County-level Predictors of Growth in Community-based Primary Care Use Among Veterans

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.