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Amy Kilbourne, Ph.D., M.P.H., Director of QUERI

Director's Letter

VA Research Informing Health Policy

Veterans healthcare is currently at the intersection of several important policy changes, including those under the Patient Protection and Affordable Care Act (ACA), which incorporates Medicaid expansion, in addition to recent changes to VA care such as the Veterans Access, Choice, and Accountability ("Choice Act") in 2014. The Choice Act allows Veterans waiting for longer than 30 days or living greater than 40 miles from a VA facility to use non-VA providers, making VA a payer as well as a provider of healthcare for many Veterans.

Together, Medicaid and VA represent the largest single providers of healthcare services in the U.S. for individuals with low income and/or who have chronic mental or physical health conditions. Many Veterans will seek VA care, but some also will be eligible for Medicaid under the Affordable Care Act. Additionally, many providers caring for patients through Medicaid expansion are facing similar challenges in caring for a more vulnerable population with disproportionate rates of mental health needs, substance use, and disability. Hence, many trends in health policy outside VA will have implications for Veteran care, notably with the transformation of the VA healthcare system into an Accountable Care Organization (ACO)-type model, in which it both pays for and provides care for Veterans.

As non-VA healthcare systems increasingly integrate their services under ACOs, they will look to VA for lessons learned on how to deliver optimal care, particularly for vulnerable populations with complex care needs. VA research has much to offer the health policy world, particularly in the development of rigorous evaluation designs and the use of large outcomes data to evaluate different program and policies across different organizational contexts. In the U.S. Government, there also has been an increasing call to implement programs or policies that have a proven evidence track record.¹ In doing so, there has been greater emphasis on the use of stronger evaluations designs, particularly randomized program evaluations, in order to determine whether new policies or programs are effective before they are implemented fully. This approach to data-driven decision-making has been referred to as evidence-based policy, which is an extension of the concept of evidence-based medicine. HSR&D and QUERI are forging a path towards the emerging field of evidence-based policy.

Evidence-based policy studies, especially those that employ randomized designs can inform state and federal policymakers regarding where to invest resources, thus preventing wasted effort and expense on ineffective programs or policies, and producing a greater return on investment. As with evidence-based medicine, "strong" evidence is derived from sound study designs. Nonetheless, increasing the number of rigorous program evaluations takes concerted effort by leaders/policymakers and scientific investigators working in advance to plan the study design, as well as garnering input from the parties involved (e.g., consumers and providers) about the benefits of randomization (e.g., ensuring equity). Having investigators involved upfront in study design decisions is a crucial step for designs to be used effectively.

Even without the ability to randomize new programs or policies, program evaluations can provide important information and support toward understanding a program or policy's long-term implementation and value. In response to the Choice Act, the U.S. Office of Management and Budget (OMB) asked VA to support rigorous internal evaluations of its implementation. While the requirements of the Choice Act made it impossible to randomize who would get access to non-VA care, VA's Quality Enhancement Research Initiative (QUERI) program funded seven projects that are taking a deep-dive observational evaluation of the impact of the Choice Act on patient outcomes among Veterans with mental health or chronic conditions, as well as on access to women's' health care or pain management services, and on wait times. These projects are also informing future evaluations by improving the ascertainment of crucial data on non-VA care use, as well as the development and validation of metrics to measure Veterans' experience with healthcare services.

Major transformations in U.S. healthcare policy that have not been seen in over a generation will markedly impact the care delivered for Veterans and many other individuals. Rigorous program evaluations will be crucial in informing VA and other federal and state policymakers in regard to key decisions on the value of new programs or policies. In turn, this will put VA investigators on the national and international map of evaluation and policy expertise that can be applied to other healthcare systems. Ultimately, such work will require the very types of scientific-policymaker partnerships that already exist in VA, in which practical study designs are executed to ultimately inform the enhancement of healthcare for Veterans.

Amy Kilbourne, Ph.D., M.P.H.
Director, Quality Enhancement Research Initiative

REFERENCE

1. Executive Office of the President. Office of Management and Budget. Next Steps in the Evidence and Innovation Agenda. Memorandum M-13-17. Accessed on August 17, 2015.