Completing the MISSION: a Blueprint for Helping Veterans Make the Most of New Choices

  • Jeffrey T. KullgrenEmail author
  • Angela Fagerlin
  • Eve A. Kerr


The June 6, 2019, implementation of the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act commenced a new era in health care for Veterans in which the more than 9 million Veterans who use VA care can now choose community (i.e., non-VA) clinicians or facilities when certain new criteria are met. This expansion of Veterans’ health care options could give many Veterans more freedom to decide which settings best meet their individual needs and expectations, and could also lead to unintended consequences for Veterans who do not have all of the information they need to make personalized decisions about VA and community care. In this Perspective article, we recommend initial steps that VA leaders and VA clinicians need to take, and community clinicians should be aware of, in order to ensure that Veterans’ expanded health care options translate into improvements in their access and outcomes.



We thank Megan Adams, MD, JD, of the VA Center for Clinical Management Research and the University of Michigan for her valuable feedback on an earlier version of this manuscript.

Funding Information

Support was provided by the Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development (HSR&D) Service. Dr. Kullgren is a VA HSR&D Career Development awardee (CDA 13-267) at the Ann Arbor VA.

Compliance with Ethical Standards

Conflict of Interest

Dr. Kullgren has received consulting fees from SeeChange Health and HealthMine, and honoraria from AbilTo, Inc., the Robert Wood Johnson Foundation, the American Diabetes Association, and the Kansas City Area Life Sciences Institute. Dr. Kerr is on the clinical advisory board for BIND Health Insurance.


The views expressed in this article are those of the authors and do not reflect the position or policy of the Department of Veterans Affairs or the United States government.


  1. 1.
    John S. McCain III, Daniel K. Akaka, and Samuel R. Johnson VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act of 2018.; 2018. Accessed June 12, 2018.
  2. 2.
    VA launches new health care options under MISSION Act. Accessed July 5, 2019.
  3. 3.
    Weeks WB, West AN. Veterans Health Administration Hospitals Outperform Non–Veterans Health Administration Hospitals in Most Health Care Markets. Ann Intern Med. 2018. Scholar
  4. 4.
    Penn M, Bhatnagar S, Kuy S, et al. Comparison of Wait Times for New Patients Between the Private Sector and United States Department of Veterans Affairs Medical Centers. JAMA Netw Open. 2019;2(1):e187096. Scholar
  5. 5.
    O’Hanlon C, Huang C, Sloss E, et al. Comparing VA and Non-VA Quality of Care: A Systematic Review. J Gen Intern Med. 2017;32(1):105-121. Scholar
  6. 6.
    Kramer BJ, Vivrette RL, Satter DE, Jouldjian S, McDonald LR. Dual Use of Veterans Health Administration and Indian Health Service: Healthcare Provider and Patient Perspectives. J Gen Intern Med. 2009;24(6):758-764. Scholar
  7. 7.
    VA Office of Public and Intergovernmental Affairs. VA announces access standards for health care. Published January 30, 2019. Accessed January 30, 2019.
  8. 8.
    Veterans Community Care Program. Fed Regist. June 2019. Accessed July 5, 2019.
  9. 9.
    Wait Times at Individual Facilities Search - VA Access to Care. Accessed May 2, 2018.
  10. 10.
    How Does Your Medical Center Perform? Accessed May 2, 2018.
  11. 11.
    Kullgren JT, Cliff EQ, Krenz C, et al. Consumer Behaviors Among Individuals Enrolled in High-Deductible Health Plans in the United States. JAMA Intern Med. 2018;178(3):424-426. Scholar
  12. 12.
    Share DA, Campbell DA, Birkmeyer N, et al. How A Regional Collaborative Of Hospitals And Physicians In Michigan Cut Costs And Improved The Quality Of Care. Health Aff (Millwood). 2011;30(4):636-645. Scholar
  13. 13.
    Taylor EA, Carman KG, Lopez A, Muchow AN, Roshan P, Eibner C. Consumer Decisionmaking in the Health Care Marketplace. RAND Corporation; 2016.
  14. 14.
    Care Coordination - Community Care. Accessed February 6, 2019.
  15. 15.
    Spatz ES, Krumholz HM, Moulton BW. Prime Time for Shared Decision Making. JAMA. 2017;317(13):1309-1310. Scholar
  16. 16.
    Gadbois EA, Gordon SH, Shield RR, Vivier PM, Trivedi AN. Quality Management Strategies in Medicaid Managed Care: Perspectives From Medicaid, Plans, and Providers. Med Care Res Rev. 2019:1077558719841157.
  17. 17.
    Pope CA, Davis BH, Wine L, et al. Perceptions of U.S. Veterans Affairs and community healthcare providers regarding cross-system care for heart failure. Chronic Illn. 2017:1742395317729887. Scholar
  18. 18.
    Steinhauer JVA. Prepares for Major Shift in Veterans’ Health Care. The New York Times. Published June 5, 2019. Accessed July 7, 2019.

Copyright information

© Society of General Internal Medicine (This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply) 2019

Authors and Affiliations

  1. 1.VA Center for Clinical Management Research VA Ann Arbor Healthcare SystemAnn ArborUSA
  2. 2.Department of Internal MedicineUniversity of Michigan Medical SchoolAnn ArborUSA
  3. 3.Institute for Healthcare Policy and InnovationUniversity of MichiganAnn ArborUSA
  4. 4.Salt Lake City VA Informatics Decision-Enhancement and Analytic Sciences (IDEAS) Center for InnovationSalt Lake City VA Medical CenterSalt Lake CityUSA
  5. 5.Department of Population Health SciencesUniversity of UtahSalt Lake CityUSA

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