Highlight
- Post-2018 MISSION Act implementation, VA specialty outpatient referrals increased by 42.5% nationally.
- Proportion of specialty care referrals outsourced to community providers rose from 16.1% to 21.5%.
- Medical and surgical specialties saw greater increases in community referral rates compared to ancillary services.
- Despite expanded community care, mean wait times for new specialty visits increased, underscoring persistent access challenges.
Study Background
Access to timely specialty care within the Veterans Health Administration (VA) has historically been challenged by demand exceeding capacity and geographic constraints. In an effort to improve Veterans’ access, the MISSION Act of 2018 significantly expanded eligibility for Veterans to receive care from community providers at VA expense, particularly targeting specialty outpatient services where VA wait times were long or specialty availability limited. This policy aimed to leverage community networks to reduce bottlenecks and enhance timely care delivery for Veterans.
However, the short- and medium-term impact of this community care expansion on referral patterns, outsourcing volumes, and actual wait times have not been comprehensively quantified. Understanding these trends is crucial for assessing whether the MISSION Act’s core goal of improved access is being achieved and to guide ongoing policy and resource allocation decisions.
Study Design
This retrospective national cohort study analyzed VA administrative data on outpatient specialty care referrals among VA-enrolled Veterans from fiscal year (FY) 2019 (starting October 2018) through FY 2024 (ending September 2024). The analysis included monthly referral volumes to 24 distinct outpatient specialty services categorized as medical, surgical, or ancillary specialties.
Key measures were total specialty referral volumes, proportion of referrals outsourced to VA community-based providers, and mean new patient wait times for specialty clinic visits. Trends over the study period were assessed to evaluate changes pre- and post-MISSION Act implementation.
Key Findings
Overall Referral Volumes: Total monthly specialty referrals increased markedly from approximately 1.16 million in October 2018 to 1.66 million by September 2024, representing a 42.5% relative increase. This sharp rise may reflect growing Veteran demand or expanded capacity to refer specialty care given policy changes and demographic trends.
Referral Outsourcing to Community Providers: The percentage of specialty referrals that were outsourced to community providers increased significantly from 16.1% at baseline to 21.5% by the end of the study period, a 33.6% relative increase. This outsourcing occurred across all specialty categories initially at similar baseline rates (medical 15.7%, surgical 17.1%, ancillary 16.1%).
After MISSION Act implementation, surgical specialty referrals demonstrated the greatest relative increase in outsourcing (rising to 26.4%), followed by medical specialties (21.2%), whereas ancillary services remained relatively stable (16.7%).
Wait Time Trends: Contrary to policy goals, mean wait times for new patient specialty visits increased during the study interval despite expanded community care referral volumes. This suggests that increasing outsourcing alone did not alleviate access delays and may highlight systemic capacity issues within both VA and community networks or possible challenges in care coordination.
Expert Commentary
The MISSION Act represents a landmark shift in Veterans healthcare access strategy, emphasizing community integration. These findings indicate that while the policy effectively increased the volume and proportion of specialty care referred to community providers, it did not translate into shorter wait times. Barriers such as provider availability, referral processing delays, and coordination inefficiencies likely continue to impede timely care. Additionally, increased referral volumes might reflect unmet demand that is challenging to absorb within existing infrastructure.
Clinical leaders and policymakers should consider complementary approaches, including increased specialty workforce investment within the VA, enhanced scheduling system capabilities, and improved communication pathways between VA and community providers to ensure expedited patient flow. Further investigation into patient outcomes, satisfaction, and cost-effectiveness of community versus VA specialty care would provide a more holistic assessment of MISSION implementation impact.
Conclusion
This comprehensive national analysis reveals that the MISSION Act expanded use of community specialty care among Veterans but did not yield expected reductions in specialty clinic wait times. While community outsourcing forms one component of access improvement, multifaceted strategies addressing capacity, care coordination, and system efficiency are essential to deliver timely, high-quality specialty care to Veterans. Ongoing evaluation and policy refinement are needed to optimize Veterans Health Administration specialty services in an evolving healthcare landscape.
Funding and ClinicalTrials.gov
The original study did not specify funding sources or clinical trial registration. Further inquiries may be directed to the corresponding authors of the cited publication.
References
- Saffar D, Rose L, Gao Y, Hofer TP, Kerr EA, Saini SD, Adams MA. Trends in Outpatient Specialty Care Referrals and Specialty Clinic Wait Times in the Veterans Affairs Health System Before and After VA Community Care Expansion. J Gen Intern Med. 2026 Aug 20. PMID: 42624996.
- U.S. Department of Veterans Affairs. VA MISSION Act of 2018. Public Law No: 115-182.
- Kiser KW, et al. Evaluating specialty care access and referral patterns in Veterans Health Administration: A systematic review. Health Serv Res. 2021;56(2):123–134.
