Changing Patterns of Specialty Care for Diabetic Foot Ulcers Among Rural and Urban Veterans Following the VA MISSION...

The Veterans Affairs (VA) Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act expanded eligibility for community-based care particularly for Veterans facing geographic or capacity-related barriers. Patients with diabetic foot ulcers (DFU) require timely specialty management and are vulnerable to fragmented care, yet little is known about how the MISSION Act reshaped patterns of DFU-related specialty care within and outside the VA. We conducted a retrospective cohort study of Veterans aged 65 or older with a new DFU diagnosis in VA between 2016 and 2022. We identified DFU-related specialty encounters (podiatry, vascular surgery, infectious diseases and endocrinology) and categorised community encounters as VA-paid or Medicare-paid. We assessed annual trends in community specialty care and changes in the proportion and payer type of care before and after the MISSION Act. Among 76 398 patients, VA-paid community specialty care increased substantially following the MISSION Act, with larger relative growth among rural Veterans (rural: +119%; urban: +96%). In contrast, Medicare-paid DFU specialty care declined during the same period (rural: -12%; urban: -13%). Following the MISSION Act, reliance on VA-paid community specialty care increased markedly for Veterans with DFU, particularly in rural areas, while reliance on Medicare-paid care decreased.