Integrating Department of Defense and Department of Veterans Affairs Purchased Care: Preliminary Feasibility Assessment.

The U.S. Department of Defense (DoD) and U.S. Department of Veterans Affairs (VA) health systems provide services through a mix of direct care, delivered at government facilities, and purchased care, provided through the private sector, mainly by community-based providers who have entered into contracts with third-party administrators (TPAs). In the interest of expanding DoD-VA resource sharing that may lead to greater efficiencies and cost savings, the DoD/VA Joint Executive Committee is exploring options to integrate DoD and VA's purchased care programs. This preliminary feasibility assessment examined how an integrated approach to purchasing care could affect access, quality, and costs for beneficiaries, DoD, and VA and identified general legislative, policy, and contractual challenges to implementing an integrated purchased care program. An integrated approach to purchasing care is feasible under current legal and regulatory authorities, but policy changes may be needed-and the practicality of such an approach depends on the contract and network design. For example, legal/regulatory changes in how contracts are established would be required to achieve any real savings to the government. There are also differences in the populations served by TRICARE (DoD health care) and VA, particularly in terms of age and geographic location. Implementation would be further complicated by contractual differences in the TPA contracts for VA and DoD as they relate to network standards, provider payments, network participation requirements, and reporting requirements and incentive structures. As a result, there are significant uncertainties with respect to increased efficiency or cost savings for the government.

Introducing Value-Based Purchasing into TRICARE Reform.

TRICARE, the health benefits program created for beneficiaries of the U.S. Department of Defense, covers health care provided in military treatment facilities and by civilian providers. Congress is now considering how to update TRICARE, which was first developed in the 1980s drawing on managed care concepts from civilian health plans. This article places TRICARE's current managed care strategy in historical context and describes recent innovations by private insurers and Medicare intended to enhance the value---cost and quality---of the care they purchase for their members. With this movement toward value-based purchasing as background, the authors evaluate two existing proposals for reform and describe an alternative approach that blends the existing proposals.

Current and Projected Characteristics and Unique Health Care Needs of the Patient Population Served by the Department of Veterans Affairs.

The Veterans Access, Choice, and Accountability Act of 2014 addressed the need for access to timely, high-quality health care for veterans. Section 201 of the legislation called for an independent assessment of various aspects of veterans' health care. The RAND Corporation was tasked with an assessment of the current and projected demographics and health care needs of patients served by the Department of Veterans Affairs (VA). The number of U.S. veterans will continue to decline over the next decade, and the demographic mix and geographic locations of these veterans will change. While the number of veterans using VA health care has increased over time, demand will level off in the coming years. Veterans have more favorable economic circumstances than non-veterans, but they are also older and more likely to be diagnosed with many health conditions. Not all veterans are eligible for or use VA health care. Whether and to what extent an eligible veteran uses VA health care depends on a number of factors, including access to other sources of health care. Veterans who rely on VA health care are older and less healthy than veterans who do not, and the prevalence of costly conditions in this population is projected to increase. Potential changes to VA policy and the context for VA health care, including effects of the Affordable Care Act, could affect demand. Analysis of a range of data sources provided insight into how the veteran population is likely to change in the next decade.

Authorities and Mechanisms for Purchased Care at the Department of Veterans Affairs.

The Veterans Access, Choice, and Accountability Act of 2014 addressed the need for access to timely, high-quality health care for veterans. Section 201 of the legislation called for an independent assessment of various aspects of veterans' health care. The RAND Corporation was tasked with an assessment of the authorities and mechanisms by which the Department of Veterans Affairs (VA) pays for health care services from non-VA providers. Purchased care accounted for 10 percent, or around $5.6 billion, of VA's health care budget in fiscal year 2014, and the amount of care purchased from outside VA is growing rapidly. VA purchases non-VA care through an array of programs, each with different payment processes and eligibility requirements for veterans and outside providers. A review and analysis of statutes, regulations, legislation, and literature on VA purchased care, along with interviews with expert stakeholders, a survey of VA medical facilities, and an evaluation of local-level policy documents revealed that VA's purchased care system is complex and decentralized. Inconsistencies in procedures, unclear goals, and a lack of cohesive strategy for purchased care could have ramifications for veterans' access to care. Adding to the complexity of VA's purchased care system is a lack of systematic data collection on access to and quality of care provided through VA's purchased care programs. The analysis also explored concepts of "episodes of care" and their implications for purchased care by VA.

Balancing Demand and Supply for Veterans' Health Care: A Summary of Three RAND Assessments Conducted Under the Veterans Choice Act.

In response to concerns that the Department 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 Act") in August 2014. The law was passed to help address access issues by expanding the criteria through which veterans can seek care from civilian providers. In addition, the law called for a series of independent assessments of the VA health care system across a broad array of topics related to the delivery of health care services to veterans in VA-owned and -operated facilities, as well as those under contract to VA. RAND conducted three of these assessments: Veteran demographics and health care needs (A), VA health care capabilities (B), and VA authorities and mechanisms for purchasing care (C). This article summarizes the findings of our assessments and includes recommendations from the reports for improving the match between veterans' needs and VA's capabilities, including VA's ability to purchase necessary care from the private sector.

Measuring the Quality of Care for Psychological Health Conditions in the Military Health System: Candidate Quality Measures for Posttraumatic Stress Disorder and Major Depressive Disorder.

In recent years, the number of U.S. service members treated for psychological health conditions has increased substantially. In particular, at least two psychological health conditions-posttraumatic stress disorder (PTSD) and major depressive disorder (MDD)-have become more common, with prevalence estimates up to 20 percent for PTSD and 37 percent for MDD. Delivering quality care to service members with these conditions is a high-priority goal for the military health system (MHS). Meeting this goal requires understanding the extent to which the care the MHS provides is consistent with evidence-based clinical practice guidelines and its own standards for quality. To better understand these issues, RAND Corporation researchers developed a framework to identify and classify a set of measures for monitoring the quality of care provided by the MHS for PTSD and MDD. The goal of this project was to identify, develop, and describe a set of candidate quality measures to assess care for PTSD and MDD. To accomplish this goal, the authors performed two tasks: (1) developed a conceptual framework for assessing the quality of care for psychological health conditions and (2) identified a candidate set of measures for monitoring, assessing, and improving the quality of care for PTSD and MDD. This article describes their research approach and the candidate measure sets for PTSD and MDD that they identified. The current task did not include implementation planning but provides the foundation for future RAND work to pilot a subset of these measures.

How Deployments Affect the Capacity and Utilization of Army Treatment Facilities.

The Army was concerned about how the Army Force Generation (ARFORGEN) cycle, established to provide a predictable process by which Army units deploy, reset, and train to become ready and available to deploy again, affected the lives of Army soldiers and their families. In particular, the Vice Chief of Staff of the Army asked RAND Arroyo Center to determine whether ARFORGEN resulted in ebbs and flows in the ability of Army military treatment facilities (MTFs) to provide medical care and respond to changes in family needs as soldiers and care providers deploy and return home. This concern is especially well-founded because military health research has shown that family members of service members utilize health care differently during deployment than when the soldier is at home. This study found that MTF capacity is not greatly affected when soldiers and care providers deploy, and that MTFs may be slightly less busy than when soldiers and care providers are both at home. In aggregate, family member access to health care does not appear to be impinged when soldiers deploy, and soldiers who did not deploy with their unit slightly increase their utilization of health care during those times.

Patient Privacy, Consent, and Identity Management in Health Information Exchange: Issues for the Military Health System.

The Military Health System (MHS) and the Veterans Health Administration (VHA) have been among the nation's leaders in health information technology (IT), including the development of health IT systems and electronic health records that summarize patients' care from multiple providers. Health IT interoperability within MHS and across MHS partners, including VHA, is one of ten goals in the current MHS Strategic Plan. As a step toward achieving improved interoperability, the MHS is seeking to develop a research roadmap to better coordinate health IT research efforts, address IT capability gaps, and reduce programmatic risk for its enterprise projects. This article contributes to that effort by identifying gaps in research, policy, and practice involving patient privacy, consent, and identity management that need to be addressed to bring about improved quality and efficiency of care through health information exchange. Major challenges include (1) designing a meaningful patient consent procedure, (2) recording patients' consent preferences and designing procedures to implement restrictions on disclosures of protected health information, and (3) advancing knowledge regarding the best technical approaches to performing patient identity matches and how best to monitor results over time. Using a sociotechnical framework, this article suggests steps for overcoming these challenges and topics for future research.

Healthcare Coverage and Disability Evaluation for Reserve Component Personnel: Research for the 11th Quadrennial Review of Military Compensation.

Because Reserve Component (RC) members have been increasingly used in an operational capacity, among the policy issues being addressed by the 11th Quadrennial Review of Military Compensation (QRMC) is compensation and benefits for the National Guard and Reserve. As part of the review, RAND was asked to analyze healthcare coverage and disability benefits for RC members, including participation in the TRICARE Reserve Select (TRS) program, the potential effects of national health reform on coverage rates, and disability evaluation outcomes for RC members. This article summarizes the results of RAND's analysis. The author finds that 30 percent of RC members lack health insurance to cover care for non-service-related conditions. The TRS program offers the option of purchasing health insurance through the military on terms that are superior to typical employer benefits. Although program participation has increased, it remains low and TRS does not appear to be effectively targeting those most likely to be uninsured. TRS premiums are also lower than the premiums for the new options that will be available under health reform and the same as the penalty for not being insured. So health reform is likely to increase TRS enrollment. Finally, previously deployed RC members are referred to the Disability Evaluation System at a much lower rate than Active Component (AC) members, even for deployment-related conditions, but those who are referred receive dispositions (and thus benefits) similar to those for AC members. These findings suggest that the Department of Defense may want to consider ways to better coordinate TRS with other insurance options that will be available to RC members and that the identification of RC members who experience health consequences from deployment leading to disability merits further investigation.