Many Veterans struggle to access needed services and consultations in a timely fashion. Former Secretary Eric K. Shinseki referred to "the tyranny of distance" in speaking of the 3.3 million Veterans who struggle to access health care because they live far away from a VA medical facility. The problem is especially acute for Veterans who need specialty care. Community based outpatient clinics (CBOCs) do not typically have specialists on staff, forcing Veterans to rely on their primary care physician, seek non-VA care or travel to a tertiary VA facility. Preliminary evidence suggests that distance can lead to delays in accessing care, and greater morbidity and mortality. Further, these problems are often exacerbated when a patient has a mental health comorbidity. Limited access to specialty care can also result in longer wait times, which is of great concern as exemplified by the recent media attention on wait times at the Phoenix and other VA medical centers.
The objective of this study is to examine how patients access specialty care and the link between specialty care, quality of care, and health outcomes. Aim 1 uses VA, Fee Basis and Medicare data to examine how Veterans with heart failure (HF), hepatitis c virus (HCV), and epilepsy access specialty care. We use the Andersen model as a guide and focus on the role of enabling factors (monetary and non-monetary prices) and a mental health comorbidity. Aim 2 examines whether use of specialty care improves quality of care. Aim 3 uses qualitative methods to understand the contingences involved when a CBOC provider makes a referral to specialty care.
This mixed methods study uses observational data to understand how patients with HF, HCV and epilepsy access specialty care. The first two aims examine access to specialty care and whether use of specialty care is associated with quality of care and health care outcomes. For these aims, we will combine VA utilization with Fee Basis data from 2007-2014 and Medicare data from 2007-2012. Aim 3 uses qualitative methods to understand how primary care clinicians identify the threshold at which to make a referral and the role of patient volume in this decision making process. The qualitative methods will also examine how primary care physicians initiate specialty care referrals, and additional barriers faced by patients who have to travel a long distance to reach the tertiary care facility.
We anticipate finding: (1) what type of factors affect Veterans' use of VA specialty care and the role of non-VA specialty care; (2) whether having a mental health comorbidity poses an additional barrier to specialty care; (3) what influence provider volume and practice environment have on quality of care; and (4) what providers feel are barriers and facilitators to specialty care referrals.
From the qualitative interviews, we have learned that many primary care providers feel there are barriers to referring a patient to a specialist, due to excessive paperwork and pre-testing prior to submitting the referral. Providers also feel that provider to provider communication is difficult, especially in the case of a patient hand-off between a primary care provider and a specialist.
The proposed research will contribute to the understanding of how specialty care is being used and how Veterans are using non-VA specialty care. We aim to understand whether specialty care access is associated with higher quality of care and improved outcomes. Key informant interviews will describe the referral to specialty care process and identify lessons applicable across a variety of settings.
- Shayegani R, Pugh MJ, Kazanis W, Wilkening GL. Reducing coprescriptions of benzodiazepines and opioids in a veteran population. The American journal of managed care. 2018 Aug 1; 24(8):e265-e269.