Assessing Quality of VA and Community Care in the MISSION Era

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Background: With the goal of improving Veteran access to timely services, the MISSION Act is shifting the VA from a tightly integrated system to one that is more “dis-integrated,” with a substantial number of specialty visits now provided by community providers. The use of VA-purchased community care (VA-CC) could improve access for Veterans, but could also increase fragmentation of care, potentially resulting in delays, redundancies, and less coordinated treatment plans. While multiple previous studies have shown a quality advantage for VA relative to community care (CC), we have little understanding of how fragmentation will impact timeliness and quality of care, especially for high-risk conditions such as cancer care. Significance: Fragmented care is a common, serious, and urgent problem for individuals with cancer. This study, which is responsive to several HSR&D research priorities, will examine the quality of cancer care after the institution of CHOICE and MISSION, whether the efforts to coordinate VA-CC are successful in maintaining measured quality, and the degree of risk to quality for patients who divide their care between systems. Results can be used by our VA partners and Veterans to understand variation and deficits in quality. Innovation & Impact: This project focuses on systems of care and the potential risks and benefits to quality when policy incentivizes movement across systems, and develops measures that can be used for monitoring and targeting efforts to change practice and improve cancer care quality received by Veterans in all settings. Key products: 1) a report of cancer care quality across VA-delivered and VA-purchased CC; 2) an assessment of quality for providers in the community who contract with VA relative to geographically proximate providers who do not; 3) a set of cancer quality measures ready for implementation and new measures identified as appropriate targets for future implementation; 4) a set of measures requiring further testing and development; and 5) approaches to enhance implementation in VA and non-VA settings. Specific Aims: 1. Adapt and extend a set of claims and registry-based measures designed to assess cancer care quality in national US health systems for use within VA; 2. Compare the quality of cancer care for Veterans who receive their cancer care within an integrated system to those receiving more fragmented care across systems, and examine differences in measure performance across key predictor variables; and 3. Conduct a Stakeholder Expert Panel (SEP) to recommend a cancer performance measurement set for tracking quality of cancer care in VA and/or non-VA settings and an agenda for near term implementation. Methodology: We will operationalize previously designed claims-based measures of cancer care in VA data and extend the measure set (with additional prostate cancer measures). We will compare quality measure performance for Veterans over 64: 1) Receiving VA-delivered care only vs. receiving any VA-purchased CC; and those 2) Predominantly reliant on VA care vs. reliant on both VA and Medicare. (Data for these analyses includes: VA CDW, VA PIT/purchased care, and VA-CMS.) We will also examine, using CMS data, if quality measure performance is similar for all patients over 64 attending practices under contract with VA to provide community cancer care to patients attending non-contracted practices within the same hospital referral region. Finally, we will examine differences in measure performance across key patient and system predictor variables. Through a Stakeholder Expert Panel, we will prioritize measures, assess gaps in the current measure set and potential measures to fill those gaps, and recommend approaches for implementation. Next Steps/Implementation: Through the work of the Advisory Council and Stakeholder Expert Panel, which involve both VA and non-VA experts, we will create a multi-step process for dissemination of the research products. By engaging policy makers in the process of decision making, the results will be more implementable and sustainable.