Office of Research & Development
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VA researchers who analyzed survey data found that overall Veterans had a generally favorable view of their care at both VA facilities and in the community. (Photo for illustrative purposes only. ©iStock/izusek)
August 4, 2020
By Mitch Mirkin
VA Research Communications
“How was your experience?”
That question, or some version of it, is increasingly being asked of consumers—including in health care. Visit a medical practice nowadays and you’re likely to get a follow-up email asking you to rate the experience.
VA is no different. VA medical centers send surveys to random samples of outpatients every month asking how their visits went.
These data are part of a newly published study. Researchers compared survey responses from 2016 and 2017 from VA-enrolled Veterans who either received outpatient care in VA or went outside VA for primary, mental health, or other specialty care in their local communities. In all, survey responses from over 1 million Veterans are included in the analysis.
Dr. Megan Vanneman is a health services researcher at the VA Salt Lake City Health Care System and the University of Utah. (Photo by Jeff Grandon)
The new study, published in the August 2020 issue of Health Affairs, found that overall Veterans had a generally favorable view of their care at both VA facilities and in the community. However, VA care scored better than community care in three of the four categories covered in the surveys: overall provider rating, communication, and coordination.
In the fourth area, access to care, the results were more mixed, depending on the type of care. VA scored slightly lower on access to specialty care, such as cardiology or orthopedics. There were no differences in access to primary or mental health care.
For provider ratings, average scores in both settings were mainly between 8 and 9 on a scale on which 10 was the highest possible score. For the other areas—communication, coordination, and access—average composite scores for both settings were mainly between 3 and 4, with 4 representing the most favorable rating.
"Overall, patient experiences were quite good in both VA and community care. "
“Overall, patient experiences were quite good in both VA and community care,” says study leader Dr. Megan Vanneman. She emphasizes that VA’s goal is to promote the best patient experiences and health outcomes regardless of where Veterans end up receiving their care. “We want to see Veterans having access to high-quality care,” she says.
Thanks to recent laws, eligible VA patients—mainly those who live far from VA clinics and hospitals, or those who need types of care not provided adequately or in a timely fashion in VA—are able to see non-VA healthcare providers in their community, with VA paying for this care. These options widened under the VA MISSION Act of 2018. Prior to that, the Veterans Choice Program offered similar access to outside care, albeit on a less extensive scale.
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Given the expanded options for Veterans to seek care outside VA, comparing the two sectors “is more important than ever,” says Vanneman. Her group’s study is the first to compare the experiences of VA-enrolled Veterans in the two different care settings.
Vanneman is a health services researcher at the VA Salt Lake City Health Care System and the University of Utah. She is part of the VA Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center. Researchers at two other VA centers contributed to the study: the Center for Healthcare Organization and Implementation Research (CHOIR), in the Boston area; and the Health Economics Resource Center (HERC) , in Menlo Park, California.
The researchers also worked with staff from VA’s Office of Community Care, which oversees VA-purchased care; and the Office of Reporting, Analytics, Performance Improvement and Deployment (RAPID), which oversees VA patient surveys and other quality measures. The patient questionnaire is called the Survey of Healthcare Experiences of Patients, or SHEP. It’s based closely on the Consumer Assessment of Healthcare Providers and Systems surveys developed by the Agency for Healthcare Research and Quality and considered the industry standard.
Vanneman notes that the focus of the research was patient experience, not satisfaction. The two are related, but experience is seen as a more objective measure. For instance, the SHEP asks patients if they had to wait more than 15 minutes past their appointment time. That’s considered a reasonable standard for medical practices to meet, regardless of whether a patient objects after waiting only five minutes, or enjoys watching TV and browsing magazines and doesn’t mind waiting 30 minutes to be seen.
While patient experience is an important health care measure, it’s not the only one health systems take into account. “I think of patient experience as one type of quality metric,” says Vanneman. “There are other quality metrics that relate to care processes—for example, whether or not follow-up care occurred. And others that relate to positive or negative health outcomes—for example, complication rates of surgeries.” She notes that VA also looks at these and other metrics, in addition to patient experience.
Dr. Joe Francis, who heads VA’s RAPID team, says while past studies have compared aspects of VA and community-based care, including quality of care and patient outcomes, the new study is the first head-to-head comparison of patient experience involving VA-enrolled Veterans on both sides of the equation.
This provides a different picture, he says, than comparisons that involve patients from the community at large who don’t resemble VA’s patient mix. “There are very different inferences,” notes Francis,” and that is very important from a policy perspective.”
Vanneman says the “apples to apples” comparison in her study will help in the current “make versus buy” debate in VA on whether to purchase care in certain sectors or keep it in house. By the same token, she says, the data could help VA identify where improvements are needed.
She recommends further studies, perhaps involving interviews or focus groups, to explore why Veterans choose VA or community care. “These would provide more qualitative depth to our quantitative data,” she says.
The researcher emphasizes that while her team’s data do offer insights in the aggregate, such “population level” results can’t dictate the right approach for any individual Veteran. “The survey data can’t tell us whether a particular person would have a better or worse experience going out into the community. Those considerations need to be made at the individual level.”
The Survey of Healthcare Experiences of Patients (SHEP) asks Veterans to rate their provider from 0 to 10, with 0 being the worst and 10 the best.
It also asks patients to report on how well providers and the health care system overall did in the following areas. The answers are on a four-point scale (never, sometimes, usually, or always) with 1 being the lowest and 4 being the highest rating.
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