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

背景资料： 2014年的《退伍军人准入、选择和问责法》改变了VHA提供护理的方式， 它的重组可能会导致实质性的挑战，最终影响护理的质量，退伍军人 获得，以及随后的健康结果。 具体目标： 我们的具体目标是：1）检查VHA与社区护理（CC）的使用和获得的变化， 时间（FY 15-FY 19）; 2）开发和测试VHA和CC之间成本比较的方法;以及3） 检查专科护理的使用情况，特别是外科和心理健康。在目标1中，我们还将确定 与VHA vs. CC中接受护理相关的因素。对于目标2，我们将比较标准化的成本 在VHA和CC中进行外科护理的护理事件（SEOCs），并检查SEOCs的使用是否导致 降低成本和利用率。我们将比较VHA和 CC，并制定方法，以确定“过度使用”的低价值手术/精神卫生保健VHA与CC。 项目特色/创新： 这项研究将评估退伍军人选择计划在增加退伍军人选择方面的效果如何。 他们在哪里得到护理，以及这种“选择”是否有助于改善他们获得及时、高质量的护理， 在乎通过与主要业务伙伴（社区护理办公室、合作伙伴 循证政策研究中心（PEPReC）和报告，分析，性能， 改进和部署（RAPID）），我们将向VHA提供有关VHA 转变为护理购买者正在发挥作用。 方法学： 对于目标1，我们将对VHA和CC随时间推移的总体使用情况进行描述性分析。然后我们将运行一个 一系列分层分析，分别按住院和门诊环境、治疗类别和SEOC进行 然后是设施层面。我们将研究与以下因素相关的患者和机构层面的特征： 使用描述性分析，然后使用多变量logistic回归模型调整CC的使用程度， 患者和设施特征，将设施分类为“CC使用高于预期”和“CC使用较低 比预期的要多”。对于目标2，我们将使用差异-差异（DD）来估计 在VHA和CC（骨科和神经外科-神经心理学）的两个外科SEOC中使用SEOC。类似 将对服务的数量（而不是成本）进行分析。对于目标3，我们将使用广义线性 模型，根据患者特征和接受的服务类型进行调整，以评估结果的差异 使用VHA与CC进行手术和心理健康的患者之间的差异。一旦我们有了可靠的估计， VHA与CC中提供的SEOC内相同类型服务的护理质量和成本差异， 我们将推导出一种方法，用于识别低价值护理和资源的次优分配。 预期结果： 关于可能提供哪些服务的信息（例如，手术和心理健康）， 资源/容量以及哪些服务可能更适合购买（例如，眼科学，物理的 治疗）将是有用的，因为VHA继续沿着这条道路作为购买者和提供者的照顾。

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.