RAND Corporation study: VA Health System Generally Delivers Higher-Quality Care Than Other Health Providers

April 26, 2018 — The VA health care system performs similar to or better than non-VA systems on most measures of inpatient and outpatient care quality, although there is high variation in quality across individual VA facilities, according to a new RAND Corporation study.

Examining a wide array of commonly used measures of health care quality, researchers found that VA hospitals generally provided better quality care than non-VA hospitals and the VA's outpatient services were better quality when compared to commercial HMOs, Medicaid HMOs and Medicare HMOs. The findings are published online by the Journal of General Internal Medicine.

“Consistent with previous studies, our analysis found that the VA health care system generally provides care that is higher in quality than what is offered elsewhere in communities across the nation,” said Rebecca Anhang Price, lead author of the study and senior policy researcher at RAND, a nonprofit research organization.

While the study found wide variation in the quality of care provided across the VA health system, the variation is smaller than what researchers observed among non-VA health providers.

Some of the variation may be caused by patients being generally older and sicker at some VA facilities than at others. But researchers say the findings primarily suggest that the VA needs targeted quality improvement efforts to ensure that veterans receive uniformly high-quality care at all VA facilities.

“The variation among VA health facilities shows that veterans in some areas are not receiving the same high-quality care that other VA facilities are able to provide,” said Carrie Farmer, a study co-author and a senior policy researcher at RAND.

The Veterans Health Administration operates the nation's largest integrated health system, offering comprehensive health services to eligible U.S. military veterans who enroll. Congress and veterans' groups have expressed concerns that access to care and quality of care in the VA system are inferior to the access and quality in non-VA settings.

RAND researchers compared quality of care provided by the VA in outpatient and inpatient settings by using nationally recognized performance measures reported across several national surveys during 2013 and 2014. The information analyzed includes the Healthcare Effectiveness Data and Information Set, and the Survey of Healthcare Experiences of Veterans.

For each of the VA's 135 facilities, researchers identified three non-VA hospitals that had similar characteristics, such as geographic location and whether it resides in a rural or urban area. The performance of VA health care facilities was compared to similar non-VA facilities, as well as health systems overall.

The VA hospitals performed the same or significantly better than non-VA hospitals on all six measures of inpatient safety, all three measures of inpatient mortality and 12 measures of the effectiveness of inpatient care. The VA hospitals performed significantly worse on three readmission measures and two effectiveness measures.

For example, VA inpatient performance was significantly lower on the patient experience measure for pain management, while performance of VA hospitals was significantly higher on patient experiences for management of care transitions.

The performance of VA facilities also was significantly better than commercial HMOs and Medicaid HMOs for all 16 measures of the effectiveness of outpatient care. The VA facilities outperformed Medicare HMOs on 14 of the 16 measures of effectiveness.

The smallest difference between the VA and commercial HMOs was in the rate of antidepressant medication management during the acute phase, while the largest difference was in the rate of eye examinations for patients with diabetes. The smallest difference between the VA and Medicaid HMOs was in the rate of ongoing beta-blocker treatment after an acute heart attack, and the largest difference was in the rate of eye examinations for patients with diabetes.

The variation between individual VA facilities was large on some of the quality measures. For example, there was a 50 percentage point difference in performance between the lowest and highest performing VA facilities during 2014 on the rate of beta blocker treatment for at least six months after discharge for an acute heart attack.

The study did not examine issues related to accessing care in the VA health system, such as whether enrollees gain access to care in a timely manner.

Support for the study was provided by the U.S. Department of Veterans Affairs. Other authors of the study are Elizabeth M. Sloss, Mathew Cefalu and Peter S. Hussey.

RAND Health is the nation's largest independent health policy research program, with a broad research portfolio that focuses on population health, health care costs, quality and public health systems, among other topics.

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