Barnett PG (Stanford University)
Agonist therapy is the most effect treatment for opioid dependence disorders, but this care is offered at only 36 VA sites. This project evaluated whether economic incentives of the Veterans Equitable Resource Allocation (VERA), the case-mix adjusted capitation system used by VA to allocate resources, inhibit access to this therapy.
Annual cost, estimated VERA revenue, and the presence of any of 41 chronic diseases was obtained for a 10% sample of patients who used VA in fiscal year 2001. Multivariate analysis was used to find the marginal effect of opioid dependence disorders, other chronic disease, age, race, eligibility status, and gender on the cost of care, revenue allocations, and their difference.
VA allocated an average of $11,954 for the care of opioid-dependent patients. These patients incurred an average of $15,556 in annual health care cost. A multivariate analysis showed that opioid-dependent patients had $2,523 greater cost (p <.001) and earned $526 less (p <.001) than patients without this disorder. VA facilities lost $2,006 for each opioid-dependent patient treated, controlling for all other factors (p <.001). This problem extended to most other chronic diseases.
The VA resource allocation system doesn’t adequately case-mix adjust for the additional cost of treatment patients with chronic disease. Of the 41 chronic diseases evaluated, allocations were less than the cost of care for 36. VERA allocations exceeded the cost of care for the remaining five conditions: spinal cord injury, schizophrenia, AIDS, hepatitis C, and dementia exceeded the cost of care.
The VA resource allocation system discourages the creation of opioid substitution programs. Implementation of best practices for treatment of opioid dependence will be facilitated by adjustment to the case-mix measure used by VERA. The imperfect VERA case-adjustment represents a potential barrier to adoption of any program that might attract additional patients with any of 36 different chronic illnesses into the VA health care system.