Procedure Mix and Regional Variation in Vascular Community Care Referrals in the Veterans Administration Health Care System

The 2019 MISSION Act expanded access for veterans to receive care in facilities outside the Veterans Administration (VA) system. The effect of increasing Community Care Referrals (CCR) on vascular care for Veterans and its impact on the VA system remains unclear. We investigated the number, type, and cost of vascular surgery CCR, with the hypothesis that there could be variation in vascular community care between VA regional networks and medical centers due to VA endovascular capabilities and regional differences in vascular care. The VA CCR Dashboard and Integrated Informatics and Analytics from 2020 to 2022 were used to obtain number, cost, and paid claims for Current Procedural Terminology (CPT) codes related to vascular surgery CCRs from all 18 regional Veterans Integrated Service Networks and 140 VA medical centers. Referrals for vascular surgery were included, excluding vascular testing and dialysis management". Vascular surgery CCRs increased from 21,114 in 2020 to 41,986 in 2022 (98% increase) with an increased cost from $56,982,512 to $105,460,306 (85% increase). Although endovascular CPT codes made up just more than one-half (58%) of the top 100 paid claims, the VA paid 5.4 times more for endovascular compared to open ($220,835,958 vs $40,772,502), and endovascular procedures accounted for 85% of the vascular surgery CCR cost. Four atherectomy CPT codes (37227, 37225, 37229, and 37231) accounted for 28.4% ($73,317,966) of the total cost of the top 100 CPT codes paid. Atherectomy procedure costs were unequally distributed among individual VA medical centers with 10 out of 140 centers (7.1%) accounting for 33.5% ($24,594,566) of the total atherectomy paid claims. The geographic distribution of these 10 centers was South (n = 6), West (n = 3), North (n = 1), and East (n = 0) and 8 of the 10 centers are located in regions with high atherectomy use rates. The facility complexity classification for the 10 centers was high (n = 2), medium (n = 5), and low (n = 3), and only 2 of the 10 centers had a vascular surgeon listed on their medical staff. In the last 3 years, VA vascular CCRs have nearly doubled in number and cost. Endovascular procedures account for 85% of this cost, and over one-third of the cost involved atherectomy procedures. Of the 10 medical centers with the highest atherectomy payouts the majority were medium or low complexity, did not have vascular surgeon listed on staff, and were located in regions with high atherectomy use rate. These findings suggest that vascular CCR may be influenced by VA endovascular resources and regional differences in vascular care.