Quality Initiatives Undertaken by the Veterans Health Administration

August 13, 2009

Today CBO released a study that examines the Veterans Health Administrations (VHAs) experience with quality improvement and health information technology. The assessment also examines how VHAs system serves its patients. The information contained in this reportmay prove useful to private-sector health providers who are working to improve the quality of care in their own facilities as well as to analysts and decision makers considering how veterans health care might be affected by proposals for health care reform.

Two decades ago, the veterans health system focused largely on inpatient hospital care and had a poor reputation for quality. Beginning in the mid-1990s, the agency undertook a major transformation effort aimed at improving the quality and efficiency of the care it provides to its patients. VHA eliminated underutilized inpatient beds and facilities, expanded outpatient clinics, and restructured eligibility rules. A major focus of the transformation was the tracking of a number of performance indicatorsincluding quality-of-care measuresand holding senior managers accountable for improvements in those measures.

Since then, VHA hasachieved improvements in the quality indicatorsit measures and for whichit holdsits staffaccountable.The agencyhas relied increasingly on electronic health records and other information technology to support efforts to coordinate health care delivery. Many of VHA's quality improvement programs use data from computerized clinical records to track both process and outcome measures, includingrisk-adjusted mortality and morbidity. Those programs have helpedVHA to recognize problems in specific health care facilities as well as to improve performance throughout the agency. Additionally, much ofits own research has focused on the importance of putting evidence-based medicine into practice.

Most veterans who use VHA facilities also seek care from other providers, and this canmake it difficult toanalyze thequality of care and ensure that patients are receiving services recommended by clinical practice guidelines. These patterns of health care utilization also highlight the importance of expanding efforts to share health information not just between VHA and the Department of Defense, but also with private providers.

Determining whether VHA is a cost-effective provider of care is not simply a matter of comparing spending per enrollee. VHA spending per enrollee does not reflect the full amount of medical care received by those veterans from all sources.In this assessment,CBO took into account changes in the mix of enrollees and their reliance on VHA care and found that VHAs spending per enrollee was relatively flat from 1999 through 2002, but since then it has risen about as rapidly as spending per enrollee in the Medicare program. It is likely that rapid increases in annual appropriations for VHA, efforts to reduce waiting lists within the system, and expansion of mental health and other specialized services have contributed to the recent growth in spending per enrollee.