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VHA Spending for VHA-Medicare Advantage Dual Enrollee Veterans More than Doubled from 2011–2020 to $12B as Dual Enrollment Grew
VHA-Medicare Advantage (MA) dual enrollment may be a source of significant excess federal spending, as MA plans receive payments for comprehensive healthcare services, without having these payments reduced if Veterans receive care in VHA. Findings from this study showed that from 2011–2020, the number of VHA-MA dual enrollees who used VHA services increased by 63%, from 14% of all VHA-Medicare enrollees in 2011 to 21% of all VHA-Medicare enrollees in 2020. Total VHA spending for dual enrollees using VHA care increased from $5 billion in 2011 to $12 billion in 2020. The largest growth in spending during this period was for community care (a relative 370% increase) followed by outpatient (220% increase), pharmacy (200% increase), and inpatient (140% increase). This study highlights the need to further understand the implications of Veteran enrollment in MA on potentially duplicative federal spending.
Date: October 2, 2024
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Veterans with Diabetes Receiving Community Primary Care Had Worse Diabetes Care Quality and Higher Costs than Veterans Receiving VA Primary 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. Findings showed that Veterans who received community primary care had worse diabetes care quality and higher mean total costs (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. Thus, 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.
Date: August 5, 2024
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Post-MISSION Act Racial/Ethnic Disparities in Use and Wait Times for VA and Community Care Primary Care
This study used VA and Community Care (CC) outpatient and consult data for FY2021–FY2022 to examine whether utilization of and wait times for primary care differed between Black and Hispanic Veterans compared to White Veterans in rural and urban areas post-MISSION. Findings showed that Black and Hispanic Veterans waited significantly longer for primary care in CC, but Hispanic Veterans in urban areas had shorter wait times relative to White Veterans. Black Veterans had shorter wait times in VA than White Veterans in rural and urban areas. Black and Hispanic Veterans were less likely to use CC for primary care, regardless of rurality status. Utilization of primary care increased for all race/ethnicity groups studied, more so in CC than VA. Most Veterans (93%) received primary care exclusively in VA. The overall mean wait time was 33 days. Despite decreases in wait times over time, primary care wait times remained longer in CC than in VA. However, wait times in both settings exceeded the 20-day wait time standards established in the MISSION Act. A better understanding of the sources of healthcare disparities (e.g., unavailability of CC clinicians in areas where Black and Hispanic Veterans live) is needed to inform strategies to ensure that all Veterans obtain timely care.
Date: June 21, 2024
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QUERI Evaluation Identifies Barriers, Facilitators, Lessons Learned, and Strategies to Better Standardize Veteran Safety Practices Across VA and Community Care
VA’s “Patient Safety Events in Community Care: Reporting, Investigation, and Improvement Guidebook” was designed to standardize safety practices across VA-delivered and VA-purchased care (i.e., community care). This project identified organizational barriers and facilitators related to Guidebook implementation, identified lessons learned during implementation, and developed strategies to improve future implementation. Six constructs were identified as both facilitators and barriers to Guidebook implementation: 1) planning for implementation; 2) engaging key knowledge holders; 3) available resources; 4) networks and communications; 5) culture; and 6) external policies. Two constructs were identified as only barriers: 1) cosmopolitanism and 2) executing implementation. Lessons learned during guidebook implementation included: 1) engage all collaborators involved in implementation; 2) ensure end-users have opportunities to provide feedback; 3) describe collaborators’ purpose and roles/responsibilities clearly at the start; 4) communicate information widely and repeatedly; and 5) identify how multiple high priorities can be synergistic. Strategies to improve future Guidebook implementation included: 1) develop collaborator relationships between VA facility and VA CC staff; and 2) support ongoing collaborator training and education. Findings will help partners and VA leadership to determine next steps and future strategies to improve Guidebook implementation and sustain the Guidebook’s safety practices.
Date: May 8, 2024
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VA’s Referral Coordination Initiative Does Not Measurably Affect VA or Community Care Wait Times or Community Care Referrals
This study investigated whether the Referral Coordination Initiative (RCI) was associated with changes in the proportion of VA specialty referrals completed by community-based care (CC) providers and mean appointment waiting times for VA and CC providers. Findings showed that in the initial years of the RCI program, RCI implementation did not measurably affect CC referral rates or wait times at VA facilities or CC providers for most specialties. Investigators did not find a strong association between RCI implementation and wait times at VA facilities for any of the specialties regardless of the type of staffing models the high RCI use facilities adopted. They also did not observe a significant relationship between RCI implementation and wait times at CC providers for most specialties, regardless of the staffing model. The results do not support concerns that RCI might impede Veterans’ access to CC providers and
suggest that VA carefully consider the value of RCI, given RCI’s use of scarce resources.
Date: March 30, 2024
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Dramatic Increase in Veterans’ Use of Non-VA Emergency Care
This study used VA data from more than 19 million ED visits during FY2016–2022 to examine national trends in the frequency and types of community ED visits, and to explore the association between VA facilities’ purchase of community care and facility and regional factors. Findings showed that the majority (73%) of ED visits occurred at VA facilities. The annual number of community ED visits increased 154% from FY2016 to 2022, while the number of unique users of community emergency care increased by 134%. The proportion of all ED visits that occurred in the community progressively increased from 18% in FY2016 to 37% in FY2022. Total community care ED payments, adjusted to 2021 dollars, were $1.18 billion in FY2016. By FY2022, VA paid approximately $6.15 billion for community ED care. The average proportion of ED visits purchased by a VA facility increased from 14% in FY2016 to 32% by FY2022. Low-complexity VA facilities were more likely to purchase community emergency care than their high-complexity counterparts. Emergency care now encompasses over one-third of the total community care expenditure. This underscores the urgency of addressing the underlying factors contributing to this budgetary surge and seeking solutions for a potentially unsustainable trend.
Date: March 8, 2024
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Veterans Experience Better Outcomes in VA Hospitals for Some Conditions, but at Higher Cost
This study compared outcomes for six acute conditions in VA and non-VA hospitals for VA enrollees of all ages in 11 states discharged between 1/1/2012 and 12/31/2017. Findings showed that Veterans in VA hospitals experienced lower 30-day mortality for heart failure (HF) and stroke and lower 30-day readmission for CABG, GI hemorrhage, HF, pneumonia, and stroke compared to Veterans in non-VA hospitals, although differences for GI hemorrhage and HF were found only in patients younger than 65 years. However, Veterans in VA hospitals also had longer mean length of stay and higher mean costs for most conditions. Younger patients hospitalized for acute myocardial infarction (AMI) in VA hospitals had a higher probability of readmission than non-VA patients. However, costs of AMI hospitalizations among younger patients were lower in VA than non-VA hospitals. Findings suggest Veterans could experience worse outcomes for some types of care without well-developed community care networks based on quality standards and sufficient care coordination between VA and non-VA providers.
Date: December 1, 2023
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Timeliness of VA Purchased Community Primary Care Did Not Improve Following Early Expansion Under MISSION Act
This study examined whether early Community Care Network (CCN) implementation impacted community primary care (PC) appointment wait times. Findings showed that expanded contracting with community providers and new provider network adequacy standards implemented through CCNs did not, in early stages, improve the timeliness of community primary care for Veterans. Wait times increased sharply for both CCN and comparison appointments after CCN implementation, ranging from approximately 30 to 40 days, which is beyond VA’s new urban and rural network adequacy wait-time standard for community care.
Date: October 28, 2022
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Increased Access to VA-Paid Community Care Resulted in Shift in Location of Surgery but No Difference in Outcomes for Veterans
VA’s Veterans Choice Program (VCP) expanded access to healthcare in community settings outside VA for eligible Veterans, but little is known about the effect of VCP on access to surgery and post-operative outcomes. This study explored the healthcare use of Veterans undergoing either VA-provided or VA-paid surgery (i.e., community care) between October 1, 2014, to June 1, 2019, when VCP ended. Findings showed that expanded access to VA healthcare resulted in a shift in the location of surgical procedures but had no measurable effect on surgical outcomes. Investigators found no difference in post-operative ED visits, inpatient readmissions, or mortality between VA-provided and VA-paid surgical procedures done in a community setting. Patients who underwent VA-paid vs. VA-provided procedures were significantly more likely to be female (13% vs. 9%), younger than 65 (49% vs. 46%), and White (74% vs. 73%), and they had a significantly lower comorbidity burden. Overall, 15% of the procedures were VA-paid (community care), and the proportion of VA-paid procedures varied by procedure type (e.g., spinal fusion and knee prosthesis had higher proportions of VA-paid care). Results emphasize the importance of access to community care and help assuage concerns of worsened outcomes due to care fragmentation. However, study results are less applicable to some select procedures (i.e., transplant, gastric bypass, or transcatheter aortic valve replacement), and VA should continue to make these decisions on a case-by-case basis.
Date: October 12, 2022
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Compared to Medicare, Veterans with VA-Financed Care are More Likely to Receive Dialysis and Hospice for Kidney Disease
In contrast to Medicare, VA is committed to ensuring that Veterans have access to hospice services regardless of whether they are still receiving disease-modifying treatments, such as dialysis for end-stage kidney disease (ESKD). This study sought to answer the question: Does the frequency of concurrent hospice and dialysis (“concurrent care”) among Veterans with ESKD vary by hospice payer? Findings showed that rates of concurrent care were substantially higher among Veterans receiving VA-financed, compared with Medicare-financed, hospice services. The proportion of Veterans receiving concurrent care was lower for those receiving Medicare-financed hospice (25%) than for those receiving VA-financed hospice, either under VA Community Care (42%) or in VA inpatient hospice (55%). Regardless of hospice payer, VA paid for the majority (87%) of dialysis treatments after Veterans were enrolled in hospice. Veterans who received concurrent care had a median hospice length-of-stay of 43 days, compared with 4 days for those who did not. Findings suggest that there is probably a substantial unmet need for concurrent care among the large majority of Veterans with ESKD receiving hospice services under Medicare.
Date: October 7, 2022
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Differences between VA- and Community-Provided Behavioral Healthcare
This retrospective cross-sectional study examined differences in the amount and type of behavioral healthcare delivered in VA and purchased in the community. Findings showed that more than 25% of Veterans receiving inpatient behavioral healthcare used VA-purchased community care, but severe behavioral conditions were treated more frequently in VA. Only 4% of Veterans received outpatient behavioral healthcare in the community, but they saw less highly-trained providers. There were more highly-trained specialists, namely psychiatrists/behavioral neurologists (22% vs. 10%) and psychologists (25% vs. 18%) treating Veterans in VA compared to those treating Veterans in the community. There also was a greater presence of social workers in VA than in community care (36% vs 15%). The top two services provided during VA outpatient visits were group psychotherapy (14%) and individual psychotherapy (9%). The top two services provided in community care were individual psychotherapy (47%) and methadone administration (15%).
Date: August 30, 2022
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VA Outperforms Wait Times Compared to Community Care
This study sought to describe geographic variation in wait times experienced by Veterans for three categories of care: primary care, mental health, and other specialties, comparing differences between VA-provided and community-provided care. Findings showed that mean VISN-level wait times were shorter for VA than for community care: 29 vs 39 days for primary care, 34 vs 44 days for mental health, and 35 vs 42 days for all other specialties. A sizeable proportion of Veterans experienced wait times that exceeded the VA standard (20 days or less): 44% of VA appointments and 50% of community care appointments. There was substantial geographic variation in appointment wait times. For example, the mean wait time for a mental health appointment in VISN 1 was 33 days for community care and 31 days for VA care, while the wait times were 55 days and 42 days for VISN 6. Findings suggest that increased access to community care under the Choice and MISSION Acts may not result in lower wait times in many areas of the country.
Date: August 25, 2022
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Low-Value Service Use Common and Costly among Veterans Enrolled in VA Healthcare
This study sought to quantify Veterans’ overall use and cost of low-value services, including VA-delivered care and VA-purchased community care. Findings showed that low-value service use is common and costly across a variety of VA services. In this study cohort, 19.6 low-value services per 100 Veterans were delivered by VA facilities or VA Community Care programs in fiscal year 2018, which involved 14% of Veterans at a cost of $205.8 million. The costliest low-value services included spinal injections for low back pain, which cost $43.9M (21% of low-value care spending) and percutaneous coronary intervention for stable coronary disease, which cost $36.8M (18% of low-value care spending). Overall, the most frequently delivered low-value service was prostate specific antigen testing for men aged =75, which was also the service with the greatest proportion delivered by VA facilities, at 99%. Findings may serve as a foundation for the development of policies and interventions to more carefully monitor and ultimately reduce low-value care delivered by VA facilities – and inform the development of value-based standards for non-VA clinicians who participate in VACC programs.
Date: July 5, 2022
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Early Expansion of Benefits under Choice Act Increased Community Hospital Use but Did Not Change Mortality
This study examined changes in VA enrollees’ use of VA and non-VA hospitals from 2012-2017, as well as mortality associated with policies intended to increase access to care, such as the Choice Act. Findings showed that over the five-year study period, Veterans increased their use of community hospitals paid by VA and Medicaid and decreased their use of VA hospitals when access to non-VA care expanded. This shift in hospitalizations from VA to the community was not associated with changes in mortality rates, however, other outcomes need to be assessed to understand how changes in hospital use affected the quality of care for Veterans. Shifting inpatient care to non-VA hospitals poses significant challenges for care coordination across providers and healthcare systems and requires that outcomes be closely monitored. The VA MISSION Act of 2018 further expanded Veterans’ access to community care and is expected to amplify the trends observed in this study.
Date: June 10, 2022
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Challenges and Strain on VA System Associated with VA-Funded Community Care for Veterans with Advanced Kidney Disease
This study sought to further the understanding of the internal challenges of cross-system healthcare use to the VA healthcare system and enrolled Veterans. Three dominant themes pertaining to VA-financed community care were identified. Themes described VA as mothership, the hidden work of Veterans, and strain on the VA system. ‘VA as mothership’ describes extensive care coordination by VA staff members and clinicians to facilitate care outside VA – and the tendency of Veterans and their non-VA clinicians to rely on VA to fill gaps in this care. ‘Hidden work of Veterans’ refers to the efforts of Veterans and family members to navigate the referral process – and to serve as intermediaries between VA and non-VA clinicians. ‘Strain on the VA system’ refers to the challenging referral process and the ways in which cross-system care has stretched the traditional roles of VA staff and clinicians and interfered with VA care processes, particularly for social workers who often served as a point-of-contact for Veterans. Overall, 607 (61%) members of the study cohort had at least one active or paid claim for VA-financed non-VA care during follow-up.
Date: May 16, 2022
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Genetic Consultation Provided by VA Facilities or Centralized VA Virtual Care More Timely and Better Coordinated than Community Care Options
This study assessed care coordination and equity in the delivery of genetic care for the care models available to VA patients (i.e., VA-traditional, centralized VA-telehealth, and non-VA care). Findings showed that VA genetic care models – both traditional and centralized telehealth – had better care coordination than non-VA care. Veterans referred to non-VA care completed their consult only 57% of the time compared with 75% if referred to the VA-traditional model and 73% with the centralized VA-telehealth model. Completion of a genetic consultation if referred to non-VA care was almost 3 times longer than with either VA model (140 days vs 55 days for VA-traditional and 45 days for VA-telehealth). The centralized VA-telehealth model was associated with exacerbated healthcare disparities based on self-reported race or ethnicity and gender compared with the VA traditional model. Veterans reporting their race as Asian, American Indian, Alaskan Native, Hawaiian and other Pacific Islander, and unknown were 46% less likely to be referred to the centralized VA-telehealth model compared to the VA-traditional model. Black Veterans were significantly less likely to complete a consultation compared to White Veterans, but only if referred to the centralized VA-telehealth model. Women Veterans were 50% more likely to be referred to the centralized VA-telehealth model than the VA traditional model. VA should assess structural barriers to using centralized telehealth services and the needs and preferences of vulnerable subpopulations in order to find solutions that mitigate health disparities and improve access.
Date: April 11, 2022
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VHA In-Person Care Declined Substantially More than Community Care During Pandemic – And Has Yet to Recover
This study sought to describe how VA care patterns shifted in response to the pandemic, including all forms of care either purchased (Community Care) or provided by VA. Findings showed that overall VA healthcare use dropped precipitously in March and April of 2020, while virtual care expanded swiftly. However, VA in-person care declined substantially more than Community Care, and total encounters have yet to recover to pre-pandemic levels. The estimated total volume of missing encounters relative to the previous year (2019) was 16.5 million. Virtual care in VA increased from 6% (n=454,399) in April 2019 to 44% (n=1,894,674) in April 2020 before falling to 29% (n=1,861,922) in December 2020. As of December 2020, VA in-person care constituted just 30% of VA paid or provided care while non-acute community care accounted for 29% of all encounters. VA likely adopted a more conservative reopening strategy compared to community providers, who have different financial incentives to resume in-person care and returned close to pre-pandemic patient volume by September 2020. In the wake of concerns about access, VA has steadily increased spending on Community Care, and study results indicate existing trends pushing VA toward being a mixed payer and provider may have accelerated.
Date: October 1, 2021
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Total Knee Arthroplasties have Significantly Lower Complication Rates when Performed in VA vs. Community Care Facilities
This study compared risk-adjusted post-operative complication rates for elective total knee arthroplasties (TKAs) that were delivered vs. purchased by VA. Findings showed that overall, adjusted complication rates were significantly lower for VA-delivered vs. VA-purchased TKAs. Those TKAs delivered in VA had significantly lower risk-adjusted odds of individual complications (AMI, mechanical, joint/wound, pneumonia, and sepsis/septic shock) compared to those performed in the community. The exceptions were pulmonary embolisms (not significantly different between settings) and bleeding complications (numbers too low to calculate). Hospital-level comparisons revealed five locations where VA-purchased care out-performed VA-delivered care. These five VA locations had significantly higher complications compared to relatively low community complication rates. As the amount of VA-purchased care continues to increase under the MISSION Act, these results support VA monitoring of overall and local comparative hospital performance, in order to improve the quality of care VA delivers while ensuring optimal outcomes in VA-purchased care.
Date: August 1, 2021
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Primary Care Intensive Management for High-Risk VA Patients Did Not Improve Long-term (12-24 Month) Outcomes or Costs
This randomized trial tested whether primary care intensive management (PIM) teams could decrease acute care use, such as emergency department visits and hospitalizations, among high-risk Veterans during the second year of PIM implementation. Findings showed that offering an intensive case management program in addition to routine primary care services for high-risk patients increased outpatient use (e.g., primary care, mental health, home visits, case management, telehealth) during the 2nd year of implementation. But it did not significantly decrease inpatient use or healthcare costs, even when taking VA-covered community care costs into account. There were also no significant differences in VA healthcare use or costs for Veterans older than 65 years old or Veterans who were more frail and functionally impaired. Findings suggest approaches targeting VA patients based solely on high risk of hospitalization are unlikely to reduce acute care use or total costs beyond that provided by a well-functioning patient-centered medical home with additional support services.
Date: June 18, 2021
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Medical Care Supplement Highlights VA Efforts to Increase Healthcare Options for Veterans through Community Care
In this Medical Care Supplement, 12 articles highlight research focusing on Veterans’ use of community care and how VA facilities interact with community care providers. The Supplement offers a broad examination of VA’s expanded Community Care program, from the Choice Act through the first two years of MISSION Act implementation, and highlights areas where additional research is needed to understand Veterans’ perceptions, satisfaction, and use of VA Community Care.
Date: May 13, 2021
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Referral Coordination Team Improves Timeliness of VA Specialty Care Delivery and Patient Experience
In 2018, the Office of Veterans Access to Care (OVAC) partnered with local providers at the VA Puget Sound Medical Center to pilot a referral coordination team to manage new referrals in sleep medicine. Investigators then compared the referral coordination team and the traditional specialist-led referral method in terms of timeliness and community care referrals. Findings showed that the referral coordination team was linked to improved timeliness of specialist appointments, reduced reliance on community care services, and greater patient satisfaction, with favorable impacts on cost. Patients whose consults had been completed by the referral coordination team were much more likely to have appointment dates within 28 days after referral than matched peers in the traditional system (33% vs. 12%) and to have these appointments scheduled within 7 days (35% vs. 7%). Each year, VA Puget Sound receives approximately 6,000 sleep medicine consults. Investigators estimate that the referral coordination team could allow VA Puget Sound to accommodate 4,800 additional visits, valued at $420,368. Although referrals to community care were low among patients in both groups, patients whose consults had been managed by the referral coordination team were slightly less likely to be referred outside of VA to community care, consistent with more timely service delivery. Informed by these results, national VA partners, including OVAC and the Office of Specialty Care, are working to disseminate referral coordination to other specialties nationwide.
Date: February 1, 2021
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VA Policies to Establish National Dialysis Contracts Reduce Reimbursement Without Compromising Access or Survival
This study examined whether changes in VA reimbursement and contracting policies were associated with VA spending on dialysis, Veterans’ access to dialysis care, and mortality. Findings showed that VA policies to standardize payment and establish national dialysis contracts increased the value of community dialysis care by reducing costs without compromising access to care or survival. Over the time period that payment reforms went into effect, there was an estimated 44% reduction in average treatment prices for VA-financed community-based dialysis care. Over the same time period, there was an increase in the number of community dialysis facilities contracting with VA to deliver care to Veterans with end-stage kidney disease from 19 to 37 facilities (per VAMC), and there were no changes in either the quality of community dialysis facilities or in the 1-year mortality rate of Veterans (12% vs. 11%). Standardization of payments to community dialysis providers did not appear to have unintended adverse effects on access to care or mortality, suggesting that national price setting may be a feasible approach for VA to improve the value of community care more broadly.
Date: September 22, 2020
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Use of Community Outpatient Providers During the Choice Program was Associated with Less Attrition from VA Care
This study examined the characteristics of patients and practices that used Choice outpatient care in the first year of implementation – and whether using Choice outpatient care was associated with attrition from VA primary care over a two-year period. Findings showed that overall, the attrition rate from VA primary care was low (4.4%), and Veterans who used Choice outpatient care were less likely to leave VA primary care than VA-only users. Compared to Veterans who used only VA outpatient care, those using Choice care were more likely to be female, white, or Hispanic, to live in the Continental or Pacific region, to have a higher service-connected disability rating, to have longer driving distances to all VA care, to not have a mental health condition, and to have greater primary care and total healthcare costs at baseline. Practices that sent more patients out for Choice care had lower mean scores for patient-centered medical home implementation, especially regarding access, and longer mean waiting times for appointments. Findings suggest that the use of community care more often supplements rather than replaces VA primary care, especially for practices that experience more difficulty in providing timely patient-centered primary care.
Date: September 10, 2020
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Higher Mortality for Veterans Choosing Community Hospitals Rather than VA for Percutaneous Coronary Intervention
This study compared the clinical outcomes of Veterans undergoing elective percutaneous coronary revascularization (PCI) at VA and community hospitals after the significant expansion of the community care program. Findings showed that Veterans receiving elective PCI in the community were at higher risk of dying—especially within the first month—than those treated at a VA medical center. There was a 33% increase in death risk for Veterans treated at community hospitals versus within VA, with an absolute risk difference of 1.4%. Restricting the analysis to just the first month after the procedure showed an even sharper increase in relative risk—143%, with an absolute difference of 0.7%—for the community-hospital setting. Two-thirds (67%) of Veterans received elective PCI within VA, while 33% received PCI in community facilities. However, over the period of 2015 to 2018, the probability of having PCI performed at a non-VA hospital rose from 39% to 52%.
Date: September 1, 2020
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Wait Times Longer for Specialty Community Care vs VA Specialty Care Since Implementation of Veterans Choice Program
This study sought to: 1) Determine whether VA wait times declined after Veterans Choice Program (VCP) implementation, 2) Compare appointment wait times for specialty care in VA versus community medical centers, and 3) Identify the proportions of community care wait times that were attributable to VA administrative processes. Findings showed that within VA, orthopedics experienced the largest decline in mean wait times – from 53 days to 30 days. Lesser declines were observed for urology (42 days to 34 days) and gastroenterology (58 days to 51 days). Wait times for cardiology did not differ over time. Mean wait times for specialty care were lower at most VA medical centers compared with community care alternatives, even after accounting for administrative delays. Mean wait times at VA vs community facilities were 33 vs 38 days for cardiology; 54 vs 60 days for gastroenterology; 36 vs 44 days for orthopedics, 36 vs 51 days for urology and 41 vs 49 days overall.
Date: August 26, 2020
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Better Patient Experience for Outpatient Care Delivered by VA vs Community Care on Every Measure but Access
This study examined trends in Veterans’ experiences with outpatient community care (CC) compared with those in VA during the second and third years after Choice Act implementation. Findings showed that patient experiences were better for VA than community care in all respects except access. For specialty care, access scores were better in the community; and for primary and mental healthcare, access scores were similar in the two settings. There were significant differences in sociodemographic characteristics between VA and CC respondents across all types of outpatient care. Overall, VA respondents were older; had better perceived physical health status and mental health; had different distributions by race and ethnicity (i.e., higher portion of African American respondents); had lower education levels; lived in more urban areas; and were more likely to be insured. As purchased care further expands under the MISSION Act, the monitoring of meaningful differences between healthcare settings should continue, with the results used to inform both VA purchasing decisions and patients’ care choices.
Date: August 1, 2020
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Significant Cost Difference between VA and Community Care for Testing among Veterans with Obstructive Sleep Apnea
Traditionally, laboratory-based sleep testing was necessary to diagnose obstructive sleep apnea, but portable home sleep apnea tests provide an efficient patient-centered option, have equivalent accuracy among appropriate patients, and cost much less than lab-based testing. Using data for Veterans’ sleep studies conducted from October 2014 to July 2016 – a period of transition from Fee-Basis to Choice for community care – investigators compared sleep study use among Veterans tested by VA, Fee-Basis, and Choice providers. Findings showed that Veterans referred for community care were much less likely to receive home sleep apnea testing than Veterans cared for in the VA healthcare system, and were more likely to receive in-lab testing, leading to greater costs to the system. VA providers performed 38% of studies as home tests, compared to 19% in Fee-Basis, and 4% in Choice. Due to lower rates of home-testing, every 100 Veterans referred to Fee-Basis represented $8,831 greater costs relative to VA, and every 100 Veterans referred to Choice represented $15,814 greater costs. Results have important implications for VA as it expands the use of community care under the MISSION Act with regard to promoting efficient and patient-centered care for Veterans.
Date: June 17, 2019
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JGIM Supplement Features VA Research on Care Coordination Both within VA and with Non-VA Healthcare Providers
In March 2018, a state-of-the-art (SOTA) conference on care coordination was jointly planned by VA HSR&D and the Offices of Primary Care, Community Care, Nursing Services, and Care Management and Social Work. The SOTA was organized into three workgroups: 1) measures and models of care coordination; 2) care coordination within the VA system; and 3) care coordination between VA and non-VA providers for care paid for by VA. SOTA participants included VA and non-VA health services researchers, clinicians, and policymakers. Funded by HSR&D, this JGIM Supplement presents recommendations from the SOTA, as well as original research papers on care coordination strategies within VA and between VA and non-VA providers.
Date: May 1, 2019
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Dual Use of VA and Medicare Associated with Substantial Increase in Risk of Potentially Unsafe Opioid Use among Veterans
This study sought to estimate the prevalence and consequences of receiving prescription opioids from both VA and Medicare Part D for all dually-enrolled Veterans who filled a prescription opioid in either system in calendar year 2012. Findings showed that among Veterans dually enrolled in Medicare Part D and VA and receiving prescription opioids in 2012, more than 1 in 8 received opioids from both systems, in many cases concurrently. Compared to VA-only use of opioids, dual use was associated with a 3-fold higher risk of high-dose opioid exposure and more than twice the risk of long-term high-dose opioid exposure. Dual use also was associated with a 60-90% greater risk of these exposures than Part D only use. VA is evolving into a less integrated delivery system with more community care options. As these options increase, the prevalence of poorly coordinated dual-system care (e.g., overlapping opioids and other drug interactions and duplication) also will likely increase.
Date: February 1, 2018
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Study Compares VA Care to Community Care for Veterans Receiving Elective Coronary Revascularization
This observational study compared access, quality, and cost of elective coronary revascularization procedures between VA and community care (CC) hospitals. Findings showed that compared to CC hospitals, Veterans who underwent PCI in VA hospitals had lower mortality (1.5% vs. 0.65%), lower costs ($22,025 vs. $15,683), and similar readmission rates. Compared to CC hospitals, Veterans who underwent CABG in VA hospitals had similar mortality, similar readmission rates, but higher cost ($55,526 vs. $63,144). Compared to VA-only care, Community Care reduced net travel distance for PCI by 54 miles, and CABG by 73 miles, on average. CC care also was associated with significantly lower travel costs – an average of $156 less for PCI and $690 less for CABG. One in five coronary revascularizations for VA patients was performed at CC sites. Findings demonstrate that, on average, Veterans seeking high-quality care with low mortality and readmission rates are well-served by VA. As VA considers expansion of the CC program, ongoing assessments of value and access gains are essential to optimizing outcomes and costs.
Date: January 3, 2018
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