June 2022

In This Issue: HSR&D Research on Community Care
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Evaluating the VA Make-or-Buy Decision in Emergency Care

Feature Article

Takeaway: Enabling or encouraging Veterans to obtain care outside the VA system may lead to worse—not better—health outcomes, particularly for Veterans with established care relationships at VA facilities. For example, this study showed that Veterans transported to VA hospital emergency departments (EDs) had substantially lower risk of death within one month than those transported to non-VA hospital EDs.

In response to concerns about access to and quality of care at VA facilities, VA has begun to redirect resources toward financing care for Veterans outside the VA healthcare system. However, the quality and cost of care for Veterans that will result from this ‘make-or-buy’ decision remains unknown, with significant policy implications for how VA can optimize Veterans’ health. Quality and cost of care are particularly influenced by emergency services, with 13% of care and more than $800 million in yearly costs directed outside VA. Studying the quality and costs of VA vs. non-VA care also raises the fundamental concern that patients who receive care at VA facilities may have different levels of underlying health than those who receive care outside VA.

This ongoing study (January 2020 – December 2024) seeks to identify how quality and cost of care for Veterans are affected by its provision inside or outside the VA healthcare system. Without understanding the consequences of VA vs. non-VA emergency care on quality and cost, VA policymakers will be unable to direct Veterans to the best care location, nor will they understand mechanisms behind quality and cost differences between VA vs. non-VA care. Moreover, a lack of knowledge about the effects of VA vs. non-VA care – and how Veterans access care – prevents policymakers from predicting quality and cost outcomes for Veterans from policy interventions redirecting Veterans to non-VA care.

Methods

This retrospective study analyzed a national cohort of 583,248 Veterans (age 65 and older) who were enrolled in both VA and Medicare programs. Veterans were transported by ambulance to either a VA or non-VA hospital for emergency treatment between 2001 and 2018. Investigators then calculated Veterans’ risk of mortality following these visits (140 VA and 2,622 non-VA hospitals across 46 states and the District of Columbia). In addition to adjusting for characteristics of the ambulance ride (i.e., its origin, life support capabilities, primary diagnosis), investigators adjusted for patient characteristics, including comorbidities, and receipt of VA and/or non-VA care in the previous 12 months.

Findings

Thus far, findings from this study show that:

• Veterans transported to VA hospitals had substantially lower risk of death within one month than those transported to non-VA hospitals. The absolute difference of 2.35 deaths per 100 patients corresponds to a 20% lower mortality rate among Veterans taken to VA hospitals.
• The mortality advantage was particularly large for Hispanic patients (23% lower in VA), Black patients (26% lower), patients aged 65-74 (27% lower), and patients who arrived with a relatively low mortality risk (32% lower). Further, of the 50 subgroups of Veterans examined in this study, none experienced significantly lower mortality rates at non-VA hospitals.
• Patients taken to VA hospitals were more likely to be Black and to have used VA care in the prior year; they also were more likely to have mental health and substance use disorders.
• The only group in which VA patients did not have lower mortality rates were patients who had not received treatment in the past year at the hospital to which they were taken. However, there were relatively few patients taken to VA hospitals in that group.

Anticipated Impact

Enabling or encouraging Veterans to obtain care outside the VA system may lead to worse—not better—health outcomes, particularly for Veterans with established care relationships at VA facilities. At the same time, mounting evidence of superior performance justifies a redoubling of efforts to understand how the VA system achieves this, which may produce valuable lessons for VA as well as healthcare delivery systems globally. In partnership with VA’s Offices of Policy and Planning, Community Care, and Emergency Medicine, investigators are working to ensure that their findings will be disseminated widely – and will be applied directly to VA decisions and guidelines.

Principal Investigator: David, Chan, MD, PhD, is part of HSR&D’s Center for Innovation to Implementation (Ci2i) in Palo Alto, CA.

Publications

Chan D, Danesh K, Costantini S, et al. Mortality among US Veterans after emergency visits to Veterans Affairs and other hospitals: Retrospective cohort study. The British Medical Journal. February 16, 2022; 376:e068099

View study abstract