- VA unit costs are higher than the same unit costs from commercial providers. This does not include variation in quality, nor variation in intensity of care over time. This also does not account for the fact that VA providers may underreport units and non-VA providers may overreport units.
- Veterans who use VA are sicker than Veterans who don’t use VA (Rose 2023; Machlin 2018).
- VA purchased care is often less expensive than VA provided care because the Choice and MISSION Acts linked VA purchased care to Medicare prices (Wagner 2021).
- VA quality of care is as good or better than non-VA care (Apaydin 2023).
- VA care is less intense than non-VA care (Gidwani-Marszowski 2018) and involves better coordination of care.
Taken together the evidence suggests that VA care offers better value: It saves lives and saves money.
Recent evidence supporting the value of VA care comes from David Chan and team (2022, 2023). Chan et al. (2022, 2023) compared mortality for dually eligible Veterans above age 65 transported by ambulance to VA hospitals vs Veterans transported to non-VA hospitals.
Chan et al. (2022) found that the risk-adjusted 30-day mortality rate was 20.1% lower among patients taken to VA hospitals than among patients taken to non-VA hospitals; the difference was particularly large for black and Hispanic patients. (25.8% lower and 22.7% lower, respectively). They found that this effect was robust to adjusting for a wide range Veteran characteristics.
Using more quasi-experimental methods, involving quasi-random assignment of Veterans to VA vs. non-VA hospitals influenced by ambulance companies, Chan et al. (2023) found an even greater advantage to VA care. They found that VA reduces 28-day mortality by 46%. This survival benefit persisted at 1 year, indicating that these deaths were prevented rather than delayed.
While the survival advantage held true across a wide variety of patient demographics and health conditions, Veterans with greater previous VA attachment and socioeconomically and medically vulnerable Veterans reaped larger benefits.
Chan et al. (2023) also found that VA reduces 28-day spending by 21% with striking differences in the services provided. The VA providing more low-cost services, such as telephone calls; non-VA hospitals performed more high-cost services and may have “upcoded” their services.
The 2023 paper has been awarded the 2023 VA HSR research paper of the year. It also received the 2024 National Institute for Health Care Management (NIHCM) Research Award.
Additional Information on Study Methods
Chan et al. (2022, 2023) evaluated care initiated with a 911-dispatched ambulance ride to the emergency department. They limited the cohort to Veterans age 65+ enrolled in both Medicare and VA.
- Chan et al. (2022) includes 1,470,157 ambulance rides (583,248 patients) from 2001-2018.
- Chan et al. (2023) includes 401,319 ambulance rides from 2001-2014.
- To focus on Veterans who could plausibly use either VA or non-VA hospitals, Veterans must have resided within 20 miles of both a VA hospital and non-VA hospital in areas where ambulances regularly transported patients to both types of hospitals. Ambulance rides to hospitals more than 50 miles from patient’s residence were excluded in both papers.
- The Chan et al. (2023) builds on the previous paper by using the quasi-random variation of assignment of patients within the same zip code to ambulance companies and ambulance company’s propensity to deliver patients to a certain type of hospital (VA or non-VA) in an instrumental variable approach.
- Adjustments for patient and ambulance characteristics in Chan et al. (2023) were similar to the previous paper. Chan et al. (2023) also use patient characteristics to validate their quasi-experimental approach, by showing balance in these characteristics across ambulance companies with different propensities to send patients to VA.
References
Chan DC, Danesh K, Costantini S, Card D, Taylor L, Studdert DM. Mortality among US veterans after emergency visits to Veterans Affairs and other hospitals: retrospective cohort study. BMJ. 2022 Feb 16;376:e068099. doi: 10.1136/bmj-2021-068099. https://www.bmj.com/content/376/bmj-2021-068099.long
Chan, DC, Card D, Taylor L. Is There a VA Advantage? Evidence from Dually Eligible Veterans. American Economic Review. 2023;113 (11): 3003–43. https://web.stanford.edu/~chand04/papers/va_nonva_paper.pdf
Apaydin EA, Paige NM, Begashaw MM, Larkin J, Miake-Lye IM, Shekelle PG. Veterans Health Administration (VA) vs. Non-VA Healthcare Quality: A Systematic Review. J Gen Intern Med. 2023 Jul;38(9):2179-2188. doi: 10.1007/s11606-023-08207-2.
Gidwani-Marszowski R, Needleman J, Mor V, Faricy-Anderson K, Boothroyd DB, Hsin G, Wagner TH, Lorenz KA, Patel MI, Joyce VR, Murrell SS, Ramchandran K, Asch SM. Quality Of End-Of-Life Care Is Higher In The VA Compared To Care Paid For By Traditional Medicare. Health Aff (Millwood). 2018 Jan;37(1):95-103. doi: 10.1377/hlthaff.2017.0883.
Machlin SR, Muhuri P. Characteristics and Health Care Expenditures of VA Health System Users versus Other Veterans, 2014-2015 (Combined). 2018 Jan. In: Statistical Brief (Medical Expenditure Panel Survey (US)) [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2001–. STATISTICAL BRIEF #508.
Rose L, Schmidt A, Gehlert E, Graham LA, Aouad M, Wagner TH. Association between self-reported health and reliance on veterans affairs for health care among veterans affairs enrollees. JAMA Network Open. 2023 Jul 3;6(7):e2323884
Wagner TH, Lo J, Beilstein-Wedel E, Vanneman ME, Shwartz M, Rosen AK. Estimating the cost of surgical care purchased in the community by the Veterans Health Administration. MDM Policy & Practice. 2021 Nov;6(2):23814683211057902
Last updated: July 24, 2024
