Evaluation of Community Based Outpatient Clinic Costs Using DSS Data
Matthew L. Maciejewski PhD
Durham VA Medical Center
Durham, NC
Funding Period: October 2001 - September 2004

BACKGROUND/RATIONALE:
Caring for patients in VA-staffed CBOCs is likely to be less expensive than caring for patients in outpatient primary care clinics at the VAMC, because CBOCs have organizational features more conducive to efficient delivery of primary care services.

OBJECTIVE(S):
The purpose of this study is to evaluate CBOC cost-based performance measures using the data from the new VA cost accounting system, the Decision Support System (DSS), in FY2000 and FY2001. Cost-based performance measures for different types of patients will be compared to determine to what degree cost differences are due to patient differences and organizational differences. In addition, we will conduct two subanalyses to explore CBOC costs and quality of care for veterans with ambulatory-care sensitive conditions. The proposed study has three main specific aims and two secondary aims.

METHODS:
We will compare DSS utilization estimates with OPC and PTF utilization estimates for CBOC and VAMC patients in the facilities we have sampled. We will then compare cost estimates between DSS production (local) level data and the DSS National Extracts. Estimates of DSS National Extract costs and Medicare costs will be conducted and then we will do the cost evaluations between CBOC and VAMC patients, controlling for other factors.

FINDINGS/RESULTS:
We have found discrepancies between DSS and PTF inpatient utilization, as well as DSS and OPC outpatient utilization. These findings were presented at the 2003 VA HSR&D annual meeting. CBOC patients had lower utilization and VA expenditures than patients obtaining primary care at VAMCs, and had similar or better quality of care for veterans with COPD or diabetes. Contract CBOC patients had lower total expenditures than VA-staff CBOC patients because of lower outpatient expenditures, which was due to fewer primary care, mental health and specialty visits. Quality of care in two measures was similar in these two types of CBOCs.

IMPACT:
Results from this study indicate that DSS is generally valid for utilization and cost analysis of CBOCs It appears as though CBOCs are helpful in containing total VA expenditures for patients who obtain primary care. Contract CBOCs may be as effective VA-staff CBOCs in containing VA expenditures, but quality of care needs to be assessed more broadly. It may also be useful to examine CBOCs in general, and contract CBOCs in particular, to get into the “black box” of CBOC organizations and cultures to more fully understand why their performance is equal to, if not better than, performance of VAMC primary care clinics.

PUBLICATIONS:

Journal Articles

1. Borowsky SJ, Nelson DB, Fortney JC, Hedeen AN, Bradley JL, Chapko MK. VA community-based outpatient clinics: performance measures based on patient perceptions of care. Medical Care. 2002; 40(7): 578-86.
2. Fortney JC, Borowsky SJ, Hedeen AN, Maciejewski ML, Chapko MK. VA community-based outpatient clinics: access and utilization performance measures. Medical Care. 2002; 40(7): 561-9.
3. Hedeen AN, Heagerty PJ, Fortney JC, Borowsky SJ, Walder DJ, Chapko MK. VA community-based outpatient clinics: quality of care performance measures. Medical Care. 2002; 40(7): 570-7.
4. Maciejewski ML, Chapko MK, Hedeen AN, Fortney JC. VA community-based outpatient clinics: cost performance measures. Medical Care. 2002; 40(7): 587-95.

DRA: Health Services and Systems, Special (Underserved, High Risk) Populations
DRE: Quality of Care, Resource Use and Cost
Keywords: Cost, Outpatient, Primary care
MeSH Terms: none