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Director's Letter

Everyone seems to agree that American health care costs too much and delivers too little. An estimated 30 percent of health care spending is wasted on therapies that are unnecessary, ineffective, or poorly targeted. For health systems under a global budget such as VA, achieving higher-value care is especially critical. Low-value services can crowd out needed care or innovation.

There are essentially four ways to achieve higher-value care: (1) we can drive down the prices we pay for medical services; (2) we can seek out new interventions that lower costs of care while improving health and patient experience (the so called "triple aim"); (3) we can limit the provision of "low-value" care; or (4) we can reduce waste and inefficiency in how we deliver care. The different perspectives in this issue illustrate this range of approaches, and outline a research agenda for identifying which approaches are most effective and feasible within VA.

The list of medical innovations that actually save money is vanishingly small, but cost-effectiveness analysis (CEA) can distinguish whether new interventions provide good value relative to other services we are providing; it may even be able to help rationalize prices for new treatments. Americans have not yet embraced decisions that explicitly reference CEA, however, especially decisions to limit care. Language in the Affordable Care Act prohibits use of CEA to set a threshold for coverage.¹ Recent proposals to prioritize which patients receive hepatitis C drugs in VA caused a backlash.² Choosing Wisely (www.choosingwisely.org), a multi-specialty group initiative to reduce the use of specific services that are often unnecessary may hold more promise. Initial VA Choosing Wisely activities aim to reduce MRIs for uncomplicated low back pain and to avoid tight glycemic control in older patients.

Reducing inefficiency may be the most palatable way to achieve higher value from health care services within VA. The Veterans Engineering Resource Centers (VERCs), established in 2010, apply systems re-engineering methods to improve efficiency in areas such as scheduling, staffing, patient flow, and inventory control. Researchers have partnered with some of the VERCs through the QUERI program and the current solicitation to create an Operations Research program project should strengthen these connections.

Research has contributed a lot in helping us distinguish high-value from low-value care. Next, we need research that examines how best to use that information at different levels of decision-making—with individual patients, in facilities, and as a health system—in order to improve outcomes for all Veterans.

David Atkins, MD, MPH, Director, HSR&D

References

1. Kinney, E.D. "Comparative Effectiveness Research under the Patient Protection and Affordable Care Act: Can New Bottles Accommodate Old Wine?" American Journal of Law and Medicine 2011; 37(4):522-66.

2. Wagner, D. "VA to Outsource Care for 180,000 Vets with Hepatitis," The Republic. Azcentral.com; June 19, 2015.