Early Impact of VA MISSION Act Implementation on Primary Care Appointment Wait Time

Diana J. Govier, Alex Hickok, Samuel T. Edwards, Frances M. Weaver, Howard Gordon, Meike Niederhausen, Denise M. Hynes

Research output: Contribution to journalArticlepeer-review


Background: Through Community Care Networks (CCNs) implemented with the VA MISSION Act, VA expanded provider contracting and instituted network adequacy standards for Veterans’ community care. Objective: To determine whether early CCN implementation impacted community primary care (PC) appointment wait times overall, and by rural/urban and PC shortage area (HPSA) status. Design: Using VA administrative data from February 2019 through February 2020 and a difference-in-differences approach, we compared wait times before and after CCN implementation for appointments scheduled by VA facilities that did (CCN appointments) and did not (comparison appointments) implement CCNs. We ran regression models with all appointments, and stratified by rural/urban and PC HPSA status. All models adjusted for Veteran characteristics and VA facility–level clustering. Appointments: 13,720 CCN and 40,638 comparison appointments. Main Measures: Wait time, measured as number of days from authorization to use community PC to a Veteran’s first corresponding appointment. Key Results: Overall, unadjusted wait times increased by 35.7 days ([34.4, 37.1] 95% CI) after CCN implementation. In adjusted analysis, comparison wait times increased on average 33.7 days ([26.3, 41.2] 95% CI, p < 0.001) after CCN implementation; there was no significant difference for CCN wait times (across-group mean difference: 5.4 days, [−3.8, 14.6] 95% CI, p = 0.25). In stratified analyses, comparison wait time increases ranged from 29.6 days ([20.8, 38.4] 95% CI, p < 0.001) to 42.1 days ([32.9, 51.3] 95% CI, p > 0.001) after CCN implementation, while additional differences for CCN appointments ranged from 13.4 days ([3.5, 23.4] 95% CI, p = 0.008) to −15.1 days ([−30.1, −0.1] 95% CI, p = 0.05) for urban and PC HPSA appointments, respectively. Conclusions: After early CCN implementation, community PC wait times increased sharply at VA facilities that did and did not implement CCNs, regardless of rural/urban or PC HPSA status, suggesting community care demand likely overwhelmed VA resources such that CCNs had limited impact.

Original languageEnglish (US)
Pages (from-to)889-897
Number of pages9
JournalJournal of general internal medicine
Issue number4
StatePublished - Mar 2023


  • Veterans
  • care
  • health
  • outcomes
  • primary

ASJC Scopus subject areas

  • Internal Medicine


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