Make Versus Buy- Examining the Evidence on Access, Utilization and Cost: Are We Buying the Right Care for the Right Amount?

自制与购买——检查有关获取、利用和成本的证据：我们是否以正确的金额购买正确的护理？

• 批准号: 10216354
• 负责人: AMY K ROSEN
• 金额: --
• 依托单位: VA BOSTON HEALTH CARE SYSTEM
• 依托单位国家: 美国
• 财政年份: 2018
• 资助国家: 美国
• 起止时间: 2018-10-01 至 2021-09-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10216354
• 关键词: Accountability; Affect; Area; Caring; Categories; Characteristics; Clinic; Clinical; Collaborations; Communities; Community Networks; Congresses; Contracts; Decision Making; Eligibility Determination; Ensure; Evaluation; Foundations; Funding; Future; Grant; Health; Health Services Accessibility; Healthcare; Inpatients; Lead; Leadership; Letters; Linear Models; Logistic Regressions; Measures; Mental Health; Methodology; Methods; Modeling; Operative Surgical Procedures; Ophthalmology; Orthopedics; Outcome; Outpatients; Patients; Pattern; Performance; Physical therapy; Policy Research; Provider; Quality of Care; Reporting; Research; Resource Allocation; Resources; Rewards; Running; Series; Services; Standardization; Surveys; System; Testing; Time; Variant; Veterans; Veterans Health Administration; Work; base; care costs; care episode; care providers; care seeking; community partnership; cost; cost estimate; evidence base; experience; expiration; flexibility; health care quality; health care settings; improved; innovation; medical specialties; neurosurgery; payment; programs; provider networks; willingness

Background: The Veterans' Access, Choice, and Accountability Act of 2014 has transformed the way the VHA delivers care, and its reorganization may lead to substantial challenges that ultimately affect the quality of care that Veterans receive, and subsequently, their health outcomes. Specific Aims: Our specific aims are to: 1) examine variation in utilization and access of VHA vs. Community Care (CC) over time (FY15-FY19); 2) develop and test a methodology to compare costs between VHA and CC; and 3) examine use of specialty care, specifically surgery and mental health. Within Aim 1, we will also determine the factors associated with receiving care in VHA vs. CC. For Aim 2, we will compare cost of standardized episodes of care (SEOCs) in VHA and CC for surgical care, and examine whether use of SEOCs leads to reduced cost and utilization. We will compare quality of surgical care and mental health care between VHA and CC, and develop methods to identify “overuse” of low-value surgical/mental health care in VHA vs. CC. Unique Features/Innovations of Project: This study will evaluate how well the Veterans Choice Program is working to increase Veterans' choice about where they get their care and whether this “choice” has helped to improve their access to timely, high-quality care. Through collaboration with key operational partners (the Office of Community Care (OCC), the Partnered Evidence-based Policy Research Center (PEPReC), and the Office of Reporting, Analytics, Performance, Improvement and Deployment (RAPID)), we will provide VHA with critical information on how well VHA's transformation to a purchaser of care is working. Methodology: For Aim 1, we will conduct descriptive analyses of the overall use of VHA and CC over time. We will then run a series of stratified analyses, separately by inpatient and outpatient setting, by category of care and by SEOC and then at the facility level. We will examine patient- and facility-level characteristics that are related to the extent of use of CC using descriptive analyses and then multivariable logistic regression models adjusted for patient and facility characteristics, categorizing facilities into “higher CC use than expected” and “lower CC use than expected.” For Aim 2, we will use a difference-differences (DD) to estimate costs prior to and after the the use of SEOCs for two surgical SEOCs in VHA and CC (Orthopedics and Neurosurgery-Neuropsych). Similar analyses will be conducted for quantity of services (instead of cost). For Aim 3, we will use generalized linear models, adjusted for patient characteristics and types of services received, to evaluate differences in outcomes between patients using VHA vs. CC for surgery and mental health. Once we have a reliable estimate of the differences in quality of care and cost for the same types of services within SEOCs provided in VHA vs. CC, we will derive a method for identifying low-value care and suboptimal allocation of resources. Expected Results: Information on which services to potentially make (e.g., surgery and mental health) through increased resources/capacity and which services might be more appropriate to buy (e.g., ophthalmology, physical therapy) will be useful as VHA continues down the road as both a purchaser and provider of care.

背景： 《退伍军人的访问，选择和责任法》 2014年改变了VHA提供护理的方式， 它的重组可能导致重大挑战，最终影响退伍军人的护理质量 接收其健康成果。 具体目的： 我们的具体目的是：1）VHA与社区护理（CC）的利用率和访问的检查变化 时间（2019财年2019财年）; 2）开发和测试一种比较VHA和CC之间成本的方法； 3） 检查专业护理的使用，特别是手术和心理健康。在AIM 1中，我们还将确定 与CC接受护理有关的因素。对于AIM 2，我们将比较标准化的成本 VHA和CC中的护理（SEOC）进行手术护理，并检查使用SEOC是否导致 成本和利用率降低。我们将比较VHA和VHA之间的手术护理和心理保健质量 CC，并开发方法来识别VHA与CC中低价值外科/心理保健的“过度使用”。 项目的独特功能/创新： 这项研究将评估退伍军人选择计划正在努力提高退伍军人对 他们得到照顾的地方以及这种“选择”是否有助于改善他们及时，高质量的机会 关心。通过与主要运营合作伙伴的合作（社区护理办公室（OCC），合作 基于证据的政策研究中心（PEPREC），报告，分析，绩效， 改进和部署（快速），我们将为VHA提供有关VHA的关键信息 转换为护理购买者正在奏效。 方法论： 对于AIM 1，我们将对VHA和CC随着时间的流逝进行描述性分析。然后我们将运行 一系列分层分析，分别通过住院和门诊环境，按照类别和SEOC进行 然后在设施级别。我们将检查与患者和设施级的特征 使用描述性分析的CC使用范围，然后调整了多变量逻辑回归模型 患者和设施特征，将设施分类为“比预期更高的CC使用”和“ CC使用较低 比预期的。 在VHA和CC（骨科和神经外科神经心理）中使用SEOC进行两个手术SEOC。相似的 分析将进行服务数量（而不是成本）。对于AIM 3，我们将使用广义线性 对收到的患者特征和服务类型进行调整的模型，以评估结果的差异 在使用VHA与CC进行手术和心理健康的患者之间。一旦我们对 VHA与CC中提供的SEOC中相同类型服务的护理质量和成本差异， 我们将得出一种识别低价值护理和资源次优的方法。 预期结果： 通过增加的信息（例如，手术和心理健康）的信息 资源/能力以及哪些服务可能更适合购买（例如，眼科，物理 治疗）将很有用，因为VHA继续作为购买者和护理提供商继续前进。

项目成果

Estimating the Cost of Surgical Care Purchased in the Community by the Veterans Health Administration.

• DOI: 10.1177/23814683211057902
• 发表时间: 2021-07
• 期刊: MDM policy & practice
• 作者: Wagner TH;Lo J;Beilstein-Wedel E;Vanneman ME;Shwartz M;Rosen AK
• 通讯作者: Rosen AK

Differences Between VHA-Delivered and VHA-Purchased Behavioral Health Care in Service and Patient Characteristics.

VHA 提供的和 VHA 购买的行为健康护理在服务和患者特征方面的差异。

• DOI: 10.1176/appi.ps.202100730
• 发表时间: 2023
• 期刊: Psychiatric services (Washington, D.C.)
• 作者: Vanneman,MeganE;Rosen,AmyK;Wagner,ToddH;Shwartz,Michael;Gordon,SarahH;Greenberg,Greg;Zheng,Tianyu;Cook,James;Beilstein-Wedel,Erin;Greene,Tom;Kelley,ATaylor
• 通讯作者: Kelley,ATaylor

Comparing Driving Miles for Department of Veterans Affairs-delivered Versus Department of Veterans Affairs-purchased Cataract Surgery.

• DOI: 10.1097/mlr.0000000000001491
• 发表时间: 2021-06-01
• 期刊: Medical care
• 影响因子: 3
• 作者: Pettey WBP;Wagner TH;Rosen AK;Beilstein-Wedel E;Shwartz M;Vanneman ME
• 通讯作者: Vanneman ME

Association of Quality of Care With Where Veterans Choose to Get Knee Replacement Surgery.

• DOI: 10.1001/jamanetworkopen.2022.33259
• 发表时间: 2022-09-01
• 期刊: JAMA network open
• 影响因子: 13.8
• 作者: Giori NJ;Beilstein-Wedel EE;Shwartz M;Harris AHS;Vanneman ME;Wagner TH;Rosen AK
• 通讯作者: Rosen AK

Veterans' Experiences With Outpatient Care: Comparing The Veterans Affairs System With Community-Based Care.

• DOI: 10.1377/hlthaff.2019.01375
• 发表时间: 2020-08
• 期刊: HEALTH AFFAIRS
• 影响因子: 9.7
• 作者: Vanneman, Megan E.;Wagner, Todd H.;Shwartz, Michael;Meterko, Mark;Francis, Joseph;Greenstone, Clinton L.;Rosen, Amy K.
• 通讯作者: Rosen, Amy K.