Veterans with Diabetes Who Received Community Primary Care Had Worse Diabetes Care Quality and Higher Costs than Veterans Who Received VA Primary Care
BACKGROUND:
The MISSION Act expanded Veterans' access to non-VA community care, but little is known about how the quality, costs, and outcomes of primary care received in the community compares to VA care. This study compared the quality, costs, and outcomes of community- and VA-provided primary care for Veterans with diabetes over 12 months during FY 2021–2022 (652,648 VA patients, 3,650 community care patients; VA patients were less likely to be White, had shorter mean drive time to VA primary care, and were less likely to be rural than community care patients). Quality measures included receipt of hemoglobin A1C tests, eye exams, microalbumin urine tests (to detect kidney damage), and flu shots. Outcomes were measured by hospitalizations for an ambulatory-care sensitive condition (i.e., hospitalizations that could have been prevented with appropriate primary care). Costs were measured for VA and community outpatient care, inpatient care, and prescription drugs.
FINDINGS:
- Veterans who received community primary care had worse diabetes care quality and higher mean total costs ($1,741, driven by higher inpatient and prescription drug costs) than Veterans who received VA primary care. There was no difference in health outcomes.
- Veterans who received community care were significantly less likely to receive a hemoglobin A1C test, eye exam, microalbumin urine test, and flu shot compared to the VA group.
- Community care patients had lower emergency care costs than VA patients.
IMPLICATIONS:
- Care provided by an integrated delivery system such as VA might have quality and value advantages over community care, but there are tradeoffs such as access barriers.
- Fully staffing primary care clinics, maintaining facilities based on the patient population, and using innovative telehealth programs to improve access might be as critical to VA’s future as the community care program.
LIMITATIONS:
- The study did not account for unobservable differences in Veterans’ risk or propensity to use care and did not include data for Medicare and other insurance-covered services.
- Community care patients living farther from a VA facility may have been more likely to use other non-VA care and have underreported diabetes tests and costs.
AUTHOR/FUNDING INFORMATION:
Dr. Yoon, Mr. Chow, Hao Jiang, and Ms. Wong are with HSR’s Health Economics Resource Center (HERC). Dr. Chang is with HSR’s Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP).
Yoon J, Chow A, Jiang H, Wong EP, Chang ET. Comparing Quality, Costs, and Outcomes of VA and Community Primary Care for Patients with Diabetes. Journal of General Internal Medicine. August 5, 2024; online ahead of print.
