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Access to Care: A VA Research Agenda

In his commentary, Dr. Mayo-Smith describes how geographic, financial, cultural, and chronological aspects of health services delivery might influence access to care. He rightly notes that organization of the health care system influences access. Three questions should drive a VA research agenda regarding access to care.

What is the goal of providing access to care?

It is important that a health care system articulate the overarching goal for improving access to care. A health care system may have many such goals: to make shareholders money, to train new health care providers, to meet political needs, or to sustain a bureaucracy. However, for the VA, the goal of access should be to improve the health and well-being of its service population. Competing reasons should be subjugated to this one.

What kind of health care should VA provide access to in order to improve the health of its service population?

Not all health care is created equal. Researchers at The Dartmouth Institute for Health Policy and Clinical Practice have defined three categories of health care.¹ Effective care refers to the relatively small set of clinical services where all patients with a specific clinical indication should receive the treatment. The U.S. health care system is able to deliver such services less than 55 percent of the time, although VA performance is somewhat better.² To improve the health and well-being of its service population, VA should enhance access to effective care.

Preference-sensitive care refers to services for which there are multiple reasonable courses of action that present significant health trade-offs, such as between a potential gain in life expectancy and a greater likelihood of serious side-effects. The volume of preference-sensitive care that VA provides should depend on the values and desires of the patient population being served. Decision aids can help ensure that care is consistent with those desires. Implementation of decision aids can help patients' stated needs drive the delivery of services, while minimizing the costs of providing care that patients do not want.

Finally, Drs. Jack Wennberg and Elliott Fisher estimate that 50 percent of all medical spending in the United States is consumed in providing supply-sensitive care--where the supply of resources strongly influences the frequency of their use. Examples of supply-sensitive services include the use of the hospital as a site of care, the frequency of physician and specialist visits, and the use of imaging services. Greater use of supply-sensitive care is associated with lower quality and with equal or slightly worse health outcomes--most likely due to greater difficulty with care coordination and with unnecessary, but not risk-free, hospital stays. Provision of more supply-sensitive care is therefore the ultimate inefficiency.

How should VA enhance access to effective, patient-centered care while limiting access to supply-sensitive care for its service population?

Much of VA's service population, by choice, obtains care outside of the VA. Therefore, improving the health and well-being of the service population requires that both VA and non-VA health services provision be considered when addressing access issues. For instance, if additional VA access points provide redundant, as opposed to complementary or coordinated, care, increasing access might inadvertently increase supply sensitive care and impair population outcomes.

Given VA patients' high reliance on the private sector, for effective care, VA might best improve the health and well-being of its service population by taking on a new role: helping those who choose private-sector services find hospitals that best provide effective care.³ Finally, guided by decision aids, coordinating VA and non-VA care through collaboration across insurers could benefit veterans by improving outcomes and benefits, and by resulting in lower outof- pocket costs. This coordination could also benefit the VA health care system by more efficiently and effectively meeting the needs of its service population and taxpayers by offering greater value for their investment in veterans' health care.

A Goal of Coordinated Care Delivery

These three questions should serve as the basis for research that explores whether improving the health and well-being of the service population is the primary goal of access, whether VA is allowing patient values to drive resource allocation while minimizing supply-sensitive care, and whether care coordination across systems of care can efficiently provide value. Working with VA leadership, researchers can both create systems that inform and engage patients about health care choices, and help veterans coordinate insurance-mediated access to give them a better benefits package. Researchers can also support models of care delivery that maximize effective care and minimize wasteful supply-sensitive care, regardless of which system of care a veteran uses.

References

1. Wennberg JE, et al. Geography and the Debate Over Medicare Reform. Health Affairs, Web Exclusive February 13, 2002.
2. Asch SM, et al. Comparison of Quality of Care for Patients in the Veterans Health Administration and Patients in a National Sample. Annals of Internal Medicine 2004; 141(12):938-45.
3. Weeks WB, et al. Reducing Avoidable Deaths Among Veterans: Directing Private-Sector Surgical Care to High Performance Hospitals. American Journal of Public Health 2007; 97(12):2186-92.