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© 2007 American Public Health Association
DOI: 10.2105/AJPH.2007.124461
EDITORIAL |
The author is with the Center for Health Equity Research and Promotion, Veterans Administration Hospital, Philadelphia, Pa, and the Department of Medicine, Department of Health Care Systems, and the Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia.
Correspondence: Requests for reprints should be sent to Kevin G. Volpp, CHERP, Philadelphia Veterans Affairs Medical Center, University and Woodland Aves, Philadelphia, PA 19104 (e-mail: volpp70{at}wharton.upenn.edu).
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INTRODUCTION |
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 TOP INTRODUCTION INCENTIVES FOR QUALITY CAREWAYS TO IMPROVECONCLUSIONReferences |
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In recent years, the Veterans Health Administration of the Department of Veterans Affairs (VA) has received many accolades from the lay press and academic journals for provision of care superior in quality to that provided in the private sector.
The dramatic transformation of the VA’s health care can be attributed to changes VA leadership made in the 1990s. These changes included instituting a nationwide robust electronic health record and an accompanying quality measurement approach on which regional managers are evaluated and creating feedback loops between health services researchers and operational managers.1 Since instituting these changes, several academic studies have shown that VA care outperforms non-VA care on various dimensions, particularly process measures of quality that have been targeted for improvement.2–4 Patient satisfaction also appears to be higher within the VA than among those who receive care in the private sector.5 Numerous press accounts have extolled the VA system as a model of high-quality, efficient health care.6–9
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INCENTIVES FOR QUALITY CARE |
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TOPINTRODUCTIONINCENTIVES FOR QUALITY CAREWAYS TO IMPROVECONCLUSIONReferences |
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Although the Department of Veterans Affairs’ achievements are noteworthy, it is also important to note that quality of care in the rest of the US health care system, against which the VA is judged, is hardly impressive. Recent studies have found that Americans receive only about half of the appropriate care that they are supposed to receive,10 and even that varies on the basis of where people live.11
One important cause of the deficiencies in the US health care system is that financial incentives for providers are misaligned with the goal of providing the highest possible quality of care. The fact that provider compensation is not generally tied to the quality of the care provided creates not only neutral but negative incentives because insurers generally pay providers on the basis of the quantity of services provided, meaning that providers are paid more when their patients get sick than when they stay healthy. For providers that make most of their profits from procedures, investing in disease prevention efforts is financially unattractive; if such efforts are successful, fewer patients will need these profitable procedures. Remedies, such as "pay for performance" programs, have tried to address deficits in quality, but within the United States, these efforts have been limited by weak financial incentives and have had little impact.12,13 Weak incentives to improve quality are reflected nationwide in the low adoption rates of electronic health records, with fewer than 10% of ambulatory care physicians using a system with key features necessary to improve care14 despite strong evidence that well-designed electronic systems can improve the quality and safety of care.15
A major barrier to the adoption of quality improvement initiatives such as electronic order entry systems is the substantial investment providers must make to purchase these information systems. The systems can have an unfavorable return on investment because insurers generally pay providers the same amount whether or not they have adopted such systems. Recent efforts to change this by the Centers for Medicare and Medicaid Services not withstanding, reducing medical errors may actually reduce provider revenue given the prevalence of fee-for-service payment. High turnover rates among patients and employees make it relatively unattractive for insurers and employers to invest in disease prevention efforts. There may be concerns for providers that garnering a reputation for providing the best quality care for high-risk patients could be undesirable because such patients may be relatively high cost and more likely to have poor outcomes, an increasingly important consideration given growing interest in public reporting and tying payment to performance.
The VA has incentives that are better aligned for the provision of high-quality care. Patients rarely chose to leave the VA system, which in essence is capitated, so there are strong incentives to invest in quality and disease prevention. Eligible patients generally remain eligible for life. The integrated electronic health record allows for patients’ records to be accessible to all authorized providers within the system, from Maine to Hawaii. The leadership structure of the VA makes it much easier to institute evidence-based quality improvement on a broad scale throughout the system than it is within the fragmented non-VA system. Finally, the strong sense of mission to serve the nation’s veterans motivates many VA employees over and above their monetary compensation.
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WAYS TO IMPROVE |
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TOPINTRODUCTIONINCENTIVES FOR QUALITY CAREWAYS TO IMPROVECONCLUSIONReferences |
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Given the suboptimal quality of care in the non-VA system with which the VA is typically compared, it is important for the VA not to become complacent but to seek further improvement. Five priority ideas could further improve quality within the VA.
Address Undercapacity Where It Exists
One area that has been challenging for the VA has been ensuring access to subspecialty care, mental health care, and certain high-tech services, such as colonoscopies and magnetic resonance imaging. Capacity bottlenecks can exacerbate shortages when well-intentioned providers frequently order studies (or make referrals), knowing that it will take longer to obtain them, thus making the queue longer, than if they ordered studies less often. Although the VA has made progress in reducing wait times for primary and mental health care, it could improve access to a range of services for veterans by building greater capacity where needed, scientifically assessing scheduling practices, and selectively contracting out services.
Improve Inpatient Care
Although the VA’s achievements in the ambulatory setting are laudable, we know much less about the quality of its inpatient care. The public reporting movement within the private sector has not encompassed VA hospitals, and even if it did, this movement uses a very limited set of measures of quality. Many VA hospitals likely have low volumes for complex surgeries, and given the strong association between volume and outcomes, the VA may want to consider either contracting out high-tech services to high-volume, high-quality providers in the community or further regionalizing high-tech services (although over-regionalization has some downsides).16,17 Validated measures of inpatient quality for use within the VA, broader than the limited set commonly used in national public reporting efforts, would be of great value in accelerating improvement in inpatient care quality.
Create Stronger Incentives for Desired Behaviors
Although salaried providers may be less likely to overuse services, they may underuse effective services. The VA has started targeting providers with financial incentives to improve scores on a variety of performance metrics, but the incentives are small and are tied to performance on a limited set of process measures. Pay for performance can work, but incentives need to be adequate and target the outcomes that the system wants to improve. Systematic efforts to reward excellence among providers and staff could reduce wait times for referrals to specialty clinics, increase use of appropriate procedures, and reward providers who excel in providing care with high patient satisfaction and high scores on process and outcome measures.
Incentives for providers, however, are likely to have only limited impact on patient health behaviors such as smoking and sedentary lifestyles, which are sources of substantial morbidity for patients and cost to the health care system. Studies have shown that financial incentives offered directly to patients can significantly increase the rate of healthy behaviors. For example, a randomized trial of veterans who were heavy smokers demonstrated that those offered $20 per class to attend 5 smoking cessation classes, $100 to quit smoking, free smoking cessation counseling, and nicotine patches were nearly 4 times as likely to quit smoking as the control group, who received only the free smoking cessation counseling and nicotine patches.18 We need to better understand whether such approaches can be used more broadly for behavior change, and the VA is an optimal place for such assessment. Improving veterans’ health behaviors will reduce morbidity and mortality, and the VA will benefit from having a healthier patient population and the financial benefits that may follow.
Invest in Improving Health
Aligning the financial incentives of patients, providers, and the health care system toward achieving better outcomes could significantly improve quality, but it is most likely to do so when it enables a true redesign of the care system. One approach would be to invest in more-intensive case management and tracking of complex patients at high risk of adverse outcomes.
The VA has many patients with multiple comorbidities, and it has been shown that case management for chronically ill patients with diseases such as congestive heart failure or diabetes improves outcomes and may actually save money.19 For the sickest, most expensive patients with many chronic diseases, often complicated by mental health conditions and poor social situations, we need new ways to provide care. One exciting model now being piloted in several sites across the country is the ambulatory intensive caring model, initially developed with funding from the California HealthCare Foundation. It works on the notion that intensive provision of outpatient services to complex ambulatory patients who are chronically ill is a cost-effective approach to improve health outcomes.20 By slightly increasing spending (by about 2.5%), one can reduce visit volume per provider in primary care practices, giving providers the time to focus on keeping patients healthy. Instead of practicing reactive medicine when patients appear in clinics, providers can focus on managing the health of their patients by actively monitoring, for example, their diabetes or cholesterol. In this model, patients have longer appointments; a personal health coach; same- or next-day provider response to patient questions via e-mail, phone, or in person; and a follow-up call from their provider after the visit. The tracking of patient health and follow-up would be facilitated by the electronic health record already available throughout the VA. This type of care redesign would also be highly attractive to providers. The cost-effectiveness of this approach needs systematic testing, but it could hold great promise as a way of improving outcomes for patients with multiple comorbidities and in creating a work environment that would improve both recruitment and retention of the best primary care physicians in the country.
Improve Outreach and Continue Investment in Research
Although providing the highest possible quality of care to current VA patients is clearly important, another way that the VA could increase its impact would be to reach out more actively to recently discharged military personnel to ensure that they feel welcomed to the system and that they receive the care they need. Recently there have been efforts to improve the transition from active status to veteran status, but the importance of perfecting this transition cannot be underestimated. Continuing to invest heavily in research that helps the VA provide better care for such physical and mental health problems as those caused by intense combat is critical, as is research that helps the VA health care system understand what it is doing well and what it could do better. Utilizing this feedback is an area of strength within the VA, but it is one in which there is always potential for further advances and improvement.
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CONCLUSION |
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TOPINTRODUCTIONINCENTIVES FOR QUALITY CAREWAYS TO IMPROVECONCLUSIONReferences |
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By many metrics, the VA has established itself as a leader in health care delivery within the United States. However, more can be done to show the way for the rest of the country in using data-driven approaches to design and test innovative efforts to improving health.
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Acknowledgments |
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The author thanks the Department of Veterans Affairs Health Services Research and Development Services for support of his research and Ashish Jha and Uwe Reinhardt for helpful comments.
Accepted for publication August 27, 2007.
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References |
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3. Kerr EA, Gerzoff RB, Krein SL, et al. Diabetes care quality in the Veterans Affairs Health Care System and commercial managed care: the TRIAD study. Ann Intern Med. 2004;141(4): 272–281.
4. Asch SM, McGlynn EA, Hogan MM, et al. Comparison of quality of care for patients in the Veterans Health Administration and patients in a national sample. Ann Intern Med. 2004;141(12): 938–945.
5. Fornell C. ASCI commentary: federal government scores. Available at: http://www.theacsi.org/index.php?option=com_content&task=view&id=151. Accessed July 23, 2007.
6. Longman P. The best care anywhere. Washington Monthly. 2005;37: 38–48.
7. Gaul GM. Revamped veterans’ health care now a model. Washington Post. August 22, 2005:A01.
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9. Krugman P. Health care confidential. New York Times. January 27, 2006:A23.
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12. Rosenthal MB, Frank RG, Li Z, Epstein AM. Early experience with pay-for-performance: from concept to practice. JAMA. 2005;294:1788–1793.
13. Glickman SW, Ou FS, DeLong ER, et al. Pay for performance, quality of care, and outcomes in acute myocardial infarction. JAMA. 2007;297: 2373–2380.
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15. Bates DW, Leape LL, Cullen DJ, et al. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA. 1998;280:1311–1316.
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17. Petersen LA, Normand SL, Leape LL, McNeil BJ. Regionalization and the underuse of angiography in the Veterans Affairs Health Care System as compared with a fee-for-service system. N Engl J Med. 2003;348(22):2209–2217.
18. Volpp KG, Gurmankin Levy A, Asch DA, et al. A randomized controlled trial of financial incentives for smoking cessation. Cancer Epidemiol Biomarkers Prev. 2006;15(1):12–18.
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20. Fernandopulle, R. Ambulatory Intensive Caring Unit (A-ICU): Linking Payment Change to Clinical Redesign to Radically Improve Quality and Affordability. Barcelona, Spain: World Healthcare Congress; 2007.
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