Use and costs of low-value health services by Veterans in VA and non-VA settings

背景：过度使用直接或下游成本或危害超过其成本的卫生服务 福利(即低价值的医疗服务)是美国医疗成本的主要驱动因素。 采用了低价值服务使用的综合措施，以识别低价值服务和 非退伍军人群体的利用率和成本最高，但对哪些低价值服务最多却知之甚少 在退伍军人健康管理局(VHA)管理的退伍军人中经常使用且价格昂贵。此外，所有 65岁以上的退伍军人有资格通过医疗保险使用非退伍军人护理，所有年龄段的退伍军人都可以获得越来越多的 通过退伍军人管理局社区护理(VACC)在退伍军人管理局之外提供护理。过去的研究表明，VA和非VA的双重使用 退伍军人护理使退伍军人面临过度使用医疗服务的风险，但退伍军人使用低价值医疗服务的信息 缺乏非退伍军人管理局的服务。意义/影响：我们的目标是确定 退伍军人退伍军人在退伍军人事务部内外使用低价值服务的利用率、成本和决定因素。我们的研究将 通过退伍军人医疗中心(VAMC)确定退伍军人最常用的低价值服务， VACC，双重医疗保险福利，以及那些最昂贵的福利。这项研究将为政策和 干预措施，包括可能的新质量指标，以减少向退伍军人提供的低价值护理。结果 将对我们的退伍军人管理局合作伙伴(报告、分析、业绩改进和部署办公室、 和社区关怀办公室)致力于确保退伍军人获得高价值的服务 无论他们在哪里接受治疗。它还将使退伍军人在选择 VA设置与非VA设置之间的差异。这项研究涉及两个退伍军人护理优先事项(医疗保健价值；质量/ 护理安全)和退伍军人管理局法律优先事项，以了解非退伍军人护理对 根据《使命法》退伍军人。创新：当前的VA绩效指标捕捉到了 可获得性、质量、安全和效率，但不涉及退伍军人接受低价值护理或护理质量 在非VA设置中接收。我们的项目将使用新的方法来量化一组 退伍军人在退伍军人事务部内外可能获得的低价值服务。具体目标：目标1：量化 向VAMC和VACC中的VHA登记人员提供的低价值服务的利用率和成本，并说明 在每个环境中提供的低价值服务中，退伍军人管理局设施之间的差异。目标2：量化利用率和 VAMC和非退伍军人保险设置中的双重VHA-Medicare投保人使用低价值服务的成本 医疗保险，并表征在每个环境中提供的低价值服务的退伍军人事务部设施级别的差异。目标3： 确定在每个环境中取消实施低价值服务的障碍和促进者。方法：在目标1中， 我们将对国家/地区的VA利用率数据和VACC数据应用基于索赔的低价值关怀措施 VHA参赛者队列。我们将在6个类别中确定26项低价值服务的使用频率：癌症 筛查、诊断/预防检测、术前检测、成像、心血管检测/程序，以及 做手术。我们将应用HERC的平均成本估算来计算每项服务和类别的总成本 VAMC和VACC。我们将使用多水平建模来检查VAMC和VAcc比率的设施差异 低价值服务使用以及退伍军人和VAMC因素在多大程度上解释了这种差异。目标2将涉及 类似的分析涉及VA利用率数据和双重VA-Medicare参与者的Medicare报销。目标3将 将潜在轮廓分析应用于低价值服务类别的设施级估计，以确定 在退伍军人管理局和非退伍军人管理局的低价值服务使用模式相似的VAMC。我们将进行采访 与在不同群集的VAMC开展业务的退伍军人管理局合作，检查障碍和推动者，以消除 实施退役军人低价值服务。下一步和实施：我们将使用结果来处理 运营合作伙伴制定绩效衡量标准、政策和干预措施，以减少退伍军人的接收 随着退伍军人管理局发展成为退伍军人护理的提供者和支付者，退伍军人管理局和非退伍军人管理局在低价值护理方面取得了进展。

Background: Overuse of health services whose immediate or downstream costs or harms exceed their benefits (i.e., low-value health services) is a major driver of healthcare costs in the United States. Comprehensive measures of low-value service use have been applied to identify low-value services with the highest utilization and costs in non-VA populations, but less is known about which low-value services are most frequently used and costly in Veterans managed in the Veterans Health Administration (VHA). Also, all Veterans aged 65+ are eligible to use non-VA care via Medicare, and Veterans of all ages increasingly receive care outside VA through VA Community Care (VACC). Past research suggests that dual use of VA and non- VA care places Veterans at risk for overuse of health services, but information on Veterans’ use of low-value services in non-VA settings is lacking. Significance/Impact: Our objective is to determine the extent of utilization, costs, and determinants of Veterans' low-value service use within and outside VA. Our study will identify the low-value services most commonly used by Veterans through VA Medical Centers (VAMCs), VACC, and dual Medicare benefits, and those that are most costly. This study will inform policies and interventions, including possible new quality metrics, to reduce low-value care provided to Veterans. Results will be valuable to our VA partners (Office of Reporting, Analysis, Performance Improvement and Deployment, and Office of Community Care) who are committed to ensuring that Veterans receive high-value services regardless of where they receive care. It will also empower Veterans to consider value of care when choosing between a VA vs non-VA setting. This study addresses two Veteran Care Priorities (health care value; quality/ safety of care) and the VA legislation priority to understand impact of non-VA care on value of care received by Veterans in light of the MISSION Act. Innovation: Current VA performance metrics capture key dimensions of access, quality, safety, and efficiency, but do not address Veterans' receipt of low-value care or quality of care received in non-VA settings. Our project will use novel methods to quantify use and determinants of an array of low-value services that Veterans may receive both within and outside of VA. Specific Aims: Aim 1: Quantify utilization and costs of low-value services provided to VHA enrollees in VAMCs and VACC, and characterize variation across VA facilities in low-value services provided in each setting. Aim 2: Quantify utilization and costs of low-value services used by dual VHA-Medicare enrollees in VAMCs and non-VA settings through Medicare, and characterize VA facility-level variation in low-value services provided in each setting. Aim 3: Identify barriers and facilitators of de-implementing low-value services in each setting. Methodology: In Aim 1, we will apply a claims-based measure of low-value care to VA utilization data and VACC data for a national cohort of VHA enrollees. We will identify frequency of use of 26 low-value services in 6 categories: cancer screening, diagnostic/preventive testing, preoperative testing, imaging, cardiovascular testing/procedures, and surgery. We will apply average HERC cost estimates to calculate total costs of each service and category in VAMCs and in VACC. We will use multilevel modeling to examine facility variation in rates of VAMC and VACC low-value service use and extent to which Veteran and VAMC factors explain this variation. Aim 2 will involve similar analyses involving VA utilization data and Medicare claims for dual VA-Medicare enrollees. Aim 3 will apply latent profile analysis to facility-level estimates of low-value service categories to identify clusters of VAMCs with similar patterns of low-value service use in VA and non-VA settings. We will conduct interviews with VA providers who practice at VAMCs in different clusters to examine barriers and facilitators to de- implementing low-value services for Veterans. Next Steps & Implementation: We will use results to work with operations partners to develop performance measures, policies, and interventions to mitigate Veterans’ receipt of low-value care in VA and non-VA settings, as VA evolves as a provider and payer of Veteran care.