Understanding VA's Use of and Relationships With Community Care Providers Under the MISSION Act

BACKGROUND

Congress has enacted 2 major pieces of legislation to improve access to care for Veterans within the Department of Veterans Affairs (VA). As a result, the VA has undergone a major transformation in the way that care is delivered to Veterans with an increased reliance on community-based provider networks. No studies have examined the relationship between VA and contracted community providers. This study examines VA facility directors' perspectives on their successes and challenges building relationships with community providers within the VA Community Care Network (CCN).

OBJECTIVES

To understand who VA facilities partner with for community care, highlight areas of greatest need for partnerships in various regions, and identify challenges of working with community providers in the new CCN contract.

RESEARCH DESIGN

We conducted a national survey with VA facility directors to explore needs, challenges, and expectations with the CCN.

RESULTS

The most common care referred to community providers included physical therapy, chiropractic, orthopedic, ophthalmology, and acupuncture. Open-ended responses focused on 3 topics: (1) Challenges in working with community providers, (2) Strategies to maintain strong relationships with community providers, and (3) Re-engagement with community providers who no longer provide care for Veterans.

CONCLUSIONS

VA faces challenges engaging with community providers given problems with timely reimbursement of community providers, low (Medicare) reimbursement rates, and confusing VA rules related to prior authorizations and bundled services. It will be critical to identify strategies to successfully initiate and sustain relationships with community providers.

Developing network adequacy standards for VA Community Care

OBJECTIVES

To inform how the VA should develop and implement network adequacy standards, we convened an expert panel to discuss Community Care Network (CCN) adequacy and how VA might implement network adequacy standards for community care.

DATA SOURCES/STUDY SETTING

Data were generated from expert panel ratings and from an audio-recorded expert panel meeting conducted in Arlington, Virginia, in October 2017.

STUDY DESIGN

We used a modified Delphi panel process involving one round of expert panel ratings provided by nine experts in network adequacy standards. Expert panel members received a list of network adequacy standard measures used in commercial and government market and were provided a rating form listing a total of 11 measures and characteristics to rate.

DATA COLLECTION METHODS

Items on the rating form were individually discussed during an expert panel meeting between the nine expert panel members and VA Office of Community Care leaders. Attendees addressed discordant views and generated revised or new standards accordingly. Recorded audio data were transcribed to facilitate thematic analysis regarding opportunities and challenges with implementing network adequacy standards in VA Community Care.

PRINCIPAL FINDINGS

The five highest ranked standards were network directories for Veterans, regular reporting of network adequacy data to VA, maximum wait time/distance standards, minimum ratio of providers to enrolled population, and qualitative assessments of network adequacy. During the expert panel discussion with VA Community Care leaders, opportunities and challenges implementing network adequacy standards were highlighted.

CONCLUSIONS

Our expert panel shed light on priorities for network adequacy to be implemented under CCN contracts, such as developing comprehensive provider directories for Veterans to use when selecting community providers. Remaining questions focus on whether the VA could reasonably develop and implement network adequacy standards given current Congressional restraints on VA reimbursement to community providers.

Longitudinal assessment of motor and sensory skills in academically disabled and control children

Motor and tactile integration skills were sequentially assessed with academically average (N = 28) and academically disabled children (N = 17) over a 3-year period. The initial results demonstrated considerable differences between the groups. Analysis of variance and visual inspection of trends in the longitudinal data for the academically disabled group revealed a mixed pattern with catch-up in the motor areas and persistent delays in sensory areas. The results suggest different developmental patterns depending on the skill and group assessed. Right hand advantages were found across groups with motor speed whereas a left hand advantage was demonstrated on a stereognosis task. These right-left differences suggest an important developmental role for corpus callosum myelinization. The interpretation of soft neurological signs needs to be refined to allow for these sensory-motor, right-left parameters.

Intra-individual variation in commonly analyzed serum constituents

Concentrations of 27 commonly estimated serum constituents were measured in blood sampled from 20 apparently healthy volunteers at 0830, 1230, and 1630 hours on each of four days, at weekly intervals. Time-dependent statistically significant (p less than or equal to 0.01) variation was observed in 12 of the constituents. The 15 constituents that showed no statistically significant diurnal variation included the immunoglobulins, other specific proteins, enzymes, cholesterol, calcium, copper, and magnesium. On the different days of the study consistent temporal patterns were observed in urea, creatinine, phosphate, zinc, bilirubin, triglyceride, total protein, and albumin. The magnitude of variation was particularly great in potassium, iron, zinc, and bilirubin. In general, day-to-day changes in concentration exceeded within-day changes, except for potassium, phosphate, and zinc, for which greater changes could be observed within-day than from one day to another at the same time.

Intra-individual variation in commonly analyzed serum constituents

Concentrations of 27 commonly estimated serum constituents were measured in blood sampled from 20 apparently healthy volunteers at 0830, 1230, and 1630 hours on each of four days, at weekly intervals. Time-dependent statistically significant (p less than or equal to 0.01) variation was observed in 12 of the constituents. The 15 constituents that showed no statistically significant diurnal variation included the immunoglobulins, other specific proteins, enzymes, cholesterol, calcium, copper, and magnesium. On the different days of the study consistent temporal patterns were observed in urea, creatinine, phosphate, zinc, bilirubin, triglyceride, total protein, and albumin. The magnitude of variation was particularly great in potassium, iron, zinc, and bilirubin. In general, day-to-day changes in concentration exceeded within-day changes, except for potassium, phosphate, and zinc, for which greater changes could be observed within-day than from one day to another at the same time.