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Could Specialty Care Access be VA's Achilles Heel?

In any given year, 50 percent of Veterans receiving care within VA require specialty care services. While there have been major initiatives to bolster the availability of primary care and mental health services, little effort has been placed on re-envisioning how specialty care medicine can increase its services. Expansion of community-based outpatient clinics has improved primary care access, but it has likely exacerbated challenges for VA to provide seamless specialty care services for these patients. At the time of primary care expansion, the assumption was that Veterans would continue to receive VA specialty care services at medical centers, typically located in urban environments. However, there is now a mandate to provide Veterans with care closer to home regardless of the need, whether it is primary or specialty care. A coordinated effort is urgently needed to conceptualize delivery of specialty care that is patient centered and meets the needs of Veterans. The time for this effort is now.

In the context of the MISSION Act, how to deliver specialty care services has become an important question that requires reflection beyond the current care delivery models. “Make vs buy” discussions often focus on the time needed to receive specialty services at a unit cost. As a result, VA focuses on filling the demand without accounting for the urgency of the demand that is needed to meet the specific clinical context. Currently proposed access benchmarks continue to reflect the belief that acting within ever shortening predefined timeframes will drive high quality access and satisfy the needs of patients. That construct is a fallacy because fixed timeframes do not necessarily align with patient preferences, the clinical context, or availability of resources.

VA needs to more effectively organize its approach to delivering care to satisfy the healthcare needs of Veterans, whether that care is delivered within VA or community settings. In that context, high quality access should be measured based on the ability of the health system to deliver services that will achieve desirable health outcomes for patients. From a patient perspective, access to services will need to accommodate the natural ebb and flow of changes within a patient’s clinical condition. Applied as a function of timeliness of care, high quality access could be measured in minutes, hours, days, months, or potentially years.

Specialty care encompasses more than 20 different clinical services that each require a specialized knowledge base, infrastructure, supply chain, scheduling, administrative and clinical staff. Because these assets are relatively scarce, specialty care services are typically concentrated within larger urban medical center-based facilities that have sufficient patient volume to justify support for these dedicated services. For example, in most primary care settings, the loss of a physician will lead to a decrease in the number of patients seen in clinic and overall productivity. However, in specialty care services, the loss of a single physician could eliminate some services altogether. Many specialty care services are also procedure-based; these services require sufficient volume to maintain quality as well as staff and IT support to coordinate multiple services (e.g., primary care, radiology, anesthesia), maintain infrastructure, and sequence care appropriately for patients who may live significant distances from the medical center.

Community based outpatient clinics (CBOCs) are not only geographically distant but also culturally distinct, as many specialty care clinicians share joint university appointments and place significant value on the research and educational missions of VA in addition to care delivery. From the patient perspective, although primary care is now closer to their homes, there has not been a similar transformation in specialty care medicine. In contrast to the billions of dollars committed to the reorganization of primary care within VA, support provided to redesigning the delivery of specialty care services has been negligible.

Common across VHA is the desire to deliver highly effective and quality care to achieve favorable health outcomes—regardless of the type of service. VA needs to develop a conceptual model of specialty care access, starting with defining high quality access that is not fixed on arbitrary timelines. A model would need to include population-based approaches and take responsibility for the entire anticipated episode of care. Outcomes would be patient centered but incorporate value as an explicit measure, facilitating discussion about make vs. buy decisions. As part of a learning health system, VA could empirically study and evaluate theory driven approaches to the delivery of specialty care services, including the utility of telehealth and other technology-based approaches to care. For example, many specialty services focus on cognitive rather than procedural knowledge, such as the case with common chronic comorbidities (e.g., diabetes). In principle, these services do not require in-person visits and can be provided via various telehealth modalities.

For some specialty care procedures, VA is already testing, in non-systematic fashions, different approaches to non-invasive procedures that are performed by technical staff near patients’ homes and interpreted by specialty care clinicians at distant medical centers. Models about how to manage procedures such as echocardiography or pulmonary function testing optimally could compare strategies that maximize patient experiences including embedding technicians within or close to primary care settings, using mobile units that bring equipment and staff to CBOC’s, or outsourcing these procedures to the community.

Specialty care services provide an invaluable contribution to overall Veteran well-being. VA needs to commit to finding effective and value-based approaches to specialty care services. To continue to neglect this important part of healthcare delivery may serve to endanger more than Veterans’ health, but the well-being of VHA altogether.

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