ESRD is more prevalent among the VHA patient population than the general US population and is associated with substantial morbidity, mortality, and VA health care costs. Demand for dialysis treatment for ESRD exceeds VA's limited supply, requiring VA to outsource dialysis care from non-VA providers through the VA Fee Basis program. VA costs for Fee Basis dialysis have been increasing at an astonishing rate with little understanding of its value to VA or its Veterans This has prompted concerns in VA, particularly because VA exerts little clinical oversight or accountability for outsourced care for its patients. In light of these concerns, VA is exploring ne care and payment models to improve quality of care and reduce costs. It remains unclear how dialysis patient outcomes differ between Veterans obtaining dialysis care in various settings. VA needs this comparative information about outcomes to understand if new models are improving quality compared to historic care and payment models. Determination of quality of care and optimal resource allocation is complicated by heterogeneity in insurance coverage and treatment settings among Veterans receiving chronic dialysis. Veterans can receive dialysis care at VAMC or in community settings that is financed either by VA Fee Basis or by the Medicare ESRD program. Efforts to improve the quality and cost of VA dialysis care is further complicated by recent payment policies that VA and Medicare have independently implemented for dialysis treatment, which may have together conspired to change the incentive structure for Veterans' receiving dialysis care in one system or another. Identifying these potential determinants shaping Veteran's choice of care is needed to adjust for confounding in comparative outcomes assessment and to understand the implications of policy changes on Veteran care. The objectives of this study are to examine the comparative effectiveness of Veterans' chronic dialysis care settings. Through a merge of VA and Medicare administrative and claims data, this study will identify a national sample of incident ESRD Veterans in 2008-2012 to (1) examine the extent of Veterans' dialysis utilization in VA-financed VAMC clinics, VA-financed Fee Basis, and Medicare settings and the proportion of patients switching between dialysis settings; (2) identify patient and VAMC-level characteristics associated with Veterans' choice of dialysis setting; and (3) examine whether all-cause and cause-specific hospitalization and mortality rates vary by dialysis setting.
The efficient organization of Veterans' chronic dialysis care is of emerging importance to the VA due to exploding Fee Basis expenditures for outpatient dialysis and recent payment reforms for dialysis in VA and Medicare. This research will assess the comparative effectiveness of Veterans' chronic dialysis care settings in a national sample of Veterans in 2008-2013. Findings from this study will identify opportunities for VA to improve the quality and efficiency of dialysis care to a growing population of Veterans with end-stage renal disease. This research is consistent with VA's goals to improve the quality and accessibility of health care services while optimizing value. The proposal is responsive to the HSRD priority of healthcare access as well as Veteran centric research (e.g., care of complex, chronic conditions and management research).