-provider relationships in VA-delivered and VA-purchased care. For instance, Jason said what he likes about VA-delivered care is having providers that “establish a relationship” and make patients feel comfortable—a key factor when he chooses care: “If I go into a civilian doctor and see them, a specialist or any of them, and we don’t kind of connect and have a good patient-practitioner relationship going and stuff, I’ll find another one.” Aspects of relationships participants found important included mutual trust and authenticity, good communication practices, and continuity of care.

Mutual Trust and Authenticity

Having a provider whom participants trust and feel cares about their wellbeing was a driving factor in where they choose to receive care. For instance, Theresa chooses to drive farther to see a VA provider she trusts:

“I would travel two hours to go to that doctor that I trust…it’s trust and concern about my issues. And the doctor I’ve had stays a good 45 minutes to an hour with me. That’s what I love about her... she cares. She cares about those Veterans.”

The patient-provider relationship was often assessed in terms of authenticity. Participants discussed the importance of feeling genuinely cared for and listened to, often in terms of a personal, rather than professional, nature. For instance, George emphasized sincerity: “You can tell when you talk to somebody if they enjoy talking to you, or if they just are bored because they have to talk to you.” Similarly, Ronald said:

“Some providers have a great ability to come across and demonstrate to you that they genuinely care about your health, and there are providers that you don’t get that sense from, you know, they’re just doing their job kind of thing.”

Good Communication Practices

Good communication practices, including listening and responsiveness, were often discussed as crucial to a good patient-provider relationship. Alexis explained: “people are looking for convenience, quality, and information…as long as the [provider] listens to the patient, takes care of the patient’s needs, is understanding of the patient’s needs, then it’s a win/win for everybody.” For Alexis and others, quality and information are interwoven with and dependent on provider communication practices.

Many participants reported (un)responsiveness from their provider or care team as a factor that affects where they receive care. Kimberly, for instance, described feeling frustrated when her VA primary care provider (PCP) does not respond to messages sent via the patient portal:

“If I still had my private insurance, I would still be seeing my [non-VA PCP] who I had for like eight years because she was responsive to my needs. Which is a thing that I find with primary care at the VA—They’re not responsive to your needs. […] I asked a week ago for [my VA PCP] to refill a prescription and she hasn’t responded…that’s been a consistent thing with her… I understand that they’re busy, but like how can you be too busy to just answer a message?”

Kimberley’s preference to see a responsive provider reflects that of many participants, but her care choice in this instance was limited by her eligibility.

Continuity of Care

Participants reported the importance of maintaining continuity in their provider relationships. For example, Mary stressed the temporal component of patient-provider relationships: “It all comes down to the doctors. If you get good doctors and if you keep the good doctors.” Participants said they wanted providers who are familiar with their health history, as Alexis explained:

“… when I first meet with a PCP... I just want to make sure [they] are aware of what my history is- I don’t have to repeat it every 15, 20 minutes...that they’re just knowledgeable as to what it is that I need help with...”

Provider continuity is an important factor for participants when deciding where to seek care. They described provider turnover as a barrier to high-quality care, often referencing frequent changes with their VA providers. Walter, for instance, talked about his concerns around seeing six or seven VA providers over two years:

“Some of them decided to retire. Some of them decided to leave the VA… So, I was kind of dropped or forgotten about… I worried about getting the proper care… the bedside manner was bad and the switching of doctors…”

Some participants said provider turnover would affect where they choose to seek care in the future. For instance, Brian explained that while he is satisfied with his current VA provider, he would choose community care if he encountered problems with provider continuity:

“it’s important to me to…see the same person year over year…you develop a history and a rapport with that person…I might start getting concerned every time I go in and I’m seeing somebody completely different…If I felt like it was just a revolving door of people, I’d probably want to go back out on the [community] where I’d be seeing the same person every time.”

Positive Environment or “eco-system of care”

Many participants talked about the positive environment of care when referencing VA-delivered care. Part of that environment consisted of feeling supported and cared for by all VA staff, as well as quality customer service, and feelings of community and camaraderie among fellow Veteran patients. For example, Ronald said: “folks at VA clinics are just exceptional. They’re very polite, very considerate, understanding. They listen to you.” Patrick said he would rather drive 65 miles from home to visit a VA hospital for procedures rather than go to a nearby non-VA hospital because of the caring environment:

“the people are so much nicer. And I might have to wait six months to get an appointment, but I don’t mind. I feel better about it…you’re not rushed at the VA, you’re treated like a person, and they don’t just treat you like cattle…It makes a big difference to me, to be treated right.”

The supportive “eco-system of care” in VA was similarly described by Brian:

“Well, the people that I’ve dealt with like the pharmacist, their whole in-processing process, even the one appointment that I had with the social worker, I just felt, it felt good. It felt like the people cared. And every time I’ve gone out there, I felt like they cared about why I was there, so that helps.”

Quality Customer Service

When asked what was important when choosing where to receive care, participants stressed quality customer service, or as Susan put it: “How am I gonna be treated? How have I been treated?” Similarly, Alexis emphasized the role of service in healthcare: “You’re there to provide a service…it’s your job to make sure that that person gets that issue resolved before they leave.” Some participants highlighted the comprehensive service they felt throughout visits at VA:

“It just starts from when you walk in the building, even at the front counter. They’ll greet you… it’s important to me that they acknowledge you. … it was like, “what can I do to make sure that you leave here today with everything done?”…they make sure they take care of me.” (Brian)

“I can tell like with the difference from being at a civilian hospital versus being at the VA hospital… if you go to the [VA] ER they go above and beyond to make sure that before you leave you have an answer as to why you were in the ER versus when you go to a civilian hospital.” (Alexis)

Community and Camaraderie of Veterans

For some participants, the environment at VA produced a sense of belonging stemming from feelings of shared community and camaraderie with other Veterans and staff committed to serving Veterans:

“Part of what makes [VA] work is smart caring people who are extremely dedicated to accomplishing service for Veterans. Mostly, well partly, because an awful lot of them are Veterans themselves.” (Carl)

“It’s the other Veterans helping Veterans, too. Don’t be afraid of a Veteran or helping Veterans. And don’t be afraid to give the VA a good name.… It’s the workers that work for VA....They are super, very professional….They take care.” (Theresa)

While connections with other Veterans can foster an environment of camaraderie, it is worth noting some participants reported feeling an “attitude” from other Veteran patients or out of place at VA based on their identities. For instance, the environment of care for Susan felt compromised while going in for VA-delivered gender-specific services without a dedicated women’s-only clinic/space:

“Where we get our mammograms, males get whatever kind of services that they get. And then the way the area is, it’s a common space. And I guess my expectation of women’s healthcare everything I need is in that one shop.”

In addition to wanting a women-focused space, Susan said she has experienced turnover of black women providers and would like to see more diversity, or, “race relative to services that are being provided” to improve the environment of care. Kimberly similarly said the environment of care and programs for women Veterans at VA has left her disappointed in the past, but she said over the past eight years, “the program for women has actually gotten better, the…treatment of women has gotten better…it just depends on [what facility] you’re at…” This improvement in the environment has affected her experience and engagement with VA-delivered care.

Transparent and Accessible Information About Providers and Services

Given the important role of patient-provider relationships, participants said they would like more information about providers and services to inform their care decisions. They stressed information should be easily accessible, such as being able to view provider bios on websites or credentials on the clinic walls. Information participants found important included provider education and experience, demographics, and patient reviews. Several participants talked about a lack of information available about their VA providers:

“There’s nothing out there that tells you the quality care of that provider. So, before I went and seen the orthopedic doctor I seen at the VA, I had no idea who this person was, where they been, what they’ve done, whether they’ve done five surgeries or if they’ve done 10,000 surgeries. I had no idea, so you go in there blind.” (Lori)

“I want to know what the knowledge of the person is, their capabilities… I want to know that that’s what they studied in. I want to know that they are proficient in that area…In the VA, I can’t do that. So, I’m like… are they really qualified?” (Barry)

“What’s the demographics of the providers…gender, race? For some Veterans that is important.” (Susan)

Steven said he does his own research and gets recommendations from others when looking for a provider. He considers provider years of experience and whether they have complaints against them. Similarly, Alexis said she is “really big on reviews” and will look potential providers up online to see what other patients have said.

Patient information needs can also be addressed via providers, who can present options and guide patients in care decisions. Anthony, for instance, valued the shared decision-making facilitated by his VA provider in the referral process to see a specialist in the community:

“[My VA provider] knew all the doctors in the community…knew who to refer you to. And he would give me some choices… options with recommendations. And he wouldn’t necessarily say “go to this doctor,” but he’d ask me—"How do you feel about going to this doctor?” And that gives you the opportunity to …have a conversation about how you’re going to make that decision.”

Adequate Information Around Care Coordination and Referrals

When participants are considering where to receive care, they said they need more information about the referral process prior to receiving VA-purchased care, and the implications of going outside VA, particularly for switching to VA-purchased primary care.

Carl, for instance, did not realize that switching to a community PCP closer to his home meant he would be disenrolled in the VA home telehealth program. His VA PCP asked him during a visit if he would prefer to have a PCP closer to home, and he agreed without discussing details or understanding the implications. When Carl realized how switching to a community PCP affected other aspects of his care, he switched back to VA-delivered primary care. He said he experienced “unintended consequences” because he had initially decided without all the information and suggested it would be helpful if:

“VA had counselors like [Medicare] that could explain things and answer questions and … try to help people like me who are making decisions on the imperfect information to get more information.”

DISCUSSION

Existing research demonstrates mixed experiences and outcomes among Veterans using multiple systems of care.21–28 Yet, evidence is limited on what guides Veterans’ decisions about using VA-delivered or VA-purchased care―an important area of study as one-third of VA-enrolled Veterans are now eligible for VA-purchased care.13, 14 Our study addresses this gap by illustrating how the values and preferences of Veterans we interviewed informed their decisions about using VA-delivered or VA-purchased care, and suggests information Veterans need to make these decisions. In considering where to receive care, nearly all Veterans we interviewed reported the importance of high-quality relationships with providers characterized by trust, empathy, authenticity, communication, and continuity. Importantly, they had mixed feelings about whether VA-delivered or VA-purchased care providers delivered on high-quality relationships, impacting their decisions about where to seek care. This finding aligns with a meta-analysis demonstrating that patient-provider relationship quality influences whether and how often patients return to providers34 and existing research demonstrating Veterans’ mixed experiences with VA-purchased care.28, 30

Veterans also highlighted the importance of an ecosystem of care in which all staff and fellow Veterans foster a sense of community and belonging, creating welcoming, Veteran-oriented environments. In this regard, VA stood out for many Veterans for its positive ecosystem. Previous research has demonstrated the importance of the healthcare ecosystem,35–37 including showing that among Veterans, sense of belonging promotes appointment attendance and care engagement.37 However, not all Veterans in our study shared positive feelings about VA’s ecosystem―some Veterans reported feeling uncomfortable or unwelcome. Similar results have been described in the literature, such as some women Veterans feelings that VA facilities were less comfortable and safe.38

Participants reported needing more information on processes and implications of VA-purchased care use, describing confusion about referrals and care coordination. Although concerns about VA-purchased care information sharing have been previously raised, 25, 39 more research is needed regarding barriers for Veterans. Veterans also discussed needing transparent, accessible information about providers when navigating care decisions. Unfortunately, several Veterans reported that information they wanted (e.g., provider bios, education, reviews) was unavailable or inaccessible, a phenomena observed within38, 39 and outside of1, 40 Veteran-specific literature. Yet, the need for this type of information when making healthcare decisions is well-documented.4–10

With implementation of the VA MISSION Act and corresponding increase in VA-purchased care use, these findings have important implications for VA and other providers. First, it is critical that health systems including VA undertake efforts to measure and utilize information on more subjective aspects of healthcare that are important to patients. In deciding whether to send Veterans out for VA-purchased care, VA relies on common access metrics such as appointment wait times and drive distance. However, few Veterans in our study described these as key considerations impacting their decisions about where to receive care. Rather, high-quality relationships with providers and a positive ecosystem of care, reflecting key aspects of patient-centered care were important to Veterans.41 To date, research comparing patient-centeredness of VA and non-VA care is lacking,42 underscoring the need for VA and other health systems to prioritize measurement and assessment of this aspect of care.

Another important implication of our findings is that VA and community providers could improve the patient-centeredness of their care to better serve all Veterans. For example, providers can build trust with new patients by taking time to explain their clinical reasoning.43 Employing structured communication and regular care team meetings can improve teamwork, care coordination, and patient engagement.43, 44 Health systems can also develop strategies to improve workplace efficiency so providers have adequate time to establish rapport with patients.41, 43, 45 In addition, communications (e.g., appointment reminders) that are personalized to Veterans may be helpful toward promoting their sense of belonging in the healthcare ecosystem.37

Our study has several limitations. Our sample was small and comprised an older, white population of Veterans that is not representative of all Veteran experiences and perspectives. While Veterans we spoke with held generally favorable views of VA-delivered care and providers, their views may not necessarily represent those of all users. This study may suffer from selection, moderator acceptance, and recall biases.

CONCLUSION

Veterans who were eligible for both VA-delivered and VA-purchased care make valuations of the quality of their relationships with providers and the larger environment or ecosystem of care, which inform their decisions about where to receive their VA-covered care. These Veterans require accessible information on providers and care processes in order to inform their care decisions. However, Veteran reports were mixed on whether VA-delivered or VA-purchased care addressed these values and needs. Our findings point to the need for VA and other health systems to collect and utilize information that reflects patients’ priorities when working with them to navigate their care.