STATEMENT OF
THE HONORABLE JONATHAN PERLIN, MD, PHD, MSHA, FACP
UNDER SECRETARY FOR HEALTH
VETERANS HEALTH ADMINISTRATION
DEPARTMENT OF VETERANS AFFAIRS
BEFORE THE
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENATIVES

June 23, 2005

Mr. Chairman and Members of the Committee:  I am pleased to be here this morning to discuss the Department of Veterans Affairs’ (VA’s) actuarial health care demand model.   Accompanying me this morning are Rita Reed, VA’s Deputy Assistant Secretary for Budget, Jimmy Norris, VHA’s Chief Financial Officer, and Art Klein, Director for VHA’s Policy and Planning.  Mr. Chairman, I would like to submit a copy of my testimony for the record.

Background

Mr. Chairman, the Veterans’ Health Care Eligibility Reform Act of 1996 established a uniform package of health care services for enrollees. The legislation also established a priority-based enrollment system and required the VA Secretary to annually assess veteran demand for VA health care to determine whether resources are available to provide timely, quality care to all enrollees. 

Eligibility reform contributed to the transformation of the Veterans Health Administration (VHA) from a health care system that provided episodic, inpatient care to a health care system that provides a full range of comprehensive health care services to enrollees.  The focus on health promotion, disease prevention and chronic disease management has resulted in more effective and more efficient health care.  As a result, the range of health care services utilized by VHA patients began to mirror that of other large health care plans.  Therefore, VHA decided to follow private sector practice and use a health care actuary to predict future demand for VA health care services.  Mr. Chairman, transforming from a hospital system to a health care system has facilitated VA’s ability to take a leadership position in health care quality in the United States.  A recent Washington Monthly article stated the Veterans Health Administration gives the “best care anywhere.”  Additionally, the results of a recent study conducted by the independent RAND Corporation revealed that based on 348 measures of performance, VA provides systematically better care in disease prevention and treatment.  We believe our modeling and forecasting have seen dramatic improvements as well.

In the past, VHA budgets (and most Federal budgets) were based on historical expenditures that were adjusted for inflation and then increased based on proposed new initiatives.   However, rather than an arbitrary increase over prior budgets, with the implementation of eligibility reform and the shift to ambulatory care, VHA needed to more rationally budget for veteran requirements in a transformed health care system.  It also needed to be able to continually adjust its budgetary projections for effects of shifting trends in the veteran population, increasing demand for services, and the escalating cost of health care, e.g., pharmaceuticals. 

As a result, VA engaged Milliman, Inc., to produce actuarial projections of veteran enrollment, health care service utilization, and expenditures.  Milliman consults to health insurers and as such, is the largest and most respected actuarial firm in the country in the area of providing actuarial health care modeling.   We appreciate the Committee issuing a separate invitation to testify to Kathi Patterson, a principal and consulting actuary with Milliman and the lead actuary working with VHA. 

VHA Enrollee Health Care Demand Model

The VHA Enrollee Health Care Demand Model (model) develops estimates of future veteran enrollment, enrollees’ expected utilization for 55 health care services, and the costs associated with that utilization.   These projections are available by fiscal year, enrollment priority, age, VISN, market, and facility and are provided for a 20-year period.

The model provides risk-adjustment and reflects enrollees’ morbidity, mortality, and their changing health care needs as they age.   Because many enrollees have other health care options, the model reflects how much care enrollees receive from the VA health care system versus other health care providers.  This is known as VA reliance.  Enrollee reliance on VA is assessed using VA and Medicare data and a survey of VA enrollees.  The VA/Medicare data match provides VA with enrollees’ actual use of VA and Medicare services and the survey provides detailed responses from enrollees regarding any private health insurance and their use of VA and non-VA health care. 

The model projects future utilization of numerous health care services based on private sector utilization benchmarks that are adjusted for the unique demographic and health characteristics of the veteran population and the VA health care system.   The actuarial data on which the benchmarks are based represent the health care utilization of millions of Americans and include data from both commercial plans and Medicare, and are used extensively by other health plans to project future service utilization and cost. 

The model produces projections for future years using health care utilization, cost, and intensity trends.   These trends reflect the historical experience and expected changes in the entire health care industry and are adjusted to reflect the unique nature of the VA health care system.  These trends account for changes in unit costs of supplies and services, wages, medical care practice patterns, regulatory changes, and medical technology. 

Each year, the model is updated with the latest data on enrollment, health care service utilization, and service costs.   The methodology and assumptions used in the model are also reviewed to ensure that the model is projecting veteran demand as accurately as possible.  VHA and Milliman develop annual plans to improve the data inputs to the model and the modeling methodology.  Notably, Mr. Chairman, perhaps going to a focus of the Committee today, on average for the past three years, patient projections have been within -0.6 percent of actual patients and enrollee projections have been within +1.9 percent of actual enrollees.

As required by eligibility reform legislation, VA annually reviews the actuarial projections and determines whether or not resources are available to meet the expected demand for VA health care and develops policies accordingly.   For example, the model’s projection of continued significant growth in enrollment in Priority 8 formed the basis of VA’s decision to suspend Priority 8 enrollment in January of 2003, to ensure that resources were available to provide timely, quality health care to enrolled veterans.

Over the past six years, VHA has integrated the model projections into our financial and management processes. The VA health care budget is now formulated based on the model projections, as are the impact of most policies proposed in the budget.   The projections have been used throughout the CARES process to inform VHA’s capital planning efforts and to support the development of VISN and program strategic plans. 

Some services VA provides are not modeled by Milliman.   These include readjustment counseling, dental services, the foreign medical program, CHAMPVA, spina bifida, and non-veteran medical care.  Demand estimates and budgets for these programs are developed by their respective program managers.

Enrollee demand for long-term care services is modeled by VHA.   The VHA long-term care model uses utilization rates from nationally recognized surveys adjusted for the unique characteristics of the enrollee population and known reliance factors to account for distance (access to VA facilities), multiple eligibilities, and case management to project demand for both nursing home care and community-based care. 

The development of the actuarial model has been an evolutionary process, starting with the first model which provided single-year projections that were used only for the Secretary’s annual enrollment decision on resource availability and enrollment levels.   Enhancements include more detailed and robust adjustments for enrollee reliance, morbidity, and mortality, adding new data sources, and expanding the number of services modeled.  Future planned improvements include access to data on enrollee’s use of Medicaid, Tricare, and military treatment facilities, the integration of the VHA long-term-care model into the actuarial model, and modeling additional services such as dental care.

Conclusion

Mr. Chairman, in closing, I believe that the VHA Enrollee Health Care Demand Model is a valuable budgeting and planning tool for projecting VA health care utilization to ensure that VA can provide safe, effective, timely and efficient care.  We combine VA’s substantial experience with a contractor with unrivalled expertise in health care modeling to achieve the best actuarial projections possible.

This completes my statement.  I will be happy to respond to questions from the Committee.