Women Veterans who discontinue using VA differ in important ways from those who continue using VA, supporting our first hypothesis. Attriters seem to be in better health overall and to have stronger enabling circumstances for healthcare access in the private sector (e.g., higher income, less disability). Not surprisingly, attriters had less positive perceptions of VA than non-attriters, with attriters having relatively lower ratings of VA quality (e.g., 47 % of attriters versus 18 % of non-attriters rating quality at 6 or less out of 10) and of gender-specific features of VA care, though approximately two-thirds of attriters still rated the VA favorably on these features.
Our initial interpretation of these differences in perceptions was that they were accounted for by women Veterans who had not experienced the quality transformation in VA health services. However, when we stratified attriters by those whose last visit occurred prior to, versus after, the initiation of the transformation around 2001, our secondary hypothesis was not supported, in that we did not find substantial differences in perceptions, except that remote attriters were more likely to agree that they feel welcome as women at the VA. By virtue of the recency of their last VA use, recent attriters may have had more proximal negative experiences that affected their perception of feeling welcome.
Though thirty percent of VA attrition occurred in the past 5 years, and close to one-half occurred in the past 10 years, we found that a considerable minority of remote attriters last used VA healthcare several decades ago. A limitation of our study is that recollections about the decision to discontinue VA care are subject to recall bias, particularly for remote attriters. Nonetheless, our study provides important baseline data that warrants further investigation. To better characterize reasons for attrition, research should be directed toward characterizing women Veterans’ decision-making about discontinuing VA use as soon as they are identified as being lost to VA care. Another limitation of the study is that only about half of all women Veterans were identified for sampling by the National Survey of Women Veterans. This may limit generalizability of the study. However, the women Veterans most likely to be missing from the sampling frame were those who never enrolled in VA health care and those who separated from the military more than 20 years ago.22
Our analytic sample was comprised of women Veterans who enrolled in VA care and used it at least once.
Access to care by women Veterans is a VA priority. Since attrition is the flip side of access, preventing VA attrition is aligned with key VA priorities. In an era of increased consumer healthcare choice, the VA, like other healthcare institutions, needs to remain a provider of choice. Economies of scale often influence which healthcare services are offered on-site rather than through off-site contracts; therefore, retention of greater numbers of women in VA healthcare could potentially promote expansion of the scope of women’s health services delivered on-site at VA facilities. As only 16 % of women Veterans used VA in fiscal year 2009,27
an understanding of reasons for attrition can inform efforts to re-engage women who have attrited, to retain current users, and even, potentially, to attract new VA patients. At the patient level, increased continuity of care through re-engagement or sustained, continuous engagement in VA care could promote early intervention to avert or reduce late-life diseases and their concomitant adverse effects on healthcare costs and quality of life.3,28
While we learned that women who discontinued using VA were, on the whole, physically and socioeconomically healthier than women who continued to use VA, there is some concern in the health services field about the potential consequences of changing healthcare providers. Those who switch providers will experience at least temporary discontinuity of care, which may adversely affect health outcomes and overall healthcare costs.28,29
Provider discontinuity has been associated with less receipt of preventive services, less medication adherence, increased emergency department visits, hospitalization, specialty provider utilization, as well as increased pharmacy costs.30–33
Rarely, however, has discontinuity been examined in the context of switching from one healthcare institution to another; this potentially risky transition warrants further investigation. In recent years, VA has created a free, online personal health record for VA users [“My Healthe
], which also creates a potential portable medical record system that could be used by both VA and non-VA clinical staff to support continuity of care between healthcare systems used by the Veteran. Research is needed on ways to promote its use and effectiveness in minimizing the discontinuity effects of switching healthcare systems.
Some evidence from outside the US suggests that switching healthcare systems generally occurs more often among young and healthy people rather than among elderly or people in bad health.34
We similarly found that discontinuation of VA health care was more common among healthier individuals. However, our findings differ in that those who discontinued VA care were older. This difference in findings may be due to older Veterans being more likely to become eligible for Medicare. We also found that need characteristics such as mental health status (specifically PTSD) and history of military sexual assault were associated with continuing to use VA. Military sexual assault is associated with significant negative physical and mental health consequences.2
VA has developed specialized services for these issues (including a Military Sexual Trauma Coordinator at every VA), which may be an important facilitator of VA retention for some women Veterans.2
A study of women Veterans initiating VA care in a recent year found that three years later, 30 % of that group no longer used the VA.3
In contrast, our sampling frame was comprised of women Veterans who had used VA care at least once, and found that 54 % of this group no longer used VA care. Understanding women Veterans’ attrition from VA is urgent. Starting in 2014, Medicaid eligibility reform will provide additional options to some women, who may leave VA if services do not meet their expectations or if other available options are more appealing. Furthermore, the largest group of women currently using VA are those 45–64 years old; their ranks have recently swelled with new users.27
Therefore, over the coming decade, a large wave of women will reach age 65 and become Medicare-eligible. Women who do not see VA as the healthcare provider of choice may choose to leave for private providers, which could reduce the critical mass of women Veterans in VA and affect current system-wide efforts to provide high-quality care for women Veterans.