Differences in use of Veterans Health Administration and non-Veterans Health Administration hospitals by rural and urban Veterans after access expansions

Abstract: PURPOSE: To examine changes in rural and urban Veterans' utilization of acute inpatient care in Veterans Health Administration (VHA) and non-VHA hospitals following access expansion from the Veterans Choice Act, which expanded eligibility for VHA-paid community hospitalization. METHODS: Using repeated cross-sectional data of VHA enrollees' hospitalizations in 9 states (AZ, CA, CT, FL, LA, MA, NY, PA, and SC) between 2012 and 2017, we compared rural and urban Veterans' probability of admission in VHA and non-VHA hospitals by payer over time for elective and nonelective hospitalizations using multinomial logistic regression to adjust for patient-level sociodemographic features. We also used generalized linear models to compare rural and urban Veterans' travel distances to hospitals. FINDINGS: Over time, the probability of VHA-paid community hospitalization increased more for rural Veterans than urban Veterans. For elective inpatient care, rural Veterans' probability of VHA-paid admission increased from 2.9% (95% CI 2.6%-3.2%) in 2012 to 6.5% (95% CI 5.8%-7.1%) in 2017. These changes were associated with a temporal trend that preceded and continued after the implementation of the Veterans Choice Act. Overall travel distances to hospitalizations were similar over time; however, the mean distance traveled decreased from 39.2 miles (95% CI 35.1-43.3) in 2012 to 32.3 miles (95% CI 30.2-34.4) in 2017 for rural Veterans receiving elective inpatient care in VHA-paid hospitals. CONCLUSIONS: Despite limited access to rural hospitals, these data demonstrate an increase in rural Veterans' use of non-VHA hospitals for acute inpatient care and a small reduction in distance traveled to elective inpatient services.

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