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Commentary and Response

A Conversation with Assistant Under Secretary for Health and the VHA Office of Integrated Veteran Care (IVC), VHA HSR&D Leadership, and the VHA Community Care Research Evaluation and Knowledge (CREEK) Team

In the spring of 2022, the VHA Offce of Community Care (OCC) and the VHA Offce of Veteran Access to Care (OVAC) merged to become the VHA Offce of Integrated Veteran Care (IVC). Along with many HSR&D investigators, the VHA Community Care Research Evaluation and Knowledge (CREEK) Center has had a strong working relationship with OCC. To ensure that the successful effective collaboration between OCC, CREEK, and HSR&D researchers continued with IVC, members of CREEK, along with Dr. David Atkins and Dr. Amanda Borsky from VHA HSR&D, met with IVC leadership to discuss program and research priorities. The following interview transcript presents the highlights of that conversation.

Participants in the call included Dr. Miguel Lapuz (Assistant Under Secretary for Health for IVC), Dr. Julianne Flynn (Acting DUSH, IVC), Dr. Sachin Yende (Acting CMO, IVC), Dr. David Atkins (Director, HSR&D), and Dr. Amanda Borsky (Scientifc Program Manager, HSR&D). The following CREEK members also participated: Dr. Kristin Mattocks (Central Western Massachusetts), Dr. Michelle Mengeling (Iowa City), Dr. Denise Hynes (Portland), Dr. Megan Vanneman (Salt Lake City), and Dr. Amy Rosen (Boston).

Dr. Kristin Mattocks (CREEK): Thank you for your willingness to meet with us today. As you know, CREEK and HSR&D have had a wonderful working relationship with the Offce of Community Care over the years, and we’ve beneftted greatly from our partnership with you. Now that the IVC is up and running, I would like to start off by asking if you could tell us about the overarching goals for IVC.

Dr. Julie Flynn (IVC): The goal of IVC is to have an integrated operating model for the feld. We started by merging OCC and OVAC. Our overarching goal is to speed up the provision of care, both in the direct (VA) and the community care system. This includes speeding up scheduling and establishing a much more robust care coordination system than we have right now. Dr. Yende, do you have anything to add to that?

Dr. Sachin Yende (IVC): I agree with Dr. Flynn. There’s clearly a need to improve access within VA, but our goal is to optimize Veteran access in general and so community care will be an important part of any strategic plan. We are also trying to work out how we can be smarter about make vs. buy decisions. We recognize that at some point we have to buy care in the community, but how can we be smarter about those decisions? Many health insurance companies have launched value-based care and payment reform initiatives. I know that we’re not going to be able to tackle similar initiatives immediately, but these are the types of efforts that interest us for the future.

Dr. Miguel Lapuz (IVC): I am glad we are meeting with you all. There are many things I would like to better articulate to Congress in terms of whether our outcomes are better in comparison to what is offered in the community. This year the VA will spend more than $27 billion on community care so it is important to fgure out if there are things we are doing better in comparison to the community. Although I know from the work that has been published, and because of the work that you all have been doing, that there are many things we are doing better than the community. Continuing this partnership with CREEK and HSR&D researchers is a must because it provides direction on what we need to do from the strategy perspective to ensure that Veterans get the best care possible.

Dr. David Atkins (HSR&D): It’s great to see you again, Miguel. As you may know, our Chief Research and Development Offcer (CRADO), Dr. Rachel Ramoni, is very interested in frming up our connections with our partners and zeroing in on areas where [IVC] needs help, and making a commitment to deliver on that assistance. Is there one question that keeps you up at night or where you wish you had better information to make decisions? I realize it’s a broad question of how we balance access, quality, and coordination, so I guess it’s trying to get the right balance of things?

Dr. Miguel Lapuz (IVC): So, let’s start with what we know. We know that Veterans’ trust is higher in direct (VA) care than it is in community care. But we also know that when we look at the Veterans’ Signal, for example (the new on-line surveys that are being sent to Veterans directly after their VHA or CC outpatient care), their experience with providers is about equivalent. But what makes a big difference is the coordination of care, like the scheduling and the billing. So, if you come to think of it, that’s what the big drivers are for Veterans staying in VA. Considering their experience, and I’m not talking about outcomes here, the Veterans are rating VA and community providers on a 1-point difference – one is 92, the other is 93 – where the difference is convenience of scheduling. We also know that Veterans are complaining about  the fragmentation of care, and the hassles of the administrative work they have to do when they get care in the community (like billing).

Dr. David Atkins (HSR&D): And how about outcomes?

Dr. Miguel Lapuz (IVC): It’s not always clear to Veterans what the outcomes are. Veterans are relying on their experience to measure whether this particular healthcare route is working for them or not. We need to have a better understanding of how our Veterans are gauging the outcomes of their care apart from the satisfaction of their experience.

Dr. David Atkins (HSR&D): Right. It’s an old problem of how patients actually make decisions based on quality, some objective measure of quality.

Dr. Miguel Lapuz (IVC): Yes, and if they do, what will that be? Because if we don’t know that, then that means that we cannot differentiate between VA and communityprovider quality. One of the things I’m engaged with right now, as we’re meeting with prospective contractors who will bring us the next generation of Community Care Network (CCN), is sharing of outcomes from community providers back to VA. Because our Veteran Service Organizations (VSOs) are asking for a better gauge of the quality of care that is being provided by community providers. In VA, it is easier for VSOs to see quality because we’re quite transparent. We measure a lot of things in VA and if the VSOs want information on what we’re measuring and how we are performing on those measures (for example, wait time), we can give it to them. So, inour next generation of CCN, we would like to pursue the availability of community care quality metrics, but we want to make sure those metrics are valid.

Dr. Megan Vanneman (CREEK): Dr. Lapuz, we are launching a new grant that’s looking at improving risk adjustment methods for the purpose of comparing quality of care between VA delivered and VA purchased care by incorporating non-VA clinical metrics, including social determinants. The real ssue I see is that these comparisons have to be aggregated to the VA station level or to the group of providers that are providingcommunity care because the sample sizes are so small for any given provider, for example in the case of total knee replacements. We have historically aggregated to the station level in order to make valid statistical comparisons.

So, I think it will be a real struggle going forward because you talked about how an individual Veteran makes a decision about who he or she goes to see when we can’t compare quality of care between provider A and provider B versus the group of providers associated with that VA station.

Dr. Miguel Lapuz (IVC): These are excellent points and let us know how we can help you get there.

Dr. David Atkins (HSR&D): To wrap things up, is there anything we can do to facilitate this partnership or make communication easier between our offces (IVC and HSR&D)?

Dr. Miguel Lapuz (IVC): We already had a discussion with the leadership and stakeholders regarding changing the regulations and in one area, telehealth, we’re likely going to be changing the regulations regarding community care eligibility. That is making telehealth a qualifer for VA services. So, in other words, if we can offer telehealth in a particular clinical situation and we are within the MISSION Act wait and drive times, then the appointment would count with regard to the eligibilities. People are going to be asking how effective telehealth is in VA as a substitute for in-person care, and what are the clinics in which telehealth is better in comparison to in-person care? I think that’s a fair question and I think that that’s one area that we need to be able to respond to.

Dr. David Atkins (HSR&D): That’s an important question, and we have been working with our colleagues in the Offce of Connected Care to examine some of those questions, including outcomes of virtual care and how to classify those.

Dr. Kristin Mattocks (CREEK): We appreciate your talking with us today and we will share this information with our HSR&D colleagues. We look forward to continued collaboration.