Partnered Evidence-Based Policy Resource Center, VA Boston Medical Center.
Department of Health Law, Policy, and Management, Boston University School of Public Health.
Med Care. 2021 Jun 1;59(Suppl 3):S301-S306. doi: 10.1097/MLR.0000000000001555.
The 2014 Choice Act expanded the Veterans Health Administration's (VA) capacity to purchase services for VA enrollees from community providers, yet little is known regarding the growth of Veterans' primary care use in community settings.
The aim was to measure county-level growth in VA community-based primary care (CBPC) penetration following the Choice Act and to assess whether CBPC penetration increased in rural counties with limited access to VA facilities.
A total of 3132 counties from VA administrative data from 2015 to 2018, Area Health Resources Files, and County Health Rankings.
We defined the county-level CBPC penetration rate as the proportion of VA-purchased primary care out of all VA-purchased primary care (ie, within and outside VA). We estimated county-level multivariate linear regression models to assess whether rurality and supply of primary care providers and health care facilities were significantly associated with CBPC growth.
Nationally, CBPC penetration rates increased from 2.7% in 2015 to 7.3% in 2018. The rurality of the county was associated with a 2-3 percentage point (pp) increase in CBPC penetration growth (P<0.001). The presence of a VA facility was associated with a 1.7 pp decrease in CBPC penetration growth (P<0.001), while lower primary care provider supply was associated with a 0.6 pp increase in CBPC growth (P<0.001).
CBPC as a proportion of all VA-purchased primary care was small but increased nearly 3-fold between 2015 and 2018. Greater increases in CBPC penetration were concentrated in rural counties and counties without a VA facility, suggesting that community care may enhance primary care access in rural areas with less VA presence.
2014 年《选择法案》扩大了退伍军人健康管理局（VA）从社区供应商处为 VA 参保人购买服务的能力，但对于退伍军人在社区环境中使用初级保健的增长情况知之甚少。
本研究旨在衡量《选择法案》通过后 VA 社区初级保健（CBPC）普及率的县级增长情况，并评估在 VA 设施覆盖有限的农村县，CBPC 普及率是否增加。
使用 2015 年至 2018 年 VA 管理数据、区域卫生资源档案和县卫生排名，共纳入 3132 个县。
我们将县级 CBPC 普及率定义为 VA 购买的初级保健占 VA 购买的所有初级保健的比例（即在 VA 内部和外部）。我们估计了县级多变量线性回归模型，以评估农村地区和初级保健提供者及医疗保健设施的供应情况是否与 CBPC 增长显著相关。
全国范围内，CBPC 普及率从 2015 年的 2.7%增加到 2018 年的 7.3%。该县的农村性质与 CBPC 普及率增长增加 2-3 个百分点（P<0.001）显著相关。VA 设施的存在与 CBPC 普及率增长降低 1.7 个百分点（P<0.001）显著相关，而初级保健提供者供应较低与 CBPC 增长增加 0.6 个百分点（P<0.001）显著相关。
作为 VA 购买的所有初级保健的一部分，CBPC 虽然很小，但在 2015 年至 2018 年间几乎增加了两倍。CBPC 普及率的增长幅度更大，集中在农村县和没有 VA 设施的县，这表明社区护理可能会提高 VA 存在较少的农村地区的初级保健可及性。
