Following the VA MISSION Act, reliance on VA-paid community specialty care increased markedly for Veterans with diabetic foot ulcers, particularly in rural areas, while reliance on Medicare-paid care decreased.
Key Findings
Results
VA-paid community specialty care for diabetic foot ulcers increased substantially following the MISSION Act, with larger relative growth among rural Veterans.
Rural Veterans experienced a +119% increase in VA-paid community specialty care following the MISSION Act.
Urban Veterans experienced a +96% increase in VA-paid community specialty care following the MISSION Act.
The study cohort included 76,398 patients aged 65 or older with a new DFU diagnosis in VA between 2016 and 2022.
Specialty encounters assessed included podiatry, vascular surgery, infectious diseases, and endocrinology.
Results
Medicare-paid DFU-related specialty care declined following the MISSION Act in both rural and urban Veterans.
Medicare-paid DFU specialty care declined by 12% among rural Veterans following the MISSION Act.
Medicare-paid DFU specialty care declined by 13% among urban Veterans following the MISSION Act.
The decline in Medicare-paid care occurred concurrently with the increase in VA-paid community specialty care.
Community encounters were categorized as either VA-paid or Medicare-paid to distinguish payer type.
Methods
The study examined a retrospective cohort of Veterans aged 65 or older with a new DFU diagnosis treated within the VA system from 2016 to 2022.
The cohort included 76,398 patients total.
The study design was a retrospective cohort study.
The study period spanned 2016 to 2022, capturing both pre- and post-MISSION Act time frames.
Annual trends in community specialty care and changes in proportion and payer type of care were assessed before and after the MISSION Act.
Background
The VA MISSION Act expanded eligibility for community-based care particularly for Veterans facing geographic or capacity-related barriers, which is especially relevant for rural Veterans with diabetic foot ulcers.
The MISSION Act stands for Maintaining Internal Systems and Strengthening Integrated Outside Networks.
Patients with diabetic foot ulcers require timely specialty management and are described as 'vulnerable to fragmented care.'
Prior to this study, little was known about how the MISSION Act reshaped patterns of DFU-related specialty care within and outside the VA.
Rural Veterans showed larger relative growth in VA-paid community specialty care compared to urban Veterans, consistent with the Act's geographic access goals.
What This Means
This research examined how a major policy change — the VA MISSION Act — affected the way veterans with diabetic foot ulcers (DFUs) received specialty medical care. DFUs are serious wounds that require timely attention from specialists like podiatrists, vascular surgeons, and infectious disease doctors. The MISSION Act, implemented to improve access to care for veterans who face geographic or other barriers, allowed more veterans to receive specialty care in their local communities with the VA paying for it. The study followed over 76,000 veterans aged 65 and older who were diagnosed with a new DFU between 2016 and 2022.
The study found that after the MISSION Act took effect, the use of VA-funded community specialty care roughly doubled, with rural veterans seeing an even larger increase (119%) compared to urban veterans (96%). At the same time, the use of Medicare-funded specialty care for DFUs dropped by about 12–13% in both rural and urban groups. This suggests that veterans shifted from using their Medicare benefits to using VA-sponsored community care to access specialty treatment.
This research suggests that the MISSION Act meaningfully changed how veterans with diabetic foot ulcers access specialty care, particularly benefiting those in rural areas who previously had fewer options. The shift from Medicare-paid to VA-paid community care also raises important questions about care coordination, since veterans seeing community providers through the VA may require careful management to avoid fragmented treatment across different healthcare systems.
Suzuki H, Vaughan-Sarrazin M, Ohl M, Mecham B, McCoy K, Livorsi D. (2026). Changing Patterns of Specialty Care for Diabetic Foot Ulcers Among Rural and Urban Veterans Following the VA MISSION Act.. International wound journal. https://doi.org/10.1111/iwj.71039