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Testing Novel Payment and Delivery Approaches Through the Veterans Health Administration's New Center for Innovation

In May 2018, Congress passed the VA [Veterans Affairs] Maintaining Systems and Strengthening Integrated Outside Networks (MISSION) Act to consolidate programs that provide veterans access to non-VA care and to formally establish a coordinated, high-performing network of VA and private-sector providers (1). The MISSION Act also established a VA Center for Innovation for Care and Payment (Center) to be staffed by VA employees and contractors with expertise in demonstrations and evaluations. Through the Center, the VA will have the ability to test novel payment and service delivery models. Although the VA is already recognized as a national leader in quality improvement and best-practice implementation, the new Center will facilitate the VA's shift toward value-based coverage strategies with a greater emphasis on population health. It will also empower the VA to collaborate with other payers to drive improvements in quality, costs, and efficiency. As its first initiatives are chosen, consideration will be given to feasibility and the scale of the improvements in quality and efficiency that could be achieved. The opportunity to undertake these initiatives comes with risk for unintended consequences. A commitment to rigorous evaluation along with the VA's strong research infrastructure will be crucial to the Center's ultimate success. The goals of the new VA center are similar to those of the Center for Medicare & Medicaid Innovation (CMMI) created by the Patient Protection and Affordable Care Act. Both are empowered to engage private providers in value-oriented experiments with innovative payment models, but the VA's center is also charged with innovating within the VA's national network of public hospitals and clinics. Among the lessons learned from CMMI's early experience is that ongoing, iterative testing and learning is invaluable and will probably take time to produce measurable results (2). These lessons are likely generalizable to the VA's experience. Studying innovative care and payment models in the nation's largest integrated delivery system has several advantages. First, veterans are a large group, which allows the VA to evaluate how new delivery models affect specific patient populations. Second, the VA's comprehensive electronic health record (EHR) allows investigators to use data that are not otherwise accessible through other public or private systems (for example, by linking detailed encounter-level clinical data with social risk factors and expenditures). Third, networks that include both VA and private-sector providers enable the VA to use heterogeneity in geographic practice patterns to compare effectiveness of treatments and management strategies. In addition, the Center will have the opportunity to choose from a wide array of urgent and compelling topics. For example, no health issue is currently receiving more attention than the opioid crisis, which greatly affects veterans (3). Medication-assisted treatment for opioid use disorder is supported by strong evidence but is underprovided (4). To address this problem, the Center could help develop and test value-based payment methods with stronger incentives for community-based medication-assisted treatment. Suicide prevention is another high-priority VA issue. Using the VA's extensive data resources, VA mental health leaders and researchers have developed a risk stratification tool that identifies veterans at elevated suicide risk (5). However, the most cost-effective intensity of intervention is not known. Some medical centers contact high-risk veterans by mail, whereas others do so by telephone at a greater cost. Some target only the highest stratum of risk; others target broader populations. The Center could sponsor an evaluation of targeting and outreach intensity coupled with a rigorous accounting of costs and outcomes to support evidence-based policy in this vital area. Success in innovations like these will depend on navigating several important challenges. An integrated network that combines public and private providers will increase demands on the VA's patients and providers to coordinate care and choose among alternative care pathways. Care coordination will require staff time as well as timely and accurate exchange of information between public and private providers. Patients and providers are more likely to find increased choices to be valuable if differences in prospective access, quality, and costs are disclosed when decisions are being made. Innovations can also fail because of insufficient support from local leaders and staff. The VA's established research infrastructure will be an invaluable resource to the new Center for demonstration design and implementation experience. Furthermore, paying for value could backfire without accurate measurement of costs and outcomes. Cost and outcome metrics can be difficult to conceptualize, and their validation is essential before implementation of policy based on them (6). Given these challenges, the VA's growing ability to test new programs through randomized study designs and natural experiments will be critical for the Center to meet the expectations of Congress and taxpayers (7, 8). Beyond rigorous study designs, maintaining adequate funding and effective management to upgrade the VA's data infrastructure and analytic capabilities is essential. For example, there are considerable advantages to improving accessibility to veterans' private-sector EHRs. Interoperability across public and private EHRswhether it is for care providers or researchers evaluating a new delivery modelwill improve decision making, leading to better quality of care and more effectively targeted research. The VA's ongoing transition from its legacy EHR to a new commercial system that facilitates interoperability with other public and private health systems has enormous potential to improve care and management, as well as equal potential for large disruption if execution falls short (9). If these challenges can be overcome, the new VA Center for Innovation could play a pivotal role in health system transformation, not only for veterans but for millions of Americans who face the same health concerns and suffer the same consequences from the shortcomings of our current health care financing and delivery systems.