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The VA Patient-Centered Community Care
(PC3) program provides Veterans with
care that is not available from a nearby VA
provider. We are completing an HS&RD
supported study of the quality, access, and
costs of elective coronary revascularization
procedures to assess how VA care compares
to care purchased by VA.
The study identified 23,003 elective procedures
provided to 20,755 Veterans under
age 65 from 2009 to 2011. Coronary artery
bypass grafting (CABG) accounted for 28
percent of the procedures and percutaneous
coronary intervention (PCI) for 72
percent of the procedures.
Claims from the VA Community Care
program contained complete cost, diagnosis,
and procedure codes and allowed us to
identify elective coronary revascularization
procedures obtained from non-VA community
providers and their cost to VA. These
claims represented 22 percent of the cardiac
procedures in our study, with the remaining
procedures provided at VA facilities. Diagnoses
recorded in the claims data enabled us to
identify the risk factors of cohort members.
Although the final results of this investigation
are not yet ready for release, this article presents
several lessons learned from our analysis
that may be useful to other VA investigators.
In order to measure ease of access, we
needed to know the location of the hospital
where the Veterans received care. The
zip code in the claims data is the address
where remittances were sent, but it is not
necessarily the providing hospital's location.
Therefore, we obtained a database of
hospital addresses from Medicare. We also
obtained information on hospital performance
from Hospital Compare and the
annual volume of cardiac procedures from
various surveys.
Each of these sources identifies hospitals
using the Medicare hospital identification
number. The hospital identifier is available
in most VA Community Care program
inpatient claims, as it is used to determine
reimbursement at standard Medicare
rates. When the reimbursement is based
on a negotiated contract, or when the
care is provided in an outpatient setting,
the identifier is not used to determine the
payment and thus not found in the claim.
We needed a method to find the Medicare
hospital identifier for these claims in order
to identify the location and characteristics
of the hospital. This was especially important
for PCI claims; more than half of the
Community Care PCIs are provided on an
outpatient basis, and without the Medicare
hospital identifier, we had no information
on hospital location, volume, or performance.
We were able to assign a Medicare identifier
to almost every procedure purchased
from Community Care providers in our
study. We took advantage of the fact that
a VA vendor identification number is assigned
to every claim. This VA identifier
may represent a hospital, a health system,
or managed care organization. We studied
inpatient claims paid by each VA medical
center to find the Medicare hospital identifier
associated with the VA vendor number
at that VA facility during the year of
service. There were some cases where there
was more than one hospital Medicare
identifier associated with a VA vendor
number. When this occurred, we found
the correct hospital through a record-byrecord
lookup of the name of the hospital
in the detailed claims data by Community
Care program staff.
Properly accounting for the full costs of the
procedures presented additional challenges.
Like all healthcare payers, the VHA Community
Care program makes separate payment
to hospitals and individual physicians.
Payments to physicians represent about 20
percent of hospital payments.1 We needed
to account for these physician payments, as
the cost of physician services is part of the
cost determined by the VA Managerial Cost
Accounting System. Finding the physician
payment for each inpatient stay is as challenging
in the Community Care data as it is
for Medicare and other claims systems. We
found the guide to Community Care from
the HSR&D's Health Economics Resource
Center (HERC) to be a helpful reference.2
Analytic issues described in this article are
more fully discussed in the HERC Bulletin.3
It will be increasingly important for VA
to improve access without compromising
quality or incurring excessive costs.
For example, referring Veterans to the
provider closest to their home is not ideal
if that provider provides lower quality
care than another provider located farther
away. One approach to determining the
best balance of quality, access, and cost is a
cost-effectiveness analysis. Outcomes, expressed
in quality-adjusted life years, can
be compared to costs that include not only
the actual procedural costs but also the
travel expenses and time of both Veterans
and their caregivers.
We hope that our early experiences with
analyzing VA and Community Care data
will benefit future research projects, and
look forward to disseminating the peerreviewed
findings in the near future.
1. Peterson C, et al. "Professional Fee Ratios for US
Hospital Discharge Data," Medical Care 2015; 53:10,
s 840-9.
2. Gidwani R, Hong J, Murrell S. Fee Basis Data: A
Guide for Researchers. Menlo Park, CA. VA Palo
Alto, Health Economics Resource Center, November
2015.
http://vaww.herc.research.va.gov/include/page.asp?id=guidebook-fee-basis
3. VA Health Economics Bulletin. Health Economics
Resource Center, Vol 16, No. 1 and No. 2
http://vaww.herc.research.va.gov/include/page.asp?id=bulletins
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