Evaluating the Veterans Choice Act: QUERI/Program Office Partnership
In response to reports of increasing delays for care, Congress passed the Veterans Access, Choice, and Accountability Act (hereafter, the "Choice Act"), which authorized expanded availability of hospital care and medical services from non-VA providers. Although barely in its second year, the Choice Act signals a profound transformation for the VA healthcare system - and for QUERI, because it means being at "ground zero" of policymaking, evaluation, and finding evidence to support improved practice. The fundamental challenge posed by Choice is how VA should organize its structures and processes of healthcare delivery, including new partnerships with community-based providers, to achieve the best possible outcomes for Veterans within a sustainable cost.
Though the Choice Act is complex, it's well worth your time to become familiar with because it will shape nearly all we do in the coming years. Most staff are already aware of Section 101, which allows VA to purchase care in the community for Veterans waiting more than 30 days or residing more than 40 miles from needed services. Section 201 of the Act mandated a comprehensive, independent assessment of the VA healthcare system. The full report (more than 4,000 pages including comprehensive data tables) has just been released and provides an incomparable reference for VA's current state of performance (read the Integrated Assessment Report for key findings and recommendations). The 12 Assessment Teams, which included groups such as RAND, McKinsey, and the Institute of Medicine, refer heavily to peer-reviewed literature published by VA HSR&D and QUERI researchers. Sections 206 and 207 mandate VA to publicly report a wide range of quality, safety, and access data - the well-known challenges of making public reports understandable should invite many future projects. Finally, Section 303 requires VA to deploy standardized training in clinic management. This presents an unprecedented opportunity to assist with spreading improvement across all VA facilities.
The first phase of QUERI's response to the Office of Management and Budget's (OMB) request was a very rapid solicitation for short-term (6 month) projects to address a range of issues such as care coordination, new metrics of appropriate care, and challenges of special populations (e.g. women Veterans, PTSD). Not surprisingly, these nascent projects were challenged by several factors: primitive data exchange with non-VA providers, rapidly evolving policy guidance, and scarcity of external providers, particularly in areas with well-recognized shortages.
The desire for "real-time, real-life" evaluation in such a dynamic environment has tested the mettle of all QUERI teams, but also signals a new reality: This is no longer the VA of the "Kizer era" with a closed system of hospitals and clinics and ready access to complete internal data from our electronic health record. Our new "open" ecosystem cannot be studied simply with internal databases. Nor will precisely delineated protocols suffice; "rapid cycle evaluation" is the paradigm for the future. I applaud the entire QUERI community for taking on this challenge.
Joseph Francis, MD, MPH