The VA relies on outsourced care to provide services for Veterans for many reasons, though for women, the care is usually for specialized health services not provided within the VA, such as mammography and prenatal care. Recent evidence suggests that 34% of women Veterans (WVs) in VA care also utilize some fee basis care and the number of WVs using fee basis care for gender-specific conditions continues to increase on an annual basis. In FY 2010 alone, the VA spent $253 million on outsourced care for women Veterans. Outsourced care represents approximately 10% of total healthcare costs for women Veterans. Despite increasing numbers of women Veterans relying on outsourced care, little is known about the quality of outsourced care or perceptions and experiences of women Veterans who utilize such care. Understanding perceptions of women Veterans receiving outsourced care is important given previous research linking patient dissatisfaction and health plan exit. Moreover, recent studies of VA attrition among women Veterans suggests that 30% of all new women VA users leave the VA within 3 years of enrolling, which could be due, in part, with dissatisfaction with care coordination between VA and outsourced providers. Facility-level fee basis managers and VA women's health providers play central roles in facility-level fee decisions, and much of the responsibilityof care coordination between outsourced and VA providers rests in the hands of VA women's health providers. Thus, it is critical to begin to understand issues related to perceptions and experiences with outsourced care for women Veterans given the growing number of women Veterans that must use outsourced care for some of their medical needs and the centrality of providing comprehensive care for women Veterans. Understanding outsourced care utilization among women Veterans must begin with examining facility-level decisions regarding which services to provide in-house or via outsourced providers. Decisions regarding use of fee basis and contract care are made and monitored almost entirely within each VA facility (i.e., virtually no centralized oversight). Little is known about how community providers are selected or the quality of the care they provide. For example, although a majority (75%) of VA facilities contract with hospitals and other facilities for diagnostic mammograms, these non-VA facilities are not monitored for quality according to standards set forth in the Mammography Quality Standards Act of 1992 (PL 102-539). Given that mammography is the highest-volume gender-specific care for women (51,396 mammograms in FY09), understanding the quality of this type of care is of utmost importance as the VA continues to wrestle with the 'make vs. buy'decision for certain types of essential care. To address these critical issues, we propose the following aims:
Aim #1 : To understand providers'and fee basis managers'strategies for provision, coordination, and quality oversight of outsourced care.
Aim #2 : To understand perceptions and experiences with outsourced care among women Veterans.
Aim #3 : To evaluate the quality of gender-specific services for women Veterans using a case example mapped to VHA Handbook priorities (e.g., Do VA facilities utilizing outsourced care for mammography meet key quality standards compared to VA facilities providing in-house mammograms?)

Public Health Relevance

This proposal is directly relevant to VA HSR&D Priority Area for research on Women's Health. Congressional action has expanded the array of services available to eligible women Veterans to include full spectrum care to women across the life span. Despite the increase in services, providing full spectrum care to this diverse population may not be possible without the use of outsourced care. Given this limitation, it is essential to understand the implications of using outsourced care to meet these needs. Upon completion of this project, we will have made contributions to the knowledge of outsourced care in the VA for women Veterans and be poised to assist policymakers in decisions about outsourced care based on the quality of what the VA is buying compared to in-house services and the potential impact of the added burden of heading outside the VA for obtaining these services.

National Institute of Health (NIH)
Veterans Affairs (VA)
Non-HHS Research Projects (I01)
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Special Emphasis Panel (HCR4)
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Durham VA Medical Center
United States
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