Primary Care's Effects on Costs in the US Veterans Health Administration, 2016–2019: an Observational Cohort Study
Abstract: Enhancing primary care is a promising strategy for improving the efficiency of health care. Previous studies of primary care’s effects on health expenditures have mostly relied on ecological analyses comparing region-wide expenditures rather than spending for individual patients. To compare overall medical expenditures for individual patients enrolled vs. those not enrolled in primary care in the Veterans Health Administration (VHA). Research design included a cohort study with stratification for clinical risk and multivariable linear regression models adjusted for clinical and demographic confounders of expenditures. Participants were, in total, 6,009,973 VHA patients in fiscal year (FY) 2019—5,410,034 enrolled with a primary care provider (PCP) and 599,939 without a PCP—and similar numbers in FYs 2016–2018. Total annual cost per patient to the VHA (including VHA payments to non-VHA providers) stratified by a composite health risk score previously shown to predict VHA expenditures, and multivariate models additionally adjusted for VHA regional differences, patients’ demographic characteristics, non-VHA insurance coverage, and driving time to the nearest VHA facility. Sensitivity analyses explored different modeling strategies and risk adjusters, as well as the inclusion of expenditures by the Medicare program that covers virtually all elderly VHA patients for care not paid for by the VHA. Within each health-risk decile, non-PCP patients had higher outpatient, inpatient, and total costs than those with a PCP. After adjustment for health risk and other factors, lack of a PCP was associated 27.4% higher VHA expenditures, $3274 per patient annually (p < .0001). Sensitivity analyses using different risk adjusters and including Medicare’s spending for VHA patients yielded similar results. In the VHA system, primary care is associated with substantial cost savings. Investments in primary care in other settings might also be cost-effective.
Abstract: INTRODUCTION: Substance use disorders (SUDs) are an ongoing public health crisis in the United States. A large body of research indicates an urgent need for increased training in SUD research and treatment for trainees in mental health service disciplines. The VA Health Care System is well positioned, as the largest trainer and employer of health service psychologists and other mental health professionals, to address the SUD training gap and serve as a leader in training the upcoming health care workforce. METHOD: To this end, we conducted two pilot studies to (1) examine the feasibility of implementing supplemental SUD training for VA health service trainees, among current VA mental health service providers in psychology, social work, and medical care (N = 37) and (2) the efficacy of a single 2-hour interdisciplinary SUD training seminar for VA health service trainees in mental health (N = 13). The training seminar consisted of several components including lecture, facilitated discussion, and role play, aimed at increasing trainee self-efficacy in assessing and diagnosing SUDs. RESULTS: Findings suggest that current providers are supportive of supplemental SUD training for VA trainees and believe that such training is beneficial for those wishing to pursue a career within the VA Health Care System. Additionally, results suggest that a single session didactic seminar improved trainees' self-reported efficacy in the assessment and referral of veterans diagnosed with SUDs. CONCLUSIONS: Overall, the above studies support additional feasibility investigations that would pave the way for successful implementation of widespread SUD training programs across the VA Health Care System and beyond. Successful implementation would then serve to reduce the increasingly critical SUD provider shortage, thus leading to significant public health gains.