Department of Veterans Affairs MISSION Act Quality Standards Request for Public Comment September 22, 2018

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1 Department of Veterans Affairs MISSION Act Quality Standards Request for Public Comment September 22, 2018 The Veterans Healthcare Policy Institute, a non-partisan think tank focused on the provision of quality healthcare to veterans, is pleased to respond to the Department of Veterans Affairs Request for Information from the public to assist in implementing section 1703C(a)(3)-(4) of title 38 United States Code, added by section 104(a) of the VA MISSION Act of This is a unique opportunity to improve not only the quality of VA s internal hospital care, medical services and extended care, but also that provided by Veterans Community Care Program (VCCP) partners as well. Six different sections of the VA MISSION Act (summarized below) authorize the VA to establish systems of monitoring the quality of health care furnished at the VA and in the community. These quality metrics are intended to (a) offer covered veterans relevant comparative data to assist making informed health care decisions, (b) designate underperforming VA clinics whose patients should be granted automatic VCCP vouchers, and (c) decide whether to renew contracts for VCCP providers. We enthusiastically endorse the VA MISSION Act s commitment to guaranteeing that our veterans receive high quality care. However, we wish to register concern that the manner in which the systems of measuring quality are defined and implemented could severely erode rather than enhance the care of veterans. There are three potential problems VA should rectify in order to assure that quality care is provided: 1. Use of peripheral measures of quality. Quality measures is a catchall term that may or may not directly pertain to patients diagnoses or outcome of services. The term occasionally includes something that isn t quality at all, for example patient satisfaction with services. 2. Lack of sufficient VCCP data. Comparing the quality of VA to non-va care may be flawed because many VCCP providers do not regularly collect or report data. 3. Comparison to the wrong population. Contrasting VA to non-va care may be flawed because the compared populations are disparate. We are deeply concerned that unless the issues are resolved, vouchers may be granted to tens of thousands of veterans without any assurance that they will receive better care in their community. That in and of itself would be a grave disservice to our veterans. But it may also potentially harm veterans by accelerating a one-directional flow of patients and resources out of the VA to private sector providers, many of who are ill equipped to care for veterans complex needs. This will progressively diminish the option for other veterans to seek VA care, since payment for community services comes at the expense of existing VA facility staffing, services and programs. Below, we identify the sections of the legislation pertaining to the implementation of quality standards, review the serious shortcomings and suggest recommendations that would accomplish the bill s quality assurance objectives in a productive manner.

2 Sections of the VA MISSION Act Pertaining to Quality The following are the sections of the legislation that refer to quality care. Section 101. Veterans Community Care Program Covered veterans can receive care in the community if VA determines that a medical Service Line (i.e. a VA clinic) is not meeting VA s standards for quality (and access). Quality at VA clinics is compared to two or more distinct quality measures at non-va clinics. VA establishes a system for monitoring quality of care furnished through community network providers and makes annual progress reports. Section 102. Contract Agreements with Non-VA Providers Veteran Care Agreements (i.e. provider agreements) are established with community health care entities/providers. The quality of care is assessed and used for contract renewal for those VCAs that exceed $5 million annually. Section 104. Access and Quality Standards VA establishes new quality (and access) standards. VA will publish by June 2019 quality ratings of VA facilities (but not VCCP partners) on CMS s Hospital Compare website so that covered veterans have relevant VA to non-va comparative data to make informed decisions regarding their health care. Veterans are surveyed on their satisfaction with VHA services and quality of care regarding timeliness, effectiveness, safety and efficiency. Section 106. High Performing Integrated Health Networks A Quadrennial Review occurs to assess the effects of quality (and access) standards on capacity. Section 133. Competency Standards for Non-VA Providers VA establishes standards and requirements for the provision of care by non-va providers in clinical areas for which the VA has special expertise, including posttraumatic stress disorder (PTSD), military sexual trauma-related (MST) conditions, and traumatic brain injuries (TBI). Each VCCP provider must meet the requirements and standards on how to deliver evidence-based treatments (EBT) in order to furnish care. Section 152. Center for Innovation for Care and Payment VA will establish a Center for Innovation for Care and Payment to conduct up to 10 pilot programs intended to cut costs while maintaining/improving quality of care. VA may expand the duration and scope of any of the models if it reduces spending or improves quality of care.

3 Problems with Implementing VA MISSION Act Requirements to Measure Quality 1. Quality measures can miss the relevant processes and outcomes that directly relate to treatment. The VA MISSION Act of 2018 dictates that relevant comparative quality metrics are to be made available to covered veterans to assist them in making informed health care decisions. Those metrics are also used for provider contract renewals and for assessment of clinic performance. But quality measures can often miss the outcomes and processes that are most important to the patient s diagnosis/symptoms/functioning. Take for example the assessment of quality treatment of PTSD, a common disorder among veterans, and an emphasis of Section 133. The prevailing standard of quality PTSD treatment is the provision of one of four extensively researched, evidence-based treatments that were selected by a panel of subject matter experts for the 2017 VA/DoD Clinical Practice Guidelines for PTSD and Acute Stress Reaction. Yet, websites contrasting care, such as CMS s Hospital Compare or VA s Access to Care websites, don t list PTSD as a searchable category. Also, there are no PTSD treatment processes (e.g. whether an EBT is used) or outcomes (e.g. symptom improvement assessed via PCL-5) among the metrics shown. The closest available quality metrics are the use of recommended standards for screening for clinical depression, adherence to anti-depressant medication management, screening for unhealthy alcohol use, initiation and engagement of alcohol and other drug dependence treatment, or depression remission. In short, by next spring when systems of monitoring quality are supposed to be implemented, there will be no available quality metrics available to veterans who wish to make decisions about the quality of PTSD treatment. Using peripheral metrics like those itemized above is of little value. Further, section 133 stipulates VCCP clinicians must fulfill PTSD training requirements established by the VA. One would hope but it remains to be seen that the trainings will be commensurate with the longitudinal training the VA requires of its own PTSD clinicians. The VCCP standard of care should never be less than the VA s. Abbreviated one-shot trainings would be insufficient, since skills acquired without follow-up feedback and supervision have been shown to decay back to pretraining. Yet even if VA s high internal standards were instituted for VCCP clinicians, the legislation failed to require quality measurement of whether EBTs were delivered or how well the treatments fared. Not every disorder is as totally lacking in quality measures as PTSD. For example, if a veteran needed cataract surgery, Hospital Compare displays scores for improvement in patient s visual function within 90 days following surgery. But for a sizable number of diagnoses and conditions there is no searchable listing by disorder, no listing of treatment outcomes and no listing of whether evidence-based standards of treatment are used. Veterans and administrators will be left without applicable, relevant information that would allow decisions about selecting providers.

4 2. Comparing the quality of VA to non-va care will be flawed because non-va providers don t regularly report performance data. The VA Office of Community Care has indicated that the majority of individual community providers are unlikely to agree to share detailed quality and performance data with VA due to the costs/burdens of such reporting. After three years of using community providers in the Choice Program, there is extremely limited data regarding quality (or access) of care rendered to veterans referred to non-va providers. Nor is there quality (or access) information at the level of a specific community Service Line clinic. Without provider and clinic level data, the VA will be unable to suitably implement Section 101 and ensure quality of care for veterans. 3. Contrasting VA to non-va care of veterans may be flawed because the compared populations are disparate. Comparing website quality numbers of the VA to those of the community is flawed since private sector statistics are based on non-veteran patients who, on average, are younger and have fewer medical and mental health conditions than veterans. Weaker outcomes are inherent for patients with more severe symptoms and complex co-morbidities. Unless VCAs are required to keep track of data on veterans referred through the VCCP, apples to apples comparisons of quality care will be challenging. An approximate solution to this type of problem was proposed in a 2018 report 1 by the Measure Applications Partnership (MAP) of the National Quality Forum, which consists of 150 healthcare leaders from 90 stakeholder 0rganizations. MAP recommended that measures be accurately risk-adjusted (i.e. for age, comorbidities and past medical history) to enable fair and valid comparisons across disparate groups. There s one other quality metric problem intrinsic to Section 101. In deciding which of the VA service lines (up to 36) are underperforming and must provide vouchers for community care, an algorithm compares a service line s metric to two or more quality metrics at non-va clinics located anywhere. The use of quality care metrics from other regions would contradict a major rationale of the MISSION Act, which is to utilize local community providers with known higher quality and access. Discussion/Recommendations The provision of health care for veterans depends on quality measurement. Data will be used to assist veterans to make informed decisions about providers, designate when automatic vouchers for non-va care are granted, and decide whether to renew contracts. Yet, given the tight timeline and absent data, the VA may be tempted to consider adopting systems of measuring quality that are deficient but expedient. MAP cautioned against federal programs taking shortcuts when obtaining meaningful quality data is effortful:

5 There may be negative unintended consequences if low burden measures are prioritized over meaningful measures with a higher burden. Using substitute data is not a solution. Just because something is labeled as quality and a number is assigned to it, this may have little bearing on whether quality care is in fact being provided to a veteran. As Albert Einstein is credited with observing: Not everything that can be counted counts. Recommended Solutions: Before full implementation of the VA Mission Act, and before further expansion of VCCP, the VA should establish meaningful quality metrics on what matters most, comparative o patient symptom improvements (outcome metrics) o patient functional improvements (outcome metrics) o provider use of standard of care EBTs (process metrics) Require quality scores to be listed according to diagnosis/condition so that veterans can readily search according to their disorder. Require that the metrics used for determining VA and non-va provider performance are identical. Require that VCAs keep separate track of the data on veterans referred through the VCCP so that the quality of care to veterans in the community and in the VA can be correctly compared. Before final determination of underperforming 36 clinics and issuance of vouchers for non-va care, require that quality metrics be obtained at the service line level and be compared to regional clinics. Ensure quality of non-va care is definitively better than VA s before referring veterans. Require all VCCP providers who treat veterans with PTSD, TBI and MST-related conditions be subject to the identical training and competence standards as VA providers. Require VCCP to perform the same regular clinical screenings as occurs in the VA. Ensure that patient satisfaction with care scores are not used as a substitute for quality of care. Conclusion Veterans deserve expert, effective care no matter where they receive it. Let s ensure that the systems and standards we use to judge the quality of that care are relevant, complete and accurate. Footnote 1 _Final_Report.aspx