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In his commentary, Dr. Mayo-Smith describes
how geographic, financial, cultural, and
chronological aspects of health services
delivery might influence access to care. He
rightly notes that organization of the health
care system influences access. Three questions
should drive a VA research agenda
regarding access to care.
What is the goal of providing access to
care?
It is important that a health care system
articulate the overarching goal for improving
access to care. A health care system may
have many such goals—to make shareholders
money, to train new health care providers,
to meet political needs, or to sustain a
bureaucracy. However, for the VA, the goal
of access should be to improve the health
and well-being of its service population.
Competing reasons should be subjugated
to this one.
What kind of health care should VA
provide access to in order to improve the
health of its service population?
Not all health care is created equal. Researchers
at The Dartmouth Institute for
Health Policy and Clinical Practice have
defined three categories of health care.1
Effective care refers to the relatively small set
of clinical services where all patients with a
specific clinical indication should receive the
treatment. The U.S. health care system is able
to deliver such services less than 55 percent
of the time, although VA performance is
somewhat better.2 To improve the health
and well-being of its service population, VA
should enhance access to effective care.
Preference-sensitive care refers to services
for which there are multiple reasonable
courses of action that present significant
health trade-offs—such as between a potential
gain in life expectancy and a greater likelihood
of serious side-effects. The volume
of preference-sensitive care that VA provides
should depend on the values and
desires of the patient population being
served. Decision aids can help ensure that
care is consistent with those desires. Implementation
of decision aids can help patients'
stated needs drive the delivery of
services, while minimizing the costs of
providing care that patients do not want.
Finally, Drs. Jack Wennberg and Elliott
Fisher estimate that 50 percent of all medical
spending in the United States is consumed
in providing supply-sensitive care—where
the supply of resources strongly influences
the frequency of their use. Examples of
supply-sensitive services include the use of
the hospital as a site of care, the frequency
of physician and specialist visits, and the
use of imaging services. Greater use of
supply-sensitive care is associated with
lower quality and with equal or slightly
worse health outcomes—most likely due to
greater difficulty with care coordination and
with unnecessary, but not risk-free, hospital
stays. Provision of more supply-sensitive
care is therefore the ultimate inefficiency.
How should VA enhance access to
effective, patient-centered care while
limiting access to supply-sensitive care
for its service population?
Much of VA's service population, by choice,
obtains care outside of the VA. Therefore,
improving the health and well-being of the
service population requires that both VA
and non-VA health services provision be
considered when addressing access issues.
For instance, if additional VA access points
provide redundant, as opposed to complementary
or coordinated, care, increasing
access might inadvertently increase supply sensitive
care and impair population outcomes.
Given VA patients' high reliance on the private
sector, for effective care, VA might best
improve the health and well-being of its
service population by taking on a new role:
helping those who choose private-sector
services find hospitals that best provide
effective care.3 Finally, guided by decision
aids, coordinating VA and non-VA care
through collaboration across insurers could
benefit veterans by improving outcomes
and benefits, and by resulting in lower outof-
pocket costs. This coordination could
also benefit the VA health care system by
more efficiently and effectively meeting the
needs of its service population and taxpayers
by offering greater value for their investment
in veterans’ health care.
These three questions should serve as the
basis for research that explores whether
improving the health and well-being of the
service population is the primary goal of
access, whether VA is allowing patient values
to drive resource allocation while minimizing
supply-sensitive care, and whether care
coordination across systems of care can
efficiently provide value. Working with VA
leadership, researchers can both create systems
that inform and engage patients about
health care choices, and help veterans coordinate
insurance-mediated access to give
them a better benefits package. Researchers
can also support models of care delivery
that maximize effective care and minimize
wasteful supply-sensitive care—regardless
of which system of care a veteran uses.
-
Wennberg JE, et al. Geography and the Debate Over
Medicare Reform. Health Affairs, Web Exclusive
February 13, 2002.
- Asch SM, et al. Comparison of Quality of Care for
Patients in the Veterans Health Administration and
Patients in a National Sample. Annals of Internal
Medicine 2004; 141(12):938-45.
- Weeks WB, et al. Reducing Avoidable Deaths Among
Veterans: Directing Private-Sector Surgical Care to
High Performance Hospitals. American Journal of Public
Health 2007; 97(12):2186-92.
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