When Did Military Start Providing Medical Services For Veterans
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Balancing Demand and Supply for Veterans' Health Care
A Summary of Three RAND Assessments Conducted Under the Veterans Option Act
This Article
RAND Health Quarterly, 2016; vi(1):12Abstract
In response to concerns that the Section of Veterans Affairs (VA) has faced about veterans' access to care and the quality of care delivered, Congress enacted the Veterans Access, Choice, and Accountability Act of 2014 ("Veterans Choice Deed") in August 2014. The police was passed to aid address access issues past expanding the criteria through which veterans tin seek care from noncombatant providers. In addition, the police force called for a series of contained assessments of the VA health care arrangement across a broad array of topics related to the delivery of health intendance services to veterans in VA-endemic and -operated facilities, as well equally those under contract to VA.
RAND conducted three of these assessments: Veteran demographics and health intendance needs (A), VA health care capabilities (B), and VA authorities and mechanisms for purchasing care (C).
This commodity summarizes the findings of our assessments and includes recommendations from the reports for improving the match between veterans' needs and VA'south capabilities, including VA's ability to purchase necessary care from the private sector.
For more information, run across RAND RR-1165/four-RC at https://www.rand.org/pubs/research_reports/RR1165z4.html
Full Text
Primal Findings from Beyond RAND'due south Three Assessments
The 3-decade decline in the number of veterans will continue. The total number of veterans is expected to subtract by 19 pct betwixt 2014 and 2024, assuming no major policy changes or big-scale conflicts. The median age of this population volition proceed to increase, and veterans are projected to become more geographically concentrated over this menstruum.
Veterans who use VA for health intendance are typically older and sicker than other veterans; however, veterans who rely most on VA care tend to be younger and poorer and to live in rural areas and lack wellness care from other sources.
Through 2019, the demand for VA services may outpace supply. From 2020 and onward, demand for VA care will level off or reject, barring any major conflicts or changes in eligibility policy.
Nosotros observed considerable variability in admission to care and found opportunities to better access, fifty-fifty at the elevation-performing VA facilities. Some veterans confront barriers to accessing VA health care in a timely way, peculiarly in a number of cardinal specialties.
Quality of care delivered past VA is generally equal to or better than intendance delivered in the private sector, though there is considerable variation across centers and types of intendance.
VA has stepped up the purchase of care from the individual sector, though its purchased care programs currently lack an overarching strategy and little is known virtually the timeliness and quality of the intendance.
Congress may need to revise VA's authorization to purchase outside care, depending on the strategy adopted for purchased care.
Introduction
U.S. veterans correspond a special population of men and women who accept served their country, many facing extraordinary health risks during their deployments. Because many veterans take served on overseas missions, including combat, veterans with service-connected health issues are a clinically circuitous and potentially vulnerable population. The mission of the Department of Veterans Affairs (VA) health care system is to meet the wellness care needs of this population.
However, in recent years VA has faced increasing concerns nigh veterans' access to care and the quality of care delivered. In February 2014, in a widely publicized episode, a retired VA physician alleged that at least 40 veterans died while waiting for intendance at the Phoenix VA Health Care Organization. The allegations of deaths were not proven, just they emerged amid wider allegations of long wait times at VA medical centers, poor patient outcomes, and other systemic issues in the VA health care system.
In response to these concerns, the Veterans Admission, Pick, and Accountability Act of 2014 ("Veterans Choice Act") was enacted in August 2014. The law attempted to address access issues by expanding the criteria through which veterans can seek care from noncombatant providers. In addition, the law called for a series of contained assessments of the VA health care organization beyond a wide array of topics related to the commitment of health care services to veterans in VA-endemic and -operated facilities, as well as those under contract to VA.
RAND conducted three of these assessments.
This article summarizes the findings of our assessments and makes recommendations for improving the lucifer between veterans' needs and VA's capabilities, including VA's ability to purchase necessary care from the private sector.
Specifically, RAND teams examined:
- The current and projected characteristics and unique health care needs of veterans
- VA'southward current and projected wellness intendance capabilities and resource for meeting veterans' needs
- The authorities and mechanisms under which VA can purchase care from the private sector
Need: How Much Care Do Veterans Use?
Assessing the demand for care among the population VA serves is challenging. Nether current policy, virtually 60 per centum of U.S. veterans are eligible for VA care, based on length of service, service-connected injuries, service in designated gainsay theaters, and income. Fewer than half of eligible veterans use VA health benefits. Most veterans who utilize VA intendance have other sources of coverage, such equally Medicare or private insurance, and rely on those other sources of care for some of their health care needs. Thus, demand for VA health services is driven largely by eligible veterans' health intendance needs and the extent to which they seek care from VA instead of other sources.
Veteran Demographics Are Changing
Since 1980, the size of the U.Due south. veteran population has declined by 21 percent. At the same time, the number of veterans using VA wellness intendance has increased essentially. The increase is largely due to expanded eligibility and greater reliance on VA health care by recent cohorts of veterans.
Our analysis looked at how these trends will evolve through 2024 (Effigy ane). We projection that the veteran population will decrease by nineteen percentage from 2014 levels. In the almost term—through 2019—the number of veterans using VA wellness care will increase. Yet, this growth in demand will level off or refuse beginning in 2020, due to the end of the wars in Iraq and Transitional islamic state of afghanistan and the continuing subtract in the veteran population. Need could increase again if eligibility is expanded, access to care improves, or there is a future conflict.
Figure 1. Despite a Shrinking Population of Veterans, the Number of Veterans Who Use VA for Health Care Will Increase Until 2019, Then Level Off or Decline
VA Serves Veterans with More-Complex Health Needs
Compared with non-veterans, veterans are disproportionately older, male, and less healthy. Veterans who use VA health care—VA patients—are typically older than other veterans. More than half—52 percent—are over age 65, compared with 39 pct of veterans who are not VA patients. VA patients are also more probable than other veterans to have been deployed. Partly equally a outcome of their older age and deployment experience, VA patients accept a college prevalence of chronic physical and mental health weather condition than other veterans. For example, rates of cancer, diabetes, and mental health conditions are college for VA patients than for veterans who do not apply VA (Effigy ii). These differences also reverberate the eligibility criteria for enrolling in VA care, which depend in part on health status.
The relatively loftier rates of these conditions for VA patients—combined with otherwise rare weather condition related to combat, such every bit limb loss, traumatic brain injury, blindness, and severe burns—mean that VA providers handle a patient mix that differs from what most community providers typically see.
Effigy 2. VA Patients Take a Higher Prevalence of Serious Health Conditions Than Other Veterans and Non-Veterans
VA Patients Who Rely Almost on VA for Care Are Younger and Lack Other Sources of Coverage
Most VA patients receive only a portion of their health care from VA. The extent to which veterans use care from VA is captured in the concept of reliance, defined as the fraction of care delivered or paid by VA. We estimated reliance using data from both VA and exterior sources, which allowed us to view VA and non-VA health care use meantime.
Certain groups of VA patients rely more heavily on VA for health care. Lower-income veterans, veterans in rural areas, veterans without other sources of coverage, and veterans with poorer self-reported health status get a higher fraction of their medical care from VA than other VA patients practice. And although, as a group, VA patients tend to be older than other veterans, those who rely near on VA for their health care are younger.
We besides plant that the mix of VA and non-VA use varies by type of intendance, but in general, VA patients get more than half of their care through not-VA sources (Effigy iii). In particular, VA patients rely most on VA for prescription drug benefits and inpatient visits associated with surgery. Even for these services, however, VA provides less than half of the care used by veterans.
Figure iii. VA Patients Rely on VA for Only a Part of Their Health Intendance
Need for VA Intendance Will Evolve by 2024
This picture will change in the decade betwixt 2014 and 2024, in the following ways.
The VA patient population will become less healthy. Owing partly to aging and the increasing share of Iraq and Afghanistan veterans, the future VA patient population will have a higher prevalence of chronic atmospheric condition (such as diabetes and hypertension) and mental health conditions (such as low and posttraumatic stress disorder).
However, the overall wellness status of new veterans will improve over time (barring another major conflict) because of the increase in the share of separating service members who did not face deployment-related health injuries. Nevertheless, this volition non exist enough to commencement the general downwardly trend in the health of the VA patient population every bit a whole.
Understanding future need for health care among veterans who served in Iraq or Afghanistan is critical to coming together their needs. By 2024, almost 19 percent of VA patients will take served in Iraq or Afghanistan (compared with 12 per centum in 2014). The long-term health impacts of deployment in these conflicts are not yet well understood, and therefore this cohort may pose new challenges for the VA health system.
A future conflict would increase need for VA services. U.S. engagement in a military disharmonize in the side by side ten years would increase the number of newly eligible veterans, many of whom would take combat exposure. Across a range of conflict scenarios of different levels of scale and intensity, our assay predicted that a future conflict would add together between 500,000 and 925,000 new VA patients.
Geographic shifts will likewise influence demand for care. As the veteran population continues to shift to the south and due west, in that location will be substantially fewer veterans in some areas in the northeast and upper Midwest (Effigy iv).
Figure four. Every bit the Veteran Population Continues to Shift to the Southward and West, There Will Be Substantially Fewer Veterans in Some Areas in the Northeast and Upper Midwest
Figure four. As the Veteran Population Continues to Shift to the South and West, There Volition Be Essentially Fewer Veterans in Some Areas in the Northeast and Upper Midwest
Supply: What Is VA'due south Capacity to Deliver Wellness Care and How Might This Bear upon Veterans' Access?
VA operates one of the virtually extensive wellness care systems in the country, with broad and deep resource and capabilities, including 144 hospitals, 700 outpatient clinics, and more than 55,000 employed clinicians. Yet, VA's ability to harness these resources effectively to meet the wellness intendance needs of veterans has been called into question.
VA's Capacity to Meet Demand
Nosotros assessed VA'southward electric current capacity to meet demand based on measures of access and quality.
Nearly veterans live nigh a VA health care facility. Although veterans are highly dispersed throughout the United states, 93 percentage of veterans alive within 40 miles' driving distance of a VA health care facility. However, geographic access to VA intendance varies by how access is measured (e.g., driving altitude, driving time, public transit time) and what services are needed (Effigy 5). For example, veterans who rely on public transportation confront a pregnant bulwark to access: Only 25 per centum of veterans live within a 60-minute transit time from a VA medical facility. Further, fewer veterans take geographic access to advanced and specialized services in VA facilities. For example, only 43 percent of veterans live within forty miles of VA interventional cardiology services, and only 55 percent of veterans live within 40 miles of VA oncology services.
Figure 5. Nearly All Veterans Live Within a 40-Mile Drive to a VA Wellness Intendance Facility; Far Fewer Have Like shooting fish in a barrel Access to VA Facilities Via Public Transit
VA Usually, only Non Always, Provides Timely Care
Co-ordinate to VA data, most veterans get care within two weeks of their preferred appointment date (that is, the engagement that the physician recommends or that the veteran prefers), as shown in Figure vi, and the vast majority complete their appointments with their primary care providers inside the VA timeliness standard of 30 days from the preferred date. This pattern persists for specialty intendance every bit well, with access to mental wellness care slightly ameliorate.
Figure 6. Virtually Veterans Get Care Within 2 Weeks of Their Desired Date Date
Still, the average number of days that veterans wait for appointments varies tremendously across VA facilities, with some patients not completing their appointments until more than 60 days after their preferred date. Merely virtually half of veterans reported getting care "as presently equally needed." The expect fourth dimension measure out used by VA (number of days post-obit the preferred date) makes it hard to compare it with other health systems. Many private-sector entities employ dissimilar strategies to capture the timeliness of intendance, such every bit the proportion of facilities that are able to offer a same-twenty-four hours appointment, or the average number of days from the current date until the tertiary-next-available appointment.
In the Near Future, Demand for VA Care Is Expected to Exceed Capacity
Equally noted before, demand for VA intendance is expected to increase through 2019 before leveling off in 2020. In particular, demand for specific types of care—including pain medicine, neurology, dermatology, and many others—is expected to grow. Overall, the near-term increase in need for care may outpace VA'due south capacity to provide timely care to all veterans.
VA Provides College-Quality Health Intendance Than Non-VA Care Sources on Many Measures
VA established itself as a leader in quality-of-care measurement and improvement in the 1990s, and, overall, quality-of-care delivered today compares favorably with that of comparable noncombatant facilities, though it falls curt on some measures and in some facilities. For case, while VA outpatient intendance outperformed non-VA outpatient care on most quality measures, VA performance on measures of inpatient care was mixed, with some better and others worse (Effigy 7). Our analysis as well found wide variation beyond VA facilities in performance on many quality measures.
Figure 7. VA Outpatient Care Outperformed Non-VA Outpatient Intendance on Almost Quality Measures; VA Performance on Measures of Inpatient Care Was Mixed, with Some Better and Others Worse
What Should Policymakers Consider When Examining Changes to Purchased Care?
Employ of Purchased Care Has Been Growing
In recent years, VA has increased its purchases of care from individual-sector providers to accommodate veterans whose needs cannot be met in-business firm. The Veterans Health Administration's (VHA's) Chief Business Office estimated that VA purchased intendance costs in fiscal year 2014 totaled $5.half-dozen billion (nine.4% of VA's medical expenditures) after steady and significant increases year after year, as shown in Figure eight. The Veterans Option Act added another $10 billion to VA's budget to expand purchased intendance in 2015–2017.
Figure 8. Cost and Need for Purchased Care Have Increased Near 3-Fold Over the Past Decade, and This Trend Volition Likely Keep
The Veterans Selection Act too expanded eligibility for veterans who are already eligible for VA health care to purchase care exterior of VA. Veterans can obtain an appointment with an outside provider under the Choice program if they live far from the wellness care they need or if they are unable to schedule an appointment at a VA hospital or other VA facility within VA'due south 30-solar day standard.
VA's Purchased Care Organisation Is Circuitous
At the time of our analysis, VA purchased outside care through various mechanisms, each guided by different structures, policies, and procedures, every bit shown in Figure 9. We constitute that decisions well-nigh which purchased care machinery to use for a particular circumstance relied on the complex judgment of VA administrators–with priority given to VA partner facilities overseen by other federal agencies or affiliated academic institutions. Beyond that, referral decisions took into business relationship other factors, such as payment levels and provider qualifications.
Figure 9. VA Purchased Care Evolved in an Unsystematic Mode
Our analysis identified a number of inconsistencies in how purchased care was administered, how referrals were made, and how claims and payments to providers were handled. It besides uncovered inconsistent procedures for purchased care decisions at the local level. For example, 1 local VA facility might purchase a specific medical service as part of a larger contract for a package of services, while another facility purchases the same service nether a separate, small contract that is subject to dissimilar levels of oversight. In July 2015 (after this assessment was completed), Congress passed new legislation requiring VA to develop a programme to consolidate its purchased intendance function.
Purchased Care Quality and Timeliness Are Unknown
Although increasing the use of purchased intendance has been suggested every bit a way to increase veterans' access to care, our analysis establish that nigh veterans who live far from a VA facility live near private-sector chief intendance but not specialty care. In add-on, the quality and timeliness of the care VA purchases relative to VA care are unknown. Currently, VA does not monitor the quality of intendance provided by exterior entities or track how long information technology takes for veterans to receive such intendance.
VA Lacks a Clear Strategy for Purchased Intendance
Our assay of VA's purchased care authorities plant inherent tensions in the goals of purchased care, reflecting doubtfulness about the extent to which policymakers may wish to preserve VA's primary function as a health care provider or allow VA to provide more care through the individual sector. Policy-makers must determine on a articulate strategy for purchased care earlier making further changes: Should purchased intendance exist used to make full gaps and provide a quick response when there are spikes in need, or is there a longer-term vision for shifting the delivery of care away from brick-and-mortar VA facilities as the demographics of the veteran population change? Possible policy objectives that could prompt such changes are explored at the cease of this section.
Given the many possible objectives for the future of purchased care, VA and Congress could discover themselves considering a range of changes to how and under what atmospheric condition VA purchases care. These changes could include enhancing relationships with individual providers, modifying the eligibility requirements for purchased care, changing how purchased care is managed, and improving contracting for purchased care.
Possible Objectives for Purchased Care
Address brusk-term gaps in VA health intendance capacity through a temporary surge in purchased care. "Short-term gaps" could be those that exist today (i.e., in the timeliness of appointments), or they could involve a future mismatch between VA resources and demand for specialty care.
Address long-term gaps in VA health care capacity through the utilise of purchased care permanently. Gaps could arise in whatsoever aspect of VA wellness care service capacity that cannot be filled feasibly or efficiently by VA chapters development.
Improve the value of health care for Veterans through purchased care. From the perspective of government, purchased intendance could be provided where doing and so would lead to improvements in such areas as clinical quality of care or cost-effectiveness.
Aggrandize or enhance purchased intendance to increase Veterans' choices. Veterans could be offered more than choice to seek coverage and care exterior of the traditional VHA system (e.g., via private providers or other government facilities, such equally those run past the Section of Defense force).
Redefine the concept of VA health intendance by aggressively outsourcing VA care. The nature of VA health care activities could be transformed by making purchased care much more focal equally a primary mechanism for delivering specific wellness care services to veterans or for delivering health care services to specific groups of veterans.
Recommendations
The following recommendations from beyond the three assessments point toward solutions that policymakers and VA should consider in progressing toward the goal of providing loftier-quality, timely, and accessible wellness intendance that meets veterans' needs.
i. Prepare for a Changing Veteran Mural
Balance the need for short-term capacity increases with longer-term preparations for declines in patient numbers.
Over the by decade, VA has faced a steady increase in demand for health care. While nosotros found that this trend volition continue in the near term, VA must prepare for a decline in the size of the patient population over the longer term. If VA responds to current increases in demand by expanding facilities, infrastructure, staffing, and other resource, the result may be a larger-than-needed footprint after 2019, when the patient population begins to level off.
Assess the best manner to provide care in unlike areas of the state and for different types of care.
The challenges facing VA will be more acute in some regions and at some VA facilities than others, so considerations of distribution volition be every bit of import as consideration of overall levels. In regions where the site of the veteran population is expected to refuse more sharply, VA might consider consolidating relatively proximal VA facilities, while in regions with projected veteran population growth, at that place may be a need to expand the availability of VA health care. Increasing the utilise of care purchased from the civilian sector may enable VA to meet the needs of veterans in regions with expected growth or few existing facilities. In other regions, care may more than efficiently exist delivered through telemedicine and customs-based outpatient clinics.
Improve and expand information collection to inform estimates and planning for time to come need of VA care.
- Re-implement information collection on veteran condition in the 2020 Census. The most comprehensive source of information on veterans is the 2000 U.S. Census, meaning that comprehensive information is now 15 years old. The 2010 Demography did not collect data on veteran status, and current efforts to study the veteran population rely on surveys of samples of the population that are less accurate.
- Closely monitor the needs of post-9/xi veterans. Mail service-9/11 veterans may accept unlike patterns of VA health care use than earlier generations of veterans. New policies accept been established to address the needs of the large number of veterans who were exposed to combat over the long elapsing of the post-9/11 conflicts. Closely monitoring the health care needs of this new generation of veterans will ensure that VA can respond rapidly and appropriately to their needs.
- Collect better data on all wellness intendance used past veterans. Little is known well-nigh the health care use and needs of veterans who receive some or all of their intendance outside VA. Information on the care used by these veterans, as well as their unmet needs for intendance, would permit VA to identify how best to serve the evolving needs of this group. Such data also would enable VA to better program for hereafter changes in VA eligibility rules or enrollment patterns.
2. Ameliorate Access and Quality
Take meaning steps to meliorate access to VA care.
Adjustments to VA's resource and capabilities will exist needed to meet the near-term demand for health services among veterans. We identified several policy options to ensure that veterans have continued access to care; those that have the highest potential bear on include the following:
- Increase the number of VA physicians to expand the number of patients who tin exist seen in a timely style.
- Formalize independent nursing practice, granting independent exercise authority for all avant-garde-exercise nurses (i.due east., nurse practitioners, clinical nurse specialists, nurse anesthetists, and nurse midwives) across VA.
- Expand virtual access to care (e.thousand., use of clinical video telehealth) to increment access to clinical care when distance separates the patient and provider.
These options are not mutually exclusive, and each has dissimilar potential barriers to implementation. For example, the main barrier to formalizing contained nursing practise is political (key stakeholder opposition); the barriers to hiring physicians are related to cost and authoritative challenges associated with the hiring process; and the primary barrier to expanding virtual access to care is price.
Reduce variability in admission and quality to ensure all veterans receive timely, high-quality care.
Although many VA facilities accomplish very high levels of performance on cardinal access and quality measures, at that place is also a dandy bargain of variation across the system in strategies used to reach high performance. A systematic, continuous performance comeback endeavor is needed to place unwarranted variation, place and develop all-time practices to improve performance, and embed these practices into routine use beyond the VA arrangement.
Consider alternative standards of timely access to care.
VA should examine the utility of alternative benchmarks of timeliness, such as those related to appointment availability. VA should develop methods to routinely compare the timeliness of VA care with non-VA benchmarks and publish these comparisons for transparency.
Develop and implement more-sensitive standards of geographic access to care.
VA and Congress should compare the "ane-size-fits-all" approach of driving distance with alternative standards that are more sensitive to differences betwixt veteran subgroups, clinical populations, geographic regions, and individual facilities. Our assessment highlighted the importance of fourth dimension spent driving, mode of transportation, traffic, and availability of needed services as key considerations in assessing geographic access to care.
iii. Make Strategic Utilise of Purchased Care
Define a strategy for purchased intendance.
Policymakers and VA should articulate a clear strategy and set of goals for how purchased care should be used and how it fits into VA's broader health care mission. The strategy should also establish benchmarks for success in adopting purchased care reforms. Specifically, it should provide a solid foundation for purchased care government and procedures going forwards while maintaining the flexibility to see surges in need and provide veteran-centered care.
Streamline management of the electric current purchased intendance arrangement.
Every bit VA and Congress work toward a consolidated approach to purchasing care, our assessment recommended a review of the purchased intendance management structure to ensure that responsibilities like contracts and referrals are allocated to the appropriate levels within the agency. Candidates for greater oversight and streamlining include processes for evaluating the third-party administrators that operate VA'southward purchased care provider network and clearer, more than-compatible policies for billing, episodes of care, and reporting requirements. VA should likewise prefer a coherent, cost-effective strategy for provider reimbursement. Policymakers will want to ensure that any changes maintain an advisable amount of flexibility at the local level.
Monitor the quality and timeliness of care purchased exterior VA.
VA is a leader in quality-of-intendance measurement and improvement, notwithstanding information technology has limited visibility into the quality and timeliness of intendance provided to veterans from outside entities. VA should require routine reporting of quality measures to ensure that the quality and timeliness of care that veterans receive from non-VA providers is as good as or ameliorate than the care offered by VA. Purchased care contracts should also make explicit how non-VA providers volition communicate and coordinate with VA counterparts.
The analyses upon which this publication is based were performed under a contract for the Department of Veterans Affairs and conducted past RAND Health, a division of the RAND Corporation. The development and production of this summary was funded through a generous philanthropic souvenir from Charles Zwick.
Related Resources
RAND Wellness Quarterly is produced by the RAND Corporation. ISSN 2162-8254.
When Did Military Start Providing Medical Services For Veterans,
Source: https://www.rand.org/pubs/periodicals/health-quarterly/issues/v6/n1/12.html
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