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Objectives: US military veterans have multiple options for health insurance coverage, including the Veterans Health Administration (VHA) and Medicare programs, which can lead to strategic selection of coverage and potentially inefficient budgetary allocations. Because coverage choices are likely to be a function of coverage availability and benefit value, understanding the relationship between benefit value and reliance on coverage is critical., Study Design: Analysis of cross-sectional, nationally representative survey data., Methods: This analysis relied on a novel measure of benefit value for the VHA and Medicare Advantage (MA) programs and nationally representative survey data of veterans and their health care use for 2016 through 2019. Linear regressions controlling for beneficiary and market characteristics with state and year fixed effects were used to first estimate the effect of VHA benefit value relative to MA benefit value on MA enrollment, and then on veteran reliance on VHA-paid care conditional on MA enrollment., Results: We found that a $1 increase in relative VHA benefit value leads to at most a 0.2% (SE = 0.04) reduction in the probability of MA enrollment and a 0.3-percentage point (SE = 0.1) increase in reliance on VHA-paid care. Results were consistent across subgroups of enrollees, with slightly larger effects for enrollees with less generous benefits., Conclusions: For most veterans, benefit value has a small, often nonsignificant, effect on reliance. These results imply that changes in VHA benefit value are unlikely to have major effects on veteran reliance on the VHA.

Objective: The objective of this analysis was to evaluate the effect of resident program training size on clinician productivity and turnover in the Veterans Health Administration (VHA), the largest education and training platform for medical professionals in the United States., Data Sources: We retrieved administrative data on training programs and training facilities from the VA Office of Academic Affiliations and the VHA Corporate Data Warehouse. Data on primary care physician shortage areas were retrieved from the Health Resources and Services Administration., Study Design: We used a quasi-experimental instrumental variables 2SLS design and constructed an exogenous predicted training allocation treatment variable as a function of the total national training program allocation. The outcome was clinical staff productivity and turnover. Secondary analyses stratified results using Health Professional Shortage Areas data (HPSA)., Data Collection/extraction Methods: Data were obtained for a national dataset of 141 VHA medical facilities and 26 specialties that hosted training programs across 11 years from 2011 to 2021 (N = 132,177)., Principal Findings: Instrumental variables results showed that on average, an increase of one training slot in a specialty leads to a decrease of 0.039 visits per standardized clinic day (p < 0.001) and a 0.02 percentage point increase in turnover (p < 0.001). The direction of this association varied by specialty: while psychiatry and psychology specialties saw a decline in productivity, fields such as primary care and cardiology experienced an increase in productivity. HPSA stratified results indicate that negative effects on productivity and turnover are driven by areas with little to no primary care physician shortage, whereas shortage areas experienced a small increase in productivity and no effect on turnover., Conclusions: This quasi-experimental evaluation indicates that resident training program size is associated with reduced productivity and increased turnover in specialties such as psychiatry and in facilities with high baseline productivity. However, in specialties like primary care and cardiology, as well as areas with shortages of primary care, larger training programs are associated with increased productivity., (© 2024 Health Research and Educational Trust.)

Background: New employees generally demonstrate lower productivity than experienced colleagues in non-healthcare sectors, but there is limited evidence on how tenure affects physician productivity., Objective: To evaluate the association between tenure and clinical productivity for attending physicians in the Veterans Health Administration (VHA) and explore whether this relationship differs by prior VHA residency or fellowship training., Design: Retrospective cohort evaluation., Participants: A total of 34,878 VHA attending physicians from 27 specialties who performed outpatient encounters between October 1, 2017, and August 1, 2023, accounting for 1,518,463 physician-months., Interventions: The primary exposure variable was VHA tenure. Physicians were categorized as new hires during their initial 2 years of employment and existing employees beyond 2 years. The secondary exposure variable was whether new hires had any VHA residency or fellowship training before becoming attending physicians (internal vs. external hires)., Main Measures: The outcome was productivity, defined as the average number of encounters per clinic day at physician-month level., Key Results: Among 34,878 VHA attending physicians (1,518,463 physician-months), 17,274 (279,263 physician-months) were new hires. New hires in their 1st quarter of employment had 1.72 fewer encounters (95% CI - 1.79 to - 1.65) per clinic day than existing employees. The negative association between tenure and productivity decreased over the first 2 years of employment. By their 8th quarter of tenure, new hires had 0.44 fewer encounters (95% CI - 0.52 to - 0.35) per clinic day. Among new hires, internal hires had higher productivity than external hires, particularly in primary care and large surgical specialties., Conclusions: New attending physicians had lower productivity than existing employees, though their productivity improved with increasing tenure. Among new hires, internal hires had higher productivity than external hires and were faster to reach equivalent levels. These findings are important for health systems calculating the extended cost and access implications of physician turnover and replacement., Competing Interests: Declarations:. Conflict of Interest:: The authors declare that they have no financial disclosures or conflicts of interest. Disclaimer:: The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the US Department of Veterans Affairs or the US government., (© 2025. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

With the rapid expansion of veterans' access to community care under the Veterans Affairs Maintaining Internal Systems and Strengthening Integrated Outside Networks (VA MISSION) Act of 2018, ensuring that veterans receive high-quality community care has become a national priority. Using Veterans Health Administration (VHA) data and Medicare performance scores, we assessed how clinicians' performance on quality measures differed between those who treated veterans within the VHA Community Care Network and those who did not. We found that in 2022, 66.0 percent of community-based clinicians treated VHA enrollees. These clinicians were more likely to be male, have less practice experience, be affiliated with group practices, and be based in rural and socially vulnerable areas compared with clinicians who did not treat VHA enrollees. Notably, clinicians in the lowest quartile of quality performance measures were 8.8 percentage points more likely to treat VHA enrollees than those in the highest quartile. This pattern was most pronounced among primary care and mental health clinicians, and it persisted across VHA Community Care Network regions. These results underscore the need for federal efforts to ensure that veterans receive care from high-performing community clinicians.