BACKGROUND/RATIONALE:
To ensure timely access to health care for Veterans enrolled in the Veterans Health Administration (VHA), President Obama signed into law the Veterans Access, Choice and Accountability Act in August, 2014. The Veterans Choice Program (VCP), a key component of the new law, enables Veterans to obtain care from eligible facilities and providers outside of VHA if they reside >40 miles from the nearest Veterans Administration (VA) or are unable to schedule appointments within 30 days of the appropriate date. However, it is unclear how receptive Veterans are to obtaining care through the VCP, or what influences eligible Veterans to enroll in the VCP while others do not. For those who use the VCP, little is known about what aspects of the initiative succeed and what aspects could be improved. In addition, knowing the perceptions of VA frontline providers and clinical and operations leaders about strengths and weaknesses of the initiative will enable the VHA to make critical early changes to the rollout of the VCP.

A key component of health care utilization in the VCP will be medication use. Although the VCP authorizes eligible Veterans to obtain health care from non-VA providers, it does not provide pharmacy benefits outside the VHA (except for urgently needed medications). Thus, prescriptions ordered by non-VA providers-- who are without access to the VHA ordering system--will be dispensed by VHA pharmacy. Large numbers of non-VA prescriptions may affect VHA's care coordination efforts, which can result in unsafe and poorer quality medication therapy, along with a potentially greater use of costly, non-formulary medications. The implementation of the VCP, thus, introduces complexities that will challenge VHA's Pharmacy Benefits Management (PBM) and its ability to provide high quality, safe, and cost-effective medications for Veterans. As Veterans historically have had high levels of satisfaction with VA pharmacy care and benefits, the practical implications of VCP may have a negative impact on their experiences with medication therapy and VA pharmacy benefits. Given these challenges, it is critical to understand the impact of the VCP on Veterans' satisfaction with these services.

We propose to leverage the infrastructure of our innovative mixed methods study of Veteran satisfaction with VA health care (Disparities In Satisfaction with Care - or DISC), our highly productive partnership with PBM, and our expertise in studying patient satisfaction and VA medication use to conduct an early assessment of Veteran satisfaction and experiences with the VCP as they relate to health care delivery and pharmacotherapy. We will also develop the foundation and infrastructure for the ongoing detailed assessment of these important outcomes by: (1) creating a pharmacy database in coordination with PBM to examine medication use among VCP enrollees, and (2) developing a machine-learning approach in partnership with the VA Informatics & Computing Infrastructure (VINCI) for the immediate capture and coding of Veteran feedback on satisfaction as called for in the VHA Blueprint for Excellence. Our proposed aims will provide critical information and valid and reliable data capture methods to fully evaluate key components of the VCP.

OBJECTIVE(S):
Specific Aim 1: We will evaluate satisfaction with VCP, VA medication therapy and pharmacy benefits, and other key domains of care, as well as drivers of personal choice to use or not to use the VCP, among Veterans who are users of the VCP and those who are eligible but who are not users.

As part of this aim, we will also partner with VINCI to develop a prototype for the immediate capture and coding of Veteran satisfaction from semi-structured interviews using machine-learning algorithms.

Specific Aim 2: We will engage VA stakeholders (i.e., pharmacists, providers, and clinical and operations leaders) in a formative evaluation to identify barriers and facilitators that affect the successful implementation of the VCP and its ability to deliver high quality care to Veterans.

Specific Aim 3: In partnership with PBM, we will create a VCP pharmacy database to examine patterns of medication prescription, use of formulary and non-formulary medications, quality and safety of medication therapy, and medication costs for enrollees in the VCP who receive medications from the VA. The creation of this database will lay the foundation for subsequent focused assessments of the VCP's impact on the quality, safety, and costs of medication therapy across patient populations, regions, and disease states.

METHODS:
Early and ongoing evaluation of the VCP on Veteran satisfaction and experiences with VA health care, medication therapy, and pharmacy benefits is imperative to inform the implementation of the VCP and support the transformation of VHA. We will leverage the established infrastructure of an innovative mixed methods study of Veteran satisfaction with VA health care (Disparities In Satisfaction with Care); our expertise in patient satisfaction, health care experiences, VA medication use, and VA bioinformatics; and our successful track record of partnership with VA Pharmacy Benefits Management (PBM) to conduct:

(1) an early assessment of Veteran satisfaction with the VCP and the impact of the VCP on VA medication therapy and pharmacy benefits, and (2) a formative evaluation of the barriers and facilitators to the successful implementation of the VCP based on interviews with key VA stakeholders. We will also (3) partner with PBM to create a pharmacy database to assess patterns of medication use, use of formulary and non-formulary medications, quality and safety of medication therapy and medication costs for enrollees in the VCP. Finally, we will partner with the VA Informatics & Computing Infrastructure (VINCI) to develop a machine learning approach for immediate capture and coding of Veteran feedback on satisfaction as called for in the VA Blueprint for Excellence.

FINDINGS/RESULTS:
Specific Aim 1:
A. Veterans interviewed rated traditional VA care significantly more highly than they did Choice care. Veterans who were actively seeking care but who had not yet received services had the lowest level of satisfaction, with 49% rating themselves as "very dissatisfied" with Choice care, as opposed to 5% very dissatisfied with VA care.

B.The goal of the current effort is to evaluate feasibility of building a computer-assisted coding system. We have developed an application that applies natural language processing (NLP) algorithm to suggest the possible codes for a human coder to review and select. The following steps are required: the transcripts of the interviews were loaded to a database and the application drew transcriptions from the database, applied NLP algorithms on the text of the transcription, presented the transcription and a short list of possible codes to a human coder, and then stored the coder's entries into the database.

Specific Aim 2: Our completed stakeholder interviews revealed numerous barriers and facilitators. The key barriers were challenges involved in working with outside providers who did not understand the VA system, the VA formulary, and the continuity of care of patients navigating between the two systems. The results of these stakeholder interviews will be included in the journal Medical Care and its special issue.

Specific Aim 3: After creation of the database, we analyzed pharmacy use in the first year of Choice. We identified the important role that hepatitis C medications and opioids played in the first year of Choice, and these data were an integral part of a mixed methods analyses of pharmacy use in the first year of Choice that was accepted in the journal Medical Care for their supplement on the Choice Act.

IMPACT:
The proposed evaluation provides VA with: (1) detailed data collected from Veterans who are Choice eligible regarding their satisfaction and experiences with key domains of care, including medication therapy, pharmacy benefits, and access to and continuity of care; (2) in-depth VA stakeholder insights regarding barriers and facilitators to successful Choice implementation; and (3) innovative development of information technology using machine learning algorithms to capture and code Veteran satisfaction with the VCP and the development of a Choice pharmacy services database to ensure high-quality, safe, and cost-effective VA medication therapy.

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External Links for this Project

NIH Reporter

Grant Number: I50HX001961-01
Link: https://reporter.nih.gov/project-details/9032096

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PUBLICATIONS:

Journal Articles

1. Gellad WF, Cunningham FE, Good CB, Thorpe JM, Thorpe CT, Bair B, Roman K, Zickmund SL. Pharmacy Use in the First Year of the Veterans Choice Program: A Mixed-methods Evaluation. Medical care. 2017 Jul 1; 55 Suppl 7 Suppl 1:S26-S32. [view]
2. Jones AL, Fine MJ, Stone RA, Gao S, Hausmann LRM, Burkitt KH, Taber PA, Switzer GE, Good CB, Vanneman ME, Zickmund SL. Veteran Satisfaction with Early Experiences of Health Care Through the Veterans Choice Program: a Concurrent Mixed Methods Study. Journal of general internal medicine. 2019 Sep 1; 34(9):1925-1933. [view]

Journal Other

1. Gellad WF. The Veterans Choice Act and Dual Health System Use. Journal of general internal medicine. 2016 Feb 1; 31(2):153-4. [view]

VA Cyberseminars

1. Gellad WF. Examining Veterans' Pharmacy Use With VA and Medicare Pharmacy Data. [Cyberseminar]. 2016 Feb 1. [view]
2. Gellad WF, Zhao X. Examining Veterans’ pharmacy use with VA and Medicare pharmacy data [VIReC Database and Methods Seminar]. [Cyberseminar]. 2015 Jun 29. [view]

DRA: Health Systems
DRE: Epidemiology, Treatment - Observational
Keywords: none
MeSH Terms: none