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Health Services Research & Development

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2023 HSR&D/QUERI National Conference Abstract

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4007 — VHA-sponsored Musculoskeletal Disorder (MSD) Treatment Costs: VA-delivered vs. Community Care

Lead/Presenter: Christina Lazar,  VA Connecticut Healthcare System
All Authors: Lazar CM (Yale/VA Connecticut Healthcare System), Gilstad-Hayden K (Yale/VA Connecticut Healthcare System) Rosen MI (Yale/VA Connecticut Healthcare System) Martino S (Yale/VA Connecticut Healthcare System) Barnett PG (Palo Alto Veterans Institute for Research)

Objectives:
The cost of MSD care among Veterans is substantial. Knowing the types and costs of pain services used by Veterans with MSD, and whether they get those services from VA providers or VHA-paid community providers is the first care step towards optimizing care. Herein we describe VHA-sponsored, MSD-related costs by deliverer (VHA or Community) in a cohort of Veterans who applied for Compensation and Pension (CandP) benefits for an MSD-related condition.

Methods:
We analyzed a cohort of Veterans who had a request for a CandP examination for a back, neck, knee, or shoulder condition between 2000 and 2018. We studied total costs of VHA sponsored care (care provided at VHA facilities and VA paid Community Care). We identified costs that were related to care for a MSD versus other medical conditions and compared the cost breakdown for VA care versus Community Care. Utilization and cost of care provided by VA facilities were obtained from the Managerial Cost Accounting national data extracts. Information on VHA-sponsored Community Care was obtained from the paid claims recorded in the Program Integrity Tool (PIT) databases. Inpatient care was categorized as treatment for an MSD or not based on principal diagnosis. Outpatient care was categorized based on procedure code or diagnosis code.

Results:
We identified 1,068,327 Veterans with an MSD-related CandP claim between 2000 and 2018, of whom 799,836 (56.5%) received VA sponsored care in FY19. This care cost $10.9 billion (mean $13,615 per person). Care for musculoskeletal conditions and pain medications accounted for 19.9% of total costs (mean $2,703 per person). These costs were divided between outpatient care (68.7%), inpatient care (17.2%) and pain medications (14.0%). Excluding the cost of medications (as they are provided almost exclusively by VA), Community Care accounted for 10.9% of total costs and for 17.9% of the cost of care for MSD. Certain care for MSDs was more likely to have been provided by community providers: acupuncture (63.3% costs from community care), spinal manipulation (47.9%), physical therapy (37.3%), acute medical-surgical hospitalization (36.0%), and outpatient surgery (16.1%). Other care for MSD was less likely to be provided by community providers, including imaging (7.8%) and emergency care (8.2%). In absolute terms, the cost of community-based MSD care was greatest for outpatient surgery ($80 million), followed by acute hospitalization ($75 million), physical therapy ($59 million), and acupuncture ($26 million).

Implications:
VA has turned to community care providers to provide a disproportionate share of certain types of care for MSD, including acupuncture, spinal manipulation, physical therapy, and surgery. The magnitude of the cost of this care merits a comparison of purchased and provided care for veterans with service-connected disabilities associated with MSD.

Impacts:
Non-pharmacological MSD care has been prioritized in response to the opioid epidemic. VHA is buying much of this MSD care from community providers and may consider whether access and efficiency would be served by more VA providers for certain types of treatments. The costing methodology, which will be detailed, can be useful to others in cost-effectiveness analyses of interventions addressing MSD.