Comparing Quality, Costs, and Outcomes of VA and Community Primary Care for Patients with Diabetes.

ABSTRACT

BACKGROUND: The Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act expanded access to independent community providers outside the Veterans Health Administration (VA). Little is known how quality, costs, and outcomes of primary care received in the community compare to that of the VA. OBJECTIVE: To compare quality, costs, and outcomes of community and VA-provided primary care for patients with diabetes over a 12-month episode. DESIGN: A cross-sectional study using VA administrative data and community care claims. Adjusted analyses were conducted using inverse probability weighted regression adjustment to balance patient characteristics. PARTICIPANTS: Veterans with diabetes receiving primary care in the VA or community. MAIN MEASURES: Quality measures included receipt of hemoglobin A1C tests, eye exams, microalbumin urine tests, and flu shots. Outcomes were measured by hospitalizations for an ambulatory care sensitive condition (ACSC). Costs were measured for VA and community outpatient care, inpatient care, and prescription drugs. KEY RESULTS: There were 652,648 VA patients and 3650 community care patients. VA patients were less likely to be White, had shorter mean drive time to VA primary care, and were less likely to be rural than community care patients. In adjusted analyses, community care patients had significantly lower probability of receiving a hemoglobin A1C test, eye exam, microalbumin urine test, and flu shot compared to the VA group. There was no difference in probability of an ACSC hospitalization. Community care patients had higher mean total costs ($1741 [95% CI, $431, $3052]), driven by higher inpatient and prescription drug costs but lower emergency care costs than VA patients. CONCLUSION: Patients receiving community primary care had worse diabetes quality and higher costs than patients receiving VA primary care. There was no difference in health outcomes. Care provided by an integrated delivery system may have advantages in quality and value.