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SDR 18-318 – HSR Study

SDR 18-318
Make Versus Buy- Examining the Evidence on Access, Utilization and Cost: Are We Buying the Right Care for the Right Amount?
Amy K. Rosen, PhD
VA Boston Healthcare System Jamaica Plain Campus, Jamaica Plain, MA
Boston, MA
Megan Vanneman PhD MPH
VA Salt Lake City Health Care System, Salt Lake City, UT
Salt Lake City, UT
Funding Period: October 2018 - September 2021


Background: The Veterans' Access, Choice, and Accountability Act of 2014 has transformed the way the VHA delivers care, and its reorganization may lead to substantial challenges that ultimately affect the quality of care that Veterans receive, and subsequently, their health outcomes. Specific Aims: Our specific aims are to: 1) examine variation in utilization and access of VHA vs. Community Care (CC) over time (FY15-FY19); 2) develop and test a methodology to compare costs between VHA and CC; and 3) examine use of specialty care, specifically surgery and mental health. Within Aim 1, we will also determine the factors associated with receiving care in VHA vs. CC. For Aim 2, we will compare cost of standardized episodes of care (SEOCs) in VHA and CC for surgical care, and examine whether use of SEOCs leads to reduced cost and utilization. We will compare quality of surgical care and mental health care between VHA and CC, and develop methods to identify “overuse” of low-value surgical/mental health care in VHA vs. CC. Unique Features/Innovations of Project: This study will evaluate how well the Veterans Choice Program is working to increase Veterans' choice about where they get their care and whether this “choice” has helped to improve their access to timely, high-quality care. Through collaboration with key operational partners (the Office of Community Care (OCC), the Partnered Evidence-based Policy Research Center (PEPReC), and the Office of Reporting, Analytics, Performance, Improvement and Deployment (RAPID)), we will provide VHA with critical information on how well VHA's transformation to a purchaser of care is working. Methodology: For Aim 1, we will conduct descriptive analyses of the overall use of VHA and CC over time. We will then run a series of stratified analyses, separately by inpatient and outpatient setting, by category of care and by SEOC and then at the facility level. We will examine patient- and facility-level characteristics that are related to the extent of use of CC using descriptive analyses and then multivariable logistic regression models adjusted for patient and facility characteristics, categorizing facilities into “higher CC use than expected” and “lower CC use than expected.” For Aim 2, we will use a difference-differences (DD) to estimate costs prior to and after the the use of SEOCs for two surgical SEOCs in VHA and CC (Orthopedics and Neurosurgery-Neuropsych). Similar analyses will be conducted for quantity of services (instead of cost). For Aim 3, we will use generalized linear models, adjusted for patient characteristics and types of services received, to evaluate differences in outcomes between patients using VHA vs. CC for surgery and mental health. Once we have a reliable estimate of the differences in quality of care and cost for the same types of services within SEOCs provided in VHA vs. CC, we will derive a method for identifying low-value care and suboptimal allocation of resources. Expected Results: Information on which services to potentially make (e.g., surgery and mental health) through increased resources/capacity and which services might be more appropriate to buy (e.g., ophthalmology, physical therapy) will be useful as VHA continues down the road as both a purchaser and provider of care.

External Links for this Project

NIH Reporter

Grant Number: I01HX002646-01

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Journal Articles

  1. Rosen AK, Vanneman ME, O'Brien WJ, Pershing S, Wagner TH, Beilstein-Wedel E, Lo J, Chen Q, Cockerham GC, Shwartz M. Comparing cataract surgery complication rates in veterans receiving VA and community care. Health services research. 2020 Oct 1; 55(5):690-700. [view]
  2. Harris AHS, Beilstein-Wedel EE, Rosen AK, Shwartz M, Wagner TH, Vanneman ME, Giori NJ. Comparing Complication Rates After Elective Total Knee Arthroplasty Delivered Or Purchased By The VA. Health affairs (Project Hope). 2021 Aug 1; 40(8):1312-1320. [view]
  3. Pettey WBP, Wagner TH, Rosen AK, Beilstein-Wedel E, Shwartz M, Vanneman ME. Comparing Driving Miles for Department of Veterans Affairs-delivered Versus Department of Veterans Affairs-purchased Cataract Surgery. Medical care. 2021 Jun 1; 59(Suppl 3):S307-S313. [view]
  4. Rosen AK, Beilstein-Wedel EE, Harris AHS, Shwartz M, Vanneman ME, Wagner TH, Giori NJ. Comparing Postoperative Readmission Rates Between Veterans Receiving Total Knee Arthroplasty in the Veterans Health Administration Versus Community Care. Medical care. 2022 Feb 1; 60(2):178-186. [view]
  5. Gordon SH, Beilstein-Wedel E, Rosen AK, Zheng T, Kelley AT, Cook J, Zahakos SS, Wagner TH, Vanneman ME. County-level Predictors of Growth in Community-based Primary Care Use Among Veterans. Medical care. 2021 Jun 1; 59(Suppl 3):S301-S306. [view]
  6. Vanneman ME, Rosen AK, Wagner TH, Shwartz M, Gordon SH, Greenberg G, Zheng T, Cook J, Beilstein-Wedel E, Greene T, Kelley AT. Differences Between VHA-Delivered and VHA-Purchased Behavioral Health Care in Service and Patient Characteristics. Psychiatric services (Washington, D.C.). 2023 Feb 1; 74(2):148-157. [view]
  7. Rosen AK, Wagner TH, Pettey WBP, Shwartz M, Chen Q, Lo J, O WJ, Vanneman ME. Differences in Risk Scores of Veterans Receiving Community Care Purchased by the Veterans Health Administration. Health services research. 2018 Dec 1; 53 Suppl 3:5438-5454. [view]
  8. Wagner TH, Lo J, Beilstein-Wedel E, Vanneman ME, Shwartz M, Rosen AK. Estimating the Cost of Surgical Care Purchased in the Community by the Veterans Health Administration. MDM policy & practice. 2021 Nov 16; 6(2):23814683211057902. [view]
  9. Mattocks KM, Cunningham KJ, Greenstone C, Atkins D, Rosen AK, Upton M. Innovations in Community Care Programs, Policies, and Research. Medical care. 2021 Jun 1; 59(Suppl 3):S229-S231. [view]
  10. Mengeling MA, Mattocks KM, Hynes DM, Vanneman ME, Matthews KL, Rosen AK. Partnership Forum: The Role of Research in the Transformation of Veterans Affairs Community Care. Medical care. 2021 Jun 1; 59(Suppl 3):S232-S241. [view]
  11. Vanneman ME, Wagner TH, Shwartz M, Meterko M, Francis J, Greenstone CL, Rosen AK. Veterans' Experiences With Outpatient Care: Comparing The Veterans Affairs System With Community-Based Care. Health affairs (Project Hope). 2020 Aug 1; 39(8):1368-1376. [view]

DRA: Health Systems
DRE: Treatment - Comparative Effectiveness, TRL - Applied/Translational
Keywords: Effectiveness, Outcomes - Patient, Quality of Life
MeSH Terms: None at this time.

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