Background: The MISSION Act of 2018 further expanded the opportunity for Veterans to receive care in
the community. While this may have led to improved access to care, it may also have resulted in decreases in
the quality of care that Veterans receive.
Significance: This study will be the first to improve existing risk adjustment methods used by VA with an
application for VA/Community Care (CC) quality comparisons. As increasing numbers of Veteran enrollees use
CC, there is an urgent need to know if the quality of care delivered in the community that is purchased by VA is
at least equivalent to the quality of care delivered in VA. We will also examine whether adding social
determinants of health (SDOH) to the risk adjustment methods impacts assessments of quality and health
disparities.
Innovation and Impact: A better understanding of which new data sources and SDOH variables improve
risk adjustment methods is needed to enable fairer and more accurate comparisons of VA/CC quality at both
the national and local area levels. We will obtain a much richer picture of the conditions and other individual-
and community-level factors that affect the risk or disease burden of Veterans by also including data from
multi-system use (Medicare and All-Payer Claims Databases).
Specific Aims: For federal fiscal years 2020-2022, our specific aims are to: 1) Examine whether adding
readily available VA, CC, and pharmacy data and individual- and community-level SDOH variables improve the
discrimination and calibration of Gagne (an easily modifiable comorbidity measure); 2) Examine whether
adding non-VA system use improves the discrimination and calibration of Gagne; and 3) Compare overall
VA/CC quality at the national and local area levels using “Gagne1” (which includes additional VA and SDOH
data), “Gagne2” (which includes non-VA system use datasets), and the Nosos risk score (an “off-the-shelf” VA
risk adjustment method). We selected two Veteran subgroups to study: Veterans with serious mental illness
(SMI) and Veterans undergoing total hip or total knee arthroplasty (THA/TKA). Both of these subgroups are in
high-cost, high-volume categories of outsourced CC. Quality of care is defined by 4 health outcomes:
emergency department (ED) visits and readmissions for Veterans with SMI, and complications and
readmissions after THA/TKA.
Methodology: For Aim 1, we will examine the extent to which the coefficients on the Gagne comorbidities
change when additional data sources (CC and pharmacy data) are added to VA utilization data and then when
SDOH variables are added to predict outcomes. We will also compare discrimination and calibration between
Gagne, Gagne1, and Nosos. For Aim 2, we will examine the effect of adding non-VA system use data to
Gagne1 and evaluate their effect on model discrimination and calibration of Gagne2. For Aim 3, we will
compare overall VA/CC quality at the national and local levels using Gagne1, Gagne2, and Nosos.
Next Steps/Implementation: Through collaboration with key operational partners (the Office of Community
Care [OCC], Analytics and Performance Integration [API], Office of Health Equity [OHE], Access Office, and
Serious Mental Illness Research and Evaluation Center [SMITREC]), we will provide VA leaders and
policymakers with equitable comparisons of quality that can be integrated into ongoing development of tools
and initiatives that are being implemented nationwide or used to help facilitate practice (which risk adjuster to
use) and policy (decisions related to whether to allocate additional resources to VA-provided care or expand
use of VA-purchased care). Our findings will also enable more informed staff, clinician, and Veteran shared
decision-making about where to receive care.
Public Health Relevance Statement
While the MISSION Act of 2018 increased access to community providers through its Veterans Community
Care Program, the quality of care provided in the community is largely unknown. We will improve existing risk
adjustment methods used by VA so that rigorous and fair VA/Community Care (CC) quality comparisons can
be conducted. We will make national and local quality comparisons of care for Veterans with serious mental
illness (SMI) and, separately, total hip and total knee arthroplasty (THA/TKA)—both of which are in high-cost
and high-volume categories of outsourced CC services. Through collaboration with our operational partners
(the Office of Community Care [OCC], Analytics and Performance Integration [API], the Office of Health Equity
[OHE], the Access Office, and the Serious Mental Illness Research and Evaluation Center [SMITREC]), we will
provide VA leaders and policymakers with the tools to enable more informed purchasing decisions and
Veterans with timely and needed guidance on which setting of care (VA/CC) is most appropriate for their care.
NIH Spending Category
No NIH Spending Category available.
Project Terms
AddressAffectAreaCalibrationCaringCategoriesCodeCollaborationsCommunitiesCommunity HealthcareCommunity PharmacyDataData SetData SourcesDatabasesDecision MakingDiscriminationDisparityEmergency department visitEnsureEquityEvaluationFutureGoalsHealthHealth Services AccessibilityHealthcareHip region structureImprove AccessIndividualMeasuresMedicareMethodologyMethodsModelingMonitorOdds RatioOutcomeOutsourcingPatientsPerformancePharmacy facilityPoliciesPolicy MakerPopulationPrivate SectorProviderQuality of CareResearchResourcesRiskRisk AdjustmentServicesSubgroupSystemTestingVeteransburden of illnesscare providerscare systemscommunity-level factorcomorbiditycostdesignhealth care availabilityhealth disparityhealth equityhigh riskhospital readmissionhousing instabilityimprovedinnovationknee replacement arthroplastymortalityoutcome predictionprogramssevere mental illnessshared decision makingsocialsocial health determinantstooltool developmentweb site
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