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The issues of value and efficiency have become central to every conversation about health care since the passage of the Affordable Care Act (ACA). In a much publicized perspective piece in the New England Journal of Medicine in March 2015, the Secretary of the Department of Health and Human Services (HHS), Sylvia Burwell, emphasized the growing role of value-based payment systems under which health care providers are accountable for the quality and cost (i.e., value) of care they deliver.1 In the same piece, Burwell outlines how HHS will focus its efforts in improving value using three strategies: (1) developing financial incentives; (2) improving integration and coordination among providers; and (3) accelerating information use to guide medical decision making.
The second HHS strategy—improving coordination among providers—should be of particular interest to VA, which shares the same goals of increasing quality and reducing costs. Many Veterans are able to receive care in both VA and the private sector, making coordination of care among providers uniquely challenging. This issue of 'dual use' has been a challenge to VA for years, but has become increasingly important over the last decade, first with the introduction of Medicare Part D prescription coverage, and most recently with Medicaid and private insurance expansions under the Affordable Care Act and with the Choice Act. Each additional opportunity for Veterans to receive care in multiple health systems—from multiple health professionals who have only limited communication with each other and limited data sharing—represents an additional opportunity for care fragmentation and its associated value and efficiency problems.
As an example of the impact of dual use on value and efficiency, consider glucose test strips. Glucose testing can be painful, burdensome, and expensive. Little consensus or evidence exists regarding the optimal frequency of testing for patients with diabetes. In a research project last year, we examined glucose test strip utilization in a national cohort of all VA patients over age 65 with diabetes using linked VA and Medicare Parts A, B, and D data.2 We measured the quantity of test strips dispensed to Veterans along with overuse of strips, defined as using more than one strip per day among those taking no diabetes medications, oral diabetes medications alone or long-acting insulin alone, or more than four strips per day among those taking short acting insulin.
In total, 363,996 community-dwelling older VA patients received at least one test strip during the year, of whom 22.8 percent received strips from Medicare alone and 5.6 percent received strips from both VA and Medicare. Among Veterans taking no diabetes medications, for whom daily glucose testing would almost never be indicated, the median number of strips received was 4 times as high in dual users compared to VA only users (400 vs 100), increasing the odds of overuse by more than 15 times after adjustment for disease severity. Our results illustrate the importance of understanding dual VA and Medicare coverage and its impact on value and efficiency.
There are other examples within VA of the adverse impacts of dual use on quality, value, and efficiency. For example, an analysis by Trivedi and colleagues of dual VA and Medicare Advantage enrollees found duplicative federal payments for services and financial waste.3 Other analyses have found higher rates of hospitalization for ambulatory care sensitive conditions and worse outcomes in cancer when care is fragmented. In ongoing work funded by VA HSR&D, our group is examining the impact of dual use on quality and efficiency among older adults with dementia and among users of opioid medications. From a measurement standpoint, more generally, there are additional concerns around capturing accurate comorbidity adjustment and utilization in Veterans who are dual users when non-VA data is not available; this inability to fully capture non-VA data impacts VA's ability to accurately measure its own quality and efficiency.
Not all studies have identified problems stemming from dual use, and in some cases there are clearly benefits for individual patients in improving access or convenience in obtaining medications, specialty care, or even diabetes testing supplies. VA's burden, however, is to reconcile the desire to increase access and choice for Veterans with the potential downsides that come with increasing levels of dual use and care fragmentation. VA HSR&D researchers can play an important role in helping VA meet this challenge.
1. Burwell, S.M. "Setting Value-based Payment Goals-HHS Efforts to Improve U.S. Health Care," New England Journal of Medicine 2015; 371(10):897-9.
2. Gellad, W.F. et al. "Dual Use of Department of Veterans Affairs and Medicare Benefits and Use of Test Strips in Veterans with Type 2 Diabetes Mellitus," JAMA Internal Medicine 2015; 175(1):26-34.
3. Trivedi, A.N. et al. "Duplicate Federal Payments for Dual Enrollees in Medicare Advantage Plans and the Veterans Affairs Health Care System," Journal of the American Medical Association 2012; 308(1):67-72.