Intensive Care Unit Admissions Purchased or Delivered by Veterans in the VA Health Care System

The Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act expanded access to community-based health care for veterans enrolled in the Veterans Affairs (VA) Health Care System. At the same time, the COVID-19 pandemic created unprecedented demand for intensive care unit (ICU) care. The combined impact of these changes on critical care delivery, outcomes, and spending remains unclear.

To describe patterns in ICU admissions, case complexity, 90-day mortality, and VA spending for VA-delivered vs VA-purchased community ICU care from 2019 to 2023.

Repeated cross-sectional study of 1 151 915 ICU admissions among veterans treated at 99 VA medical centers (VAMCs) and 4288 community hospitals reimbursed through the VA Community Care Network from January 1, 2019, to December 31, 2023. Stratified time series analyses were used to illustrate trends across 4 periods: pre-MISSION, post-MISSION, COVID-19 emergency, and post-COVID-19 stabilization. Interrupted time series analyses were then applied using unified regression models with interaction terms to assess differences across these periods.

Main outcomes were monthly ICU admission volume, Case Mix Index weight, Charlson Comorbidity Index, 90-day all-cause mortality, and VA expenditures on community ICU care. Models were adjusted for demographic, clinical, and temporal covariates.

Of 1 151 915 ICU admissions among VA-enrolled veterans, including 270 237 at 99 VAMCs and 881 678 at 4288 community hospitals reimbursed through the VA community care network, 881 678 occurred in community hospitals. From 2019 to 2023, ICU admissions decreased by 21.3% in VAMCs and increased by 46.8% in community hospitals. Interrupted time series models showed increased mortality during the COVID-19 period in both settings and decreased mortality in VAMCs following the pandemic. Stratified time series models showed a postpandemic adjusted mortality rate of 18.4% (95% CI, 18.2%-18.7%) at VAMCs compared with 20.0% (95% CI, 19.8%-20.2%) in the community. Community hospitals had higher median Case Mix Indices, and total inflation-adjusted VA spending on community ICU care increased by 50% from $2.70 billion in 2019 to $4.04 billion in 2023, driven by increased admission volume.

This study found that VA-purchased community ICU care expanded markedly while incurring higher costs and slightly worse outcomes. These shifts underscore growing reliance on external critical care infrastructure and raise policy concerns around VA capacity planning, care integration, and quality oversight for veterans with high-acuity needs.