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IIR 20-005 – HSR&D Study

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IIR 20-005
Evaluation of Community Based Outpatient Clinic Costs Using DSS Data
Matthew L Maciejewski PhD
VA Puget Sound Health Care System Seattle Division, Seattle, WA
Seattle, WA
Funding Period: October 2001 - September 2004

BACKGROUND/RATIONALE:
Caring for patients in VA-staffed CBOCs is likely to be less expensive than caring for patients in outpatient primary care clinics at the VAMC, because CBOCs have organizational features more conducive to efficient delivery of primary care services.

OBJECTIVE(S):
The purpose of this study is to evaluate CBOC cost-based performance measures using the data from the new VA cost accounting system, the Decision Support System (DSS), in FY2000 and FY2001. Cost-based performance measures for different types of patients will be compared to determine to what degree cost differences are due to patient differences and organizational differences. In addition, we will conduct two subanalyses to explore CBOC costs and quality of care for veterans with ambulatory-care sensitive conditions. The proposed study has three main specific aims and two secondary aims.

METHODS:
We will compare DSS utilization estimates with OPC and PTF utilization estimates for CBOC and VAMC patients in the facilities we have sampled. We will then compare cost estimates between DSS production (local) level data and the DSS National Extracts. Estimates of DSS National Extract costs and Medicare costs will be conducted and then we will do the cost evaluations between CBOC and VAMC patients, controlling for other factors.

FINDINGS/RESULTS:
We have found discrepancies between DSS and PTF inpatient utilization, as well as DSS and OPC outpatient utilization. These findings were presented at the 2003 VA HSR&D annual meeting. CBOC patients had lower utilization and VA expenditures than patients obtaining primary care at VAMCs, and had similar or better quality of care for veterans with COPD or diabetes. Contract CBOC patients had lower total expenditures than VA-staff CBOC patients because of lower outpatient expenditures, which was due to fewer primary care, mental health and specialty visits. Quality of care in two measures was similar in these two types of CBOCs.

IMPACT:
Results from this study indicate that DSS is generally valid for utilization and cost analysis of CBOCs It appears as though CBOCs are helpful in containing total VA expenditures for patients who obtain primary care. Contract CBOCs may be as effective VA-staff CBOCs in containing VA expenditures, but quality of care needs to be assessed more broadly. It may also be useful to examine CBOCs in general, and contract CBOCs in particular, to get into the “black box” of CBOC organizations and cultures to more fully understand why their performance is equal to, if not better than, performance of VAMC primary care clinics.

PUBLICATIONS:

Journal Articles

  1. Chapko MK, Liu CF, Perkins M, Li YF, Fortney JC, Maciejewski ML. Equivalence of two healthcare costing methods: bottom-up and top-down. Health economics. 2009 Oct 1; 18(10):1188-201.
  2. Liu CF, Chapko MK, Perkins MW, Fortney J, Maciejewski ML. The impact of contract primary care on health care expenditures and quality of care. Medical care research and review : MCRR. 2008 Jun 1; 65(3):300-14.
  3. Maciejewski ML, Perkins M, Li YF, Chapko M, Fortney JC, Liu CF. Utilization and expenditures of veterans obtaining primary care in community clinics and VA medical centers: an observational cohort study. BMC health services research. 2007 Apr 18; 7:56.
  4. Borowsky SJ, Nelson DB, Fortney JC, Hedeen AN, Bradley JL, Chapko MK. VA community-based outpatient clinics: performance measures based on patient perceptions of care. Medical care. 2002 Jul 1; 40(7):578-86.
  5. Fortney JC, Borowsky SJ, Hedeen AN, Maciejewski ML, Chapko MK. VA community-based outpatient clinics: access and utilization performance measures. Medical care. 2002 Jul 1; 40(7):561-9.
  6. Hedeen AN, Heagerty PJ, Fortney JC, Borowsky SJ, Walder DJ, Chapko MK. VA community-based outpatient clinics: quality of care performance measures. Medical care. 2002 Jul 1; 40(7):570-7.
  7. Maciejewski ML, Chapko MK, Hedeen AN, Fortney JC. VA community-based outpatient clinics: cost performance measures. Medical care. 2002 Jul 1; 40(7):587-95.
Conference Presentations

  1. Liu C. Issues for VA Health Care: Dual Use & Women's Health. Presented at: AcademyHealth Annual Research Meeting; 2009 Jun 30; Chicago, IL.
  2. Liu CF. Use of Primary Care in VA and Medicare among VAMC and CBOC Patients. Presented at: American Society of Health Economists Biennial Conference; 2008 Jun 23; Durham, NC.
  3. Liu CF, Chapko M, Burgess J, Bryson C, Perkins M, Forney J, Manning W, Sharp N, Maciejewski ML. Use of Primary Care in VA and Medicare among VAMC and CBOC Patients. Poster session presented at: AcademyHealth Annual Research Meeting; 2008 Jun 12; Washington, DC.
  4. Wang S, Liu CF, Chapko MK, Perkins M, Maciejewski ML. Racial Disparities in Quality of Preventive Care at VAMCs, Contract CBOC, and VA-staffed CBOC. Poster session presented at: AcademyHealth Annual Research Meeting; 2006 Jun 26; Seattle, WA.
  5. Liu C, Perkins M, Chapko M, Fortney J, Maciejewski M. Improving Access to Primary Care Services: Open New Clinics or Contract with Community Providers? Paper presented at: VA HSR&D National Meeting; 2006 Feb 15; Arlington, VA.
  6. Maciejewski ML, Liu CF. Make or Buy to Provide Primary Care in the VA Health Care System. Paper presented at: International Health Economics Association Biennial World Congress on Health Economics; 2005 Jul 2; Barcelona, Spain.
  7. Maciejewski M, Liu C. CBOC utilization and cost data from DSS: Can we believe what we see. Paper presented at: VA HSR&D National Meeting; 2003 Feb 14; Washington, DC.
  8. Fortney JC, Maciejewski M, Warren J, Burgess J, Booth B. Does establishing CBOC's in underserved areas impact patterns of utilization and costs? Paper presented at: VA HSR&D National Meeting; 2003 Feb 12; Washington, DC.


DRA: Health Systems
DRE: Epidemiology
Keywords: Cost, Outpatient, Primary care
MeSH Terms: none

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