Health Services Research & Development

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2006 HSR&D National Meeting Abstract


1031 — Improving Access to Primary Care Services: Open New Clinics or Contract with Community Providers?

Author List:
Liu CF (Northwest Ctr for Outcomes Research in Older Adults)
Perkins M (Northwest Ctr for Outcomes Research in Older Adults)
Chapko M (Northwest Ctr for Outcomes Research in Older Adults)
Fortney J (Ctr for Mental Healthcare and Outcomes Research)
Maciejewski ML (Northwest Ctr for Outcomes Research in Older Adults)

Objectives:
VA has established community-based outpatient clinics (CBOCs) to improve veterans’ access to primary care. An important decision to VA is whether to contract with private clinics in the community (contract CBOCs) or to operate VA-owned clinics (VA-staffed CBOCs). Cost is one critical factor in this “make or buy” decision. Contract CBOCs are usually reimbursed using capitated payments. This study compares health care costs and utilization for veterans obtaining primary care at VA-staffed CBOCs and contract CBOCs during 2000-2001.

Methods:
Utilization and expenditure data were obtained from the VA Decision Support System (DSS) Inpatient and Outpatient National Extracts. CBOCs (n=108) were selected for the study if they were in operation in 1999, were serving at least 200 veterans, and could be tracked independently in DSS. The study sample included 17,060 patients in 76 VA-staffed CBOCs and 6,482 patients in 32 contract CBOCs. We estimated utilization using negative binomial models and expenditures using generalized linear one-part or two-part models, controlling for intracluster correlation at VISN and clinic levels.

Results:
Contract CBOC patients had significantly fewer primary care visits per year and were less likely to use all types of outpatient services (including primary and specialty care, mental health, laboratory, radiology, and other outpatient services) than VA-staffed CBOC patients (p<0.001). Primary care costs for contract CBOC patients were lower than those for VA-staffed CBOC patients. Contract CBOC patients had significantly lower total outpatient costs (-$410, p<0.0001) and total VA costs (-$274, p<0.0001) than VA-staffed CBOC patients.

Implications:
Lower outpatient costs and total costs for contract CBOC patients were mainly due to fewer primary care visits and lower odds of using outpatient care than VA-staffed CBOC patients. Lower outpatient utilization may be due to differences in provider practice style influenced by financial incentives in capitated payments.

Impacts:
Assuming that contract CBOCs meet VA quality of care standards, contracted outpatient care at geographically dispersed locations appears to be an economically efficient mechanism for improving veterans’ access to primary care.