The Veterans Access, Choice, and Accountability Act of 2014 (VACAA) was intended to increase Veterans’ access to timely health care by facilitating services in non-VA settings. The resulting “Veterans Choice Program (VCP),” however, faced significant barriers during early implementation, including a shortage of available providers in many areas and low provider reimbursement rates.1,2 VA had mechanisms for community-based care that predated VCP, such as fee basis care, and it was not clear whether VCP would add significantly to the network of VA-paid providers already serving veterans in community settings. Although VA contracted with two third-party administrators tasked with administering the program in eastern (HealthNet Federal) and western (TriWest) regions of the country, the administrators had only ∼90 days in which to establish functioning networks of authorized providers before the implementation of VCP.
Therefore, at the time of VCP implementation in November 2014, the extent to which community-based providers would be willing or available to participate in VCP was largely unknown. Although the United States’ health care system has seen rapid changes in health care policy and the organization of for-profit and government-paid care in recent years, little research has examined factors affecting providers’ willingness to participate in government-paid provider networks.3,4 The question of providers’ willingness to participate in VCP was of particular concern in the case of specialty care providers, particularly those who treat complex conditions that occur with higher frequency among veteran populations5–7 than among civilians,8,9 such as posttraumatic stress disorder (PTSD). Lack of access to care for PTSD outside of VA had been previously identified as a gap in care nationwide,10,11 particularly in rural areas, suggesting that PTSD was likely to be an important “signal condition” for identifying challenges in VCP implementation.
To address these concerns, we conducted a survey of community-based mental health and primary care providers with 2 objectives. First, to identify factors associated with providers’ willingness to participate in VCP, we compared characteristics and attitudes toward VA and VCP among community providers who did or did not report interest in becoming VCP-authorized providers. Second, we examined providers’ perceptions and experiences of VCP to provide preliminary feedback on barriers and facilitators to provider participation in VCP. Our goal was to inform ongoing VCP implementation as well as future efforts to develop and strengthen government-paid provider networks, which are essential to the success of integrated care across an often-fragmented national health care landscape. To explore the potential impact of state-level variation, we examined providers’ perspectives on VCP in 2 states with marked diversity in their populations of providers and veterans, economic environments, rurality, and access to VA and other services: Texas and Vermont. Texas and Vermont also differed in being managed by third-party administrators TriWest and HealthNet Federal, respectively.
We drew upon Rogers’ Diffusion of Innovations framework12 to identify factors likely to be associated with provider willingness to participate in VCP networks, including provider characteristics, perceived needs of the patient population treated, and perceptions of the VCP and of VA. We hypothesized: (1) that providers who had a prior formal relationship with VA (eg, through PC3) would be more likely to express interest in becoming VCP-authorized providers; (2) that providers already treating patients with PTSD would be more likely to express interest in becoming VCP-authorized providers for PTSD care; and (3) that providers with more positive attitudes toward VA care would be more likely to express willingness to participate in VCP. With an eye toward program evaluation, we also invited providers to respond to an open-ended survey item inquiring about their willingness to participate in VCP.
We conducted a cross-sectional mailed survey among parallel samples of providers in both states: a Community Sample and a VCP-Authorized Sample. Both samples included community clinicians treating primarily adult patients; we reviewed both samples to ensure no overlap. We excluded providers who self-identified as treating <1 patient in the prior year, working primarily with children/adolescents, or providing services at a VA clinic; we also excluded prescribers practicing outside primary care/family medicine or psychiatry specialties.
With the Community Sample, we sought to understand provider adoption at this early period by assessing perceptions of VCP and attempts to participate among a general sample of community-based mental health and primary care providers across Texas and Vermont. Participants were identified using publicly available rosters for licensed physicians and other health care providers. We defined 2 main groups of participants: (1) prescribing providers, including physicians and nurse practitioners in psychiatry, primary care, and family medicine; and (2) psychotherapy providers, including clinical and counseling psychologists, social workers, licensed professional or mental health counselors, and licensed marriage and family therapists. We created a stratified random sampling frame by categorizing all providers into non-overlapping strata by state and provider type and sent surveys to providers in Texas (n=800 prescribers, n=800 psychotherapists) and Vermont (n=619 prescribers, n=651 psychotherapists).
With the VCP-Authorized sample, we sought to identify VCP experiences among providers participating in either VCP or Patient-Centered Community Care (PC3), a community care predecessor to VCP. It was important to assess PC3 participation because, at the time VCP was implemented, existing participants in VA’s PC3 program were automatically enrolled as VCP providers. The VCP-Authorized sample drew from a list of identified VCP and PC3 providers in Behavioral Medicine and Primary Care specialties provided by the VA Central Business Office, which was current through June 30, 2015. Surveys were sent to all listed providers in Vermont (n=30 prescribers, n=15 psychotherapists) and stratified random samples in Texas (n=391 prescribers, n=218 psychotherapists).
We recruited providers through a letter inviting participation in a survey to help the VA build stronger partnerships with community health care providers, particularly those treating patients with PTSD; this letter contained a Web link to the online survey, a unique username and password, and a hardcopy survey, allowing respondents to select their preferred response format. We sent a reminder letter 2 weeks later to all nonrespondents. All respondents received a $20 gift card. The University of Texas Health Science Center at San Antonio’s institutional review board determined this quality improvement project to be nonresearch.
We conducted data collection in summer/fall 2015. We received 553 responses from providers in the Community Sample and 115 in the VCP-Authorized sample, which, after accounting for incorrect addresses, provided an overall response rate of 21.1%. Response rates among Community Sample subgroups ranged from 16% to 25% (Table 1). In the VCP-Authorized group, the response rate among psychotherapists (42%) was higher than among prescribers (7%) (Supplementary Table 1, Supplemental Digital Content 1, http://links.lww.com/MLR/B310).
The Diffusion of Innovations framework has been repeatedly shown to predict factors associated with adoption of new practices such as program participation.12,13 Rogers’ framework notes the importance of: characteristics of the decision-making unit (provider characteristics); prior conditions (practice conditions, including patient population and perceived/felt need); and perceived characteristics of the innovation. Closed-ended and open-ended survey items covered topics in 3 domains, as follows:
- Provider and Practice Characteristics: items assessed provider (ie, state, age, sex, race/ethnicity, provider type, veteran status, distance from VA facility, prior training or employment in VA or Department of Defense facilities) and practice (eg, currently treat patients with PTSD or veterans) characteristics. We asked providers to specify their sources of reimbursement, including whether they receive VA reimbursement for fee basis care, PC3, or VCP, or for Civilian Health and Medical Program of the Veterans Health Administration (CHAMPVA), a VA-paid health benefit for spouses and children of permanently disabled or deceased veterans. Because being willing to accept reimbursement comparable with Medicare rates and to submit veteran medical records for inclusion in the VA health record are conditions of participating in VCP, we also assessed these.
- Perceptions of VA and VCP: items assessed providers’ awareness of VCP and general attitudes toward VA health care and VCP. We assessed perceptions of VCP using 6 items adapted from the Perceptions of Innovation Adoption scale14 based on the Diffusion of Innovations framework; response options included a 5-point Likert-type scale augmented with a “do not know” option.
- VCP Participation and Satisfaction: We asked providers to rate their level of interest in becoming a VCP provider (definitely yes/ probably yes/ probably no/ definitely no), followed by an open-ended item requesting providers to comment on their reasons for interest or lack of interest in VCP. We assessed whether providers had sought to become designated VCP providers and if so, asked them to rate satisfaction with the process of becoming a VCP provider on scale from 1 (lowest satisfaction) to 10 (highest possible satisfaction). Similarly, we asked providers whether they were a current VCP provider, and if appropriate, to rate their level of satisfaction with being a VCP provider (scaled, 1–10).
We drew or adapted survey items from those validated in prior studies,14–16 and refined these where necessary based on feedback from local providers, organizational leadership, and VA partners from the Office of Analytics and Business Integrity, Quality Enhancement Research Initiative, National Center for PTSD, and Office of Rural Health. The survey took an estimated 10–15 minutes to complete.
Statistical analysis compared providers’ personal and practice characteristics and attitudes regarding the VA and VCP. We weighted analyses for the Community Sample to account for differing selection and response rates across provider groups and two states of different population size; we did not weight VCP-Authorized Sample calculations because of low cell counts for Vermont. Because few differences emerged across provider characteristics and attitudes at the state level (Table 1), we combined Texas and Vermont groups in later analyses; we maintained distinction by provider type (psychotherapist and prescriber). We conducted comparisons using the Rao-Scott χ2 test for weighted Community Sample data and the binomial test of proportions or the Fisher exact test for the VCP-Authorized Sample. We created a logistic regression model with weighted Community Sample data to identify variables associated with interest in VCP participation. Variables were selected for inclusion based on statistically significant results among the comparisons; the model also included adjustments for providers’ state, age, sex, and race/ethnicity.
Finally, we conducted qualitative content analysis to identify potential barriers and facilitators to VCP participation among 520 responses to an open-ended survey item inquiring: “Please comment on why you are or are not interested in participating as a provider in the Veterans Choice Program.” Following a grounded-theory approach, we first reviewed responses independently to identify key themes emerging in the text, then met to develop a preliminary list of codes reflecting the themes identified. Three authors then independently coded 50 responses, assigning applicable codes to each response, followed by further refinement of the codebook. Two authors then applied the final coding scheme to remaining responses, with discrepancies resolved by the first author. We calculated the frequency and percentage frequency with which codes were mentioned by respondents and compared these by level of interest in VCP participation and provider type.
The majority of responding Community Sample psychotherapists were master’s-level psychotherapy providers, whereas the majority of responding prescribers were primary care physicians or nurse practitioners (Table 1). Fewer than 10% of all providers reported receiving VA reimbursement through fee basis care, PC3 or VCP.
Perceptions of VA and VCP
Attitudes toward VA health care were mixed in the Community Sample, with 36% of psychotherapists agreeing the VA health care system provides high-quality care and 33% reporting they are hesitant to refer clients to VA. Approximately one third of psychotherapists and one fourth of prescribers were aware of the VCP. Vermont prescribers were significantly more likely than those in Texas to agree that the VA health care system provides high-quality care, and were significantly more likely than Texas prescribers to be aware of VCP.
Interest in VCP Participation
Approximately half of providers reported interest in becoming a VCP provider; fewer than 3% of psychotherapists and fewer than 5% of prescribers had attempted to do so.
Factors Associated With Interest in Becoming a VCP Provider
We found in bivariate analyses (Table 2) that specific provider and practice characteristics were significantly associated with interest in VCP participation. For both psychotherapists and prescribers, those who were veterans, receive VA reimbursement (fee basis, PC3, CHAMPVA), were willing to accept Medicare rates, and were willing to submit a copy of veteran medical records for inclusion in the VA medical record were significantly more likely to report interest in VCP participation. Psychotherapists who reported interest in VCP participation were also significantly more likely to personally provide treatment for PTSD symptoms and treat more clients with PTSD.
Reported perceptions of the VA were not significantly different by level of interest in VCP participation among psychotherapists or prescribers. Certain perceptions of VCP itself, however, were associated with interest in program participation only among psychotherapists. Psychotherapists interested in VCP participation were more likely to be aware of VCP, to be familiar with the program’s goals and requirements, and to feel VCP is relevant for their patient population, likely to improve veterans’ access to mental health services, and likely to increase veterans’ access to timely appointments. Psychotherapists interested in VCP were also more likely to report that they would be more comfortable becoming a VCP provider if they were able test the program out on a limited basis.
We also conducted separate logistic regression models by provider type and found that differing factors were associated with interest in VCP participation among psychotherapists and prescribers (Table 3). Among psychotherapists, being a master’s-level psychotherapist, receiving reimbursement through a VA-paid program (eg, fee basis care or PC3), treating more patients with PTSD, and being willing to submit documentation for inclusion in VA medical records were significantly associated with interest in VCP participation. Among prescribers, interest in VCP participation was associated with being a veteran, being willing to accept Medicare rates, and being willing to submit documentation for inclusion in the VA medical record.
Provider and Practice Characteristics
A majority of providers responding from the VCP-Authorized sample reported treating veterans and treating patients with PTSD (Supplementary Table 1, Supplemental Digital Content 1, http://links.lww.com/MLR/B310). Approximately 40% of providers from this sample reported being aware of VCP; 17% reported currently receiving VA reimbursement through fee basis care, PC3 or VCP.
Barriers and Facilitators to VCP Participation
In open-ended responses, providers from both Community and VCP-Authorized Samples frequently reported barriers to participation in VCP (Table 4). The most commonly cited barriers included not knowing enough about the program, feeling VCP was not applicable to their current setting or specialty, being unwilling to deal with claims or billing, working in an organizational setting where the decision regarding VCP participation was made by others, and feeling the reimbursement rate was inadequate. Providers interested in VCP participation described barriers at lower frequency and often reported at least one potential facilitator, including desiring to work with veterans/service members, perceiving a need for the VCP, and perceiving value in the VCP. Providers were who not interested in VCP participation reported few potential facilitators.
Experiences of Actual or Attempted VCP Participation
Few providers in either Community or VCP-Authorized samples reported actively attempting to become a VCP provider (n=21). Of those, only 12 reported currently serving as a VCP provider. Providers who had attempted to become a VCP provider reported low mean satisfaction with the process (4.85 of possible 10). Mean satisfaction among current VCP providers was slightly higher (6.0).
This study examined providers’ interest in and experiences with Veterans’ Choice Program participation during its early period of implementation. As hypothesized, we found that providers who were already receiving VA reimbursement for community care or treating patients with PTSD were significantly more likely to report interest in participating in VCP for PTSD care. Contrary to expectations, we did not find that providers with more positive attitudes toward VA care were more likely to report interest in VCP.
Several findings stand out for their potential impact as VA moves ahead with merging VCP and its predecessor programs (eg, PC3) under an umbrella model of “Community Care”. First, we found that few prescribers or psychotherapists in the Community Sample reported any participation in fee basis care, VCP or PC3 programs, with participation only rising to 17% in the VCP-Authorized Sample. This last finding was surprising, as VCP-Authorized providers were drawn from a then-current list of identified VCP and PC3 providers provided by the VA Central Business Office and we expected ∼100% participation. This finding was consistent, however, with the fact that providers in both samples reported lower than expected awareness of VCP, which may reflect inadequate engagement with providers during this period. In total, these results suggest infrequent adoption of VA’s community-based care programs among providers during early implementation of the VCP, as well as relatively low satisfaction with the process of VCP authorization and referral among the few providers who had attempted to join the program.
Looking more broadly at providers’ attitudes toward VA and the VCP reveals both challenges and opportunities for continued implementation of Community Care. Providers reported a range of perspectives on the quality of VA care and their interest in participating as a VCP provider. Significantly more positive attitudes toward VA among Vermont prescribers may reflect long-standing collaborations between the community and VA facility leadership at the White River Junction VA and the National Center for PTSD, including outreach and academic-detailing activities. Although perceptions of VA were not significantly associated with interest in VCP participation in this study, examining such examples of “positive deviance” may provide insight into more effectively engaging providers in other regions.
Both quantitative and qualitative findings presented here may be of value in VA’s efforts to engage providers in community care networks. For example, while providers’ state of practice did not emerge as an important predictor of interest in VCP, interest was higher among specific groups, including master’s-level psychotherapists and prescribers who were veterans themselves. These findings may have dual utility in network-building efforts: first, by supporting efforts to identify providers most likely to respond positively to outreach; and second, by helping to tailor outreach messaging and communications. In open-ended responses to a question about why they were or were not interested in VCP, providers offered substantive insight into motivations for participating, including the desire to work with veterans and the perceived need for and value of the VCP for increasing veterans’ access to care. Results of the content analysis may also suggest that providers reporting interest in VCP participation were aware of potential challenges. Taken in sum, these data suggest that efforts to reduce barriers to VCP participation should be accompanied by efforts to emphasize the program’s opportunities and social value.
This work was conducted for the purpose of quality improvement and results were not intended to generalize beyond the states in which surveys were conducted. Limitations that should be taken into account include the relatively low survey response rate. Although our response rate (21%) is comparable with commonly reported response rates of 25%–40% among mental health service providers,17 and in line with declining response rates among health care providers overall,18 these respondents may have self-selected based on their level of interest in veterans or PTSD care. Thus, our findings may indicate a “best case” estimate of engagement in the VCP program—interest may be even lower in the general provider population than among our survey participants. Because this survey was conducted during the first year of VCP implementation, it may be appropriate to consider these findings reflective of attitudes as VCP was first getting established; awareness of and engagement with the program may improve over time.
The relatively low number of providers who reported currently receiving VA reimbursement, or having attempted to become a VCP provider, may reflect difficulty understanding the relevant survey questions, despite extensive piloting of survey language to ensure optimum clarity. Providers, particularly those in group or agency settings, may have been unaware that they were receiving VCP or PC3 reimbursement. Moreover, due to the sequence of survey questions, findings may underrepresent participation by VCP providers who, because of prior status as PC3 providers, were not required to make any active attempt to initiate VCP participation. Even so, the total number of providers reporting any participation in fee basis, VCP or PC3 care remained low. Relatively low rates of first-year VCP authorizations across the nation (described in other papers in this special issue), and our finding that only between 20% and 50% of all respondent groups reported being aware of the VCP (Table 1 and Supplementary Table 1, Supplemental Digital Content 1, http://links.lww.com/MLR/B310), are consistent with the interpretation that few mental health and primary care providers were actively participating in VCP during this time.
Because PTSD is a complex and high-prevalence condition among veterans, understanding community clinicians’ interest in providing PTSD care under VCP may offer important insight into the future of VA’s Community Care programs, particularly for conditions requiring specialty care. Encouragingly, these results suggest that VA and community providers often share a mission to serve veterans that provides common ground for developing effective partnerships in PTSD care provision. Even so, developing effective infrastructure for community-based PTSD care will likely require proactive engagement by VA with non-VA providers to achieve more robust provider networks.
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