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Response to Commentary

Passage of the Veterans Access, Accountability and Choice Act of 2014 initiated a VA metamorphosis with few precedents. As it continues to serve a population that is broadly diverse in age, income, and healthcare needs, VA is transforming from a provider of care to both a provider and purchaser. Moreover, it is doing so during a period of tremendous change across the broader U.S. healthcare system. These changes challenge the VA and translate into parallel challenges for researchers and the research infrastructure on which they rely. However, VA's evolution also offers opportunities to improve access, quality, and efficiency for patients.

To effectively manage this transition, VA must attend to several principal issues and concerns. First, VA must decide—and, before that, develop criteria for deciding—which types of care to provide versus which to purchase, and for which patients. For example, should VA purchase comprehensive care for particular Veterans, supplemental care for all Veterans, or some combination? The Choice Act's distance and wait time thresholds provide an initial approach to such 'make or buy' questions—an approach that is likely to be augmented and refined to meet operational needs and in response to performance evidence.

Second, once VA decides what care to purchase and for whom, it must determine how to contract for that care. Should it pay fee-for-service, employ capitation, pay for bundles of care, implement accountable care organization approaches, or something else? Third, VA must establish a means of coordinating across provided and purchased care in ways that foster the highest level of quality. The Community Care Network described by Dr. Yehia will continue to evolve and provide some answers to these questions.

Though these are new challenges, particularly given the scale at which VA must address them, they are not novel issues for VA or the U.S. healthcare system. Most VA patients already receive care both inside and outside VA. For example, 77 percent of VA enrollees have a non-VA source of healthcare coverage, and half of non-elderly VA enrollees' outpatient visits are to non-VA providers.1 And care coordination is a well-known mediator of quality and outcomes in every healthcare organization.

In fact, VA is not alone either in moving toward new approaches to emphasize value and quality or in seeking the coordination and information such approaches require. Medicare, Medicaid, and commercial market payers face similar challenges. History provides some guidance as to what may and may not work. Fee-for-service arrangements provide indiscriminate incentives for use of care, regardless of value. On the other end of the spectrum, capitation is prone to stinting on provision of services, quality short cuts, and biased recruitment and coverage strategies designed to preferentially attract patients requiring less care (also known as 'cream skimming'). Cost sharing can put patients in a position for which they are ill-suited: distinguishing between necessary and wasteful care. Our experience with newer care delivery models, such as accountable care organizations, is brief, so evidence of long-term outcomes is not yet available.

As VA attempts to apply these and other contracting methods and their variants, the role for rigorous research is clear. We need multidisciplinary teams—ones that include health economists, health services researchers, and clinicians—applying strong quantitative and qualitative methods to evaluate what works. When possible, approaches should be assessed with randomized designs. To facilitate high-quality investigative work, VA must continue to develop a data infrastructure that crosses the boundary between provided and purchased care. Fortunately, with today's technology, this is a solvable problem. Fostering and participating in health information exchange is key; interoperability across health information systems is a principal goal of VA's VistA Evolution initiative.

These are all familiar elements of calls for more research and a more complete research infrastructure to support the 21st century learning healthcare system. But we need one more thing that is a bit less familiar to and comfortable for investigators—a deep facility with policy developments and the ability to nimbly adapt research focus to rapid changes. This is one of the key challenges we are attempting to meet through the new Partnered Evidence-Based Policy Resource Center (PEPReC).2 This new HSR&D/QUERI-funded center is conducting and participating in a range of projects from urgent, quantitative technical assistance to multi-year, mixed methods randomized program evaluations. By design, all include close operations and research partnerships—and a commitment to publication-quality research and timely, policy-relevant results.

VA's transition to a joint provider and purchaser is a test, but also an opportunity. Fortunately, VA has already launched the information and research infrastructure that will be crucial to its ultimate success in passing this test.

1. Yee C, Frakt A, and Pizer S. "Economic and Policy Effects on Demand for VA Care," Partnered Evidencebased Policy Resource Center, U.S. Department of Veterans Affairs, March 2016.

2. For more information, please visit

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