Health Services Research & Development

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As Use of Community Care Services Increases, Researchers Examine Access, Cost, and Quality of Care

Key Points


  • The Veterans Choice Act in 2014 and the MISSION Act in 2018 have resulted in increased use of Community Care (CC) services among Veterans.

  • Researchers are examining cost, quality, and access to care given this shift.

  • Efforts include comparing access, cost, and utilization between VA and CC services, assessing approaches for coordinating care, and monitoring the quality of care across VA and community provider sites, in addition to measuring network adequacy for CC providers.

  • Findings from these partnered evaluation projects will be critical in informing future phases of program implementation.

With enactment of the Veterans Choice Act in 2014 and the MISSION Act in 2018, VA is dramatically reorganizing how it delivers healthcare services within VA facilities and across community provider networks. As the Veterans Health Administration (VHA) begins to evolve into a payer, the potential implications for Veterans, providers, and healthcare organizational leaders are unprecedented. Three teams have been working in partnership with the Office of Community Care (OCC), and collaboratively, to evaluate the VA Community Care implementation and to address issues related to Veterans’ access to care, costs, care coordination and quality, and network adequacy.1

With increased utilization of Community Care (CC) services as a consequence of the Veterans Choice Act, it is critically important for VA to better understand which areas of care it should continue to enhance as a “foundational service,” such as mental healthcare, where it currently excels. It also is important to determine which services VA might better offer through community providers, such as specific surgical specialties with increased demand relative to limited supply. Specifically, we will examine variation in utilization and access to VA versus CC over time, develop and test a methodology to compare VA to CC costs, and examine the use of mental health and surgery services.2, 3 To accomplish these aims, we have published findings on disease burden, as measured by expected costs, between Veterans receiving VA versus those receiving CC care.2

We are currently examining access, costs, and quality associated with cataract surgery, which is an excellent example of a surgery that is performed frequently in VA, and, also frequently outsourced. We have used geospatial mapping to compare distances and time that Veterans drive to obtain cataract surgery in VA and CC; examined 90-day complications of cataract surgery (as an indicator of quality); and have begun work on developing a methodology to compare VA and CC costs of cataract surgery. We also are using episodes of care to examine process measures of mental healthcare. Finally, we are using Survey of Healthcare Experiences of Patients (SHEP) data to compare Veterans’ perceptions of specialty care, mental healthcare, and primary care in VA versus CC.

In addition to comparing access, cost, and utilization between VA and CC services, VA is focusing on coordinating care and monitoring the quality of care across VA and community provider sites. The Care Coordination and Outcomes team is focused on assessing approaches used for regional and local VA facility implementation of quality, safety and value, governance and monitoring, and on identifying and evaluating health information exchange needs to support clinical care coordination and quality monitoring under expanded CC.4 Additionally, the team is developing and applying methods to evaluate and compare process and outcomes-based quality measures—and the extent of duplication of services for Veterans authorized for CC for primary care and specialty care among select high-volume and high-cost procedures (i.e., sleep studies, cardiac studies, colonoscopy, and mammography) with those Veterans receiving care for these services at VA facilities. The team also is working closely with OCC and the Care Coordination and Integrated Case Management initiative to evaluate current practice methods for ascertaining care coordination and case management services in VA and CC—and to make recommendations for additional or alternate measures for future use.

As an increasing amount of VA care shifts to third-party administrators, including Health Net, TriWest, and most recently, Optum, questions remain regarding the adequacy of those networks to provide care to Veterans. Network adequacy refers to a health plan’s ability to provide access to a sufficient number of primary care and specialty physicians within the plan’s network, as well as all healthcare services included under the terms of the contract.

Measurements of network adequacy can vary, but must include a minimum number of providers and maximum travel time and distance to those providers. These criteria are sensitive to local conditions in that they vary by type of provider and county geographic designation. The network adequacy team is focused on evaluating existing measures of network adequacy and making recommendations for additional or alternate measures of network adequacy across VAMCs and VA’s 98 markets.5 Additionally, the network adequacy team will examine how Community Care decisions are made within individual VA facilities and by individual primary and specialty care providers, and identify existing and potential opportunities to expand community partnerships to deliver CC. Finally, the team will examine Veteran preferences for VA versus CC providers and what information Veterans need to make informed decisions.

VA CC is a rapidly evolving program. Research teams are addressing emerging issues, such as working with new CC claims data sources and with dynamic CC authorization procedures. The researchers leading these projects are working collaboratively to share experiences with new data sources and procedures, and to consider insights gained from their planning efforts. As partnered evaluations, the research teams are working closely with VA leaders in CC to understand the most pressing needs, as well as to identify areas for future research. A panel presentation at the AcademyHealth Annual Research Meeting in June 2019, which included representatives from each of the research teams and the Office of Community Care, exemplifies this partnership and the commitment to disseminating information about the evaluation. With the expected expansion of VA CC, findings from these partnered evaluation projects will be critical in informing future phases of program implementation.

  1. Greenstone CL, Peppiatt J, Cunningham K, et al. “Stan­dardizing Care Coordination Within the Department of Veterans Affairs,” Journal of General Internal Medicine 2019; 34(1):4-6.
  2. Rosen AK, et al. “Differences in Risk Scores of Veterans Re­ceiving Community Care Purchased by the Veterans Health Administration,” Health Services Research Dec 2018; 53 Suppl 3:5438-54.
  3. Rosen A, Vanneman M, Wagner T. HSR&D Project: “Make Versus Buy- Examining the Evidence on Access, Utilization and Cost: Are We Buying the Right Care for the Right Amount?”
  4. Hynes DM and Weaver F. HSR&D Project: “Community Care Coordination and Outcomes in the VA Expanded Choice Program.”
  5. Mattocks K and Mengeling M. HSR&D Project: “Under­standing Network Adequacy and Community Engagement in Veteran Care.”

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