Evaluating the VA Make-or-Buy Decision in Emergency Care

背景：为了回应人们对退伍军人管理局设施准入和护理质量的担忧，退伍军人管理局已经开始 将资源重新用于资助退伍军人管理局以外的退伍军人护理。然而，护理的质量和成本 对于退伍军人来说，这一“要么制造要么购买”的决定仍然是一个科学上的未知数，有着重大的政策 对退伍军人管理局如何优化退伍军人健康的影响。护理质量和成本尤其受到以下因素的影响 急救服务，13%的护理和每年超过8亿美元的费用直接流向退伍军人管理局以外的地方。 目标：我们的目标是确定退伍军人的护理质量和成本如何受到其提供的影响 退伍军人事务部内外。研究退伍军人管理局与非退伍军人管理局医疗服务的质量和成本面临的根本问题 在退伍军人管理局接受护理的患者的潜在健康水平可能与在退伍军人管理局接受护理的患者不同 在退伍军人事务部之外接受治疗。不了解退伍军人管理局与非退伍军人管理局急救的后果 质量和成本，退伍军人政策制定者将无法引导退伍军人到最好的护理地点，他们也不会 了解退伍军人管理局和非退伍军人管理局之间的质量和成本差异背后的机制。最后，缺乏 了解退伍军人护理与非退伍军人护理的效果，以及退伍军人如何获得护理、预防 来自政策干预的政策制定者预测退伍军人的质量和成本结果 退伍军人接受非退伍军人护理。 方法：在目标1中，我们将采用基于工具变量(IVs)的准实验方法 研究护理资源对健康、利用率和支出的影响。在初步结果中，我们发现VA EDS将老年退伍军人死亡率降低50%，即5个百分点。在目标2中，我们将评估这些因素 改变退伍军人护理与非退伍军人护理的效果，评估效果背后的机制。例如，我们将 调查退伍军人退伍军人是否在某些条件或人口统计学方面表现更好，例如 精神健康诊断或社会经济地位低下。我们将评估当地退伍军人管理局的能力是否 在决定预后以及护理协调是否能改善VA预后方面起着关键作用。 在目标3中，我们将评估退伍军人如何使用退伍军人和非退伍军人教育替代方案，我们将使用这些结果和 目标1和目标2中的目标是根据扩大退伍军人管理局能力的政策模拟质量和成本结果， 与非退伍军人选项签订合同，并根据退伍军人的特征和需求重新引导他们进行护理 本地选项。 预期结果：根据我们的初步结果，我们预计在健康方面会有重要的差异 退伍军人管理局和非退伍军人管理局急救之间的结果和支出。因此，我们期望政策制定者能够 拯救数以千计的退伍军人的生命，并可以通过根据这一点做出决定来改善健康结果 研究。退伍军人和当地条件不同，退伍军人保健的效果可能会有所不同。因此，我们预计 通过调整与以下方面相关的政策，将在医疗和支出结果方面带来巨大的额外收益 这一重要的“要么做要么买”的决定。最后，通过了解不同环境和环境下的结果差异 退伍军人类型，我们希望对医疗保健的哪些组成部分有一个大致的了解 交付是实现卓越的关键。与政策和规划办公室合作， 社区护理和急救医学，我们预计我们的发现将得到广泛传播，并将 直接应用于退伍军人管理局的决定和指导方针。

Background: In response to concerns about access to and quality of care at VA facilities, the VA has begun to redirect resources toward financing care for Veterans outside of the VA. However, the quality and cost of care for Veterans that will result from this “make-or-buy” decision remain a scientific unknown, with significant policy implications for how the VA can optimize Veteran 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 the VA. Objective: Our objective is to identify how quality and cost of care for Veterans are affected by its provision inside or outside the VA. Studying the quality and costs of VA vs. non-VA care faces the fundamental concern that patients who receive care at VA facilities may have different levels of underlying health than do those who receive care outside the VA. 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. Finally, a lack of knowledge about the effects of VA vs. non-VA care, and about how Veterans access care, prevents policymakers from predicting quality and cost outcomes for Veterans from policy interventions redirecting Veterans to non-VA care. Methods: In Aim 1, we will adopt a quasi-experimental approach, based on instrumental variables (IVs), to study the effect of the care source on health, utilization, and spending. In preliminary results, we find that VA EDs reduce elderly Veteran mortality by 50%, or five percentage points. In Aim 2, we will assess the factors altering the effect of VA vs. non-VA care, evaluating mechanisms behind the effect. For example, we will investigate whether the VA performs better for Veterans with certain conditions or demographics, such as a mental health diagnosis or low socioeconomic status. We will assess whether the capacity of local VA options plays a key role in determining outcomes, and whether coordination of care mediates improved VA outcomes. In Aim 3, we will evaluate how Veteran use VA and non-VA ED alternatives, and we will use these results and those in Aims 1 and 2 to simulate quality and cost outcomes under policies for expanding VA capacity, contracting with non-VA options, and redirecting Veterans to care depending on their characteristics and on local options. Expected Outcome: Based on our preliminary results, we expect there to be important differences in health outcomes and spending between VA and non-VA emergency care. We therefore expect that policymakers can save thousands of Veteran lives and can improve health outcomes by making decisions based on this research. The effect of VA care likely differs across Veterans and local conditions. Accordingly, we expect there to be large additional gains in health and spending outcomes that result from tailoring policies related to this important make-or-buy decision. Finally, by understanding how outcomes differ across settings and Veteran types, we expect to contribute to a general understanding about which components of health care delivery are most critical to achieving excellence. In partnership with the Offices of Policy and Planning, Community Care, and Emergency Medicine, we anticipate that our findings will be disseminated widely and will be applied directly to VA decisions and guidelines.