# Comparing Quality of Care between VA-Delivered and VA-Purchased Care: The Need for Better Risk Adjustment

> **NIH VA I01** · VA BOSTON HEALTH CARE SYSTEM · 2024 · —

## Abstract

Background: The MISSION Act of 2018 further expanded the opportunity for Veterans to receive care in
the community. While this may have led to improved access to care, it may also have resulted in decreases in
the quality of care that Veterans receive.
 Significance: This study will be the first to improve existing risk adjustment methods used by VA with an
application for VA/Community Care (CC) quality comparisons. As increasing numbers of Veteran enrollees use
CC, there is an urgent need to know if the quality of care delivered in the community that is purchased by VA is
at least equivalent to the quality of care delivered in VA. We will also examine whether adding social
determinants of health (SDOH) to the risk adjustment methods impacts assessments of quality and health
disparities.
 Innovation and Impact: A better understanding of which new data sources and SDOH variables improve
risk adjustment methods is needed to enable fairer and more accurate comparisons of VA/CC quality at both
the national and local area levels. We will obtain a much richer picture of the conditions and other individual-
and community-level factors that affect the risk or disease burden of Veterans by also including data from
multi-system use (Medicare and All-Payer Claims Databases).
 Specific Aims: For federal fiscal years 2020-2022, our specific aims are to: 1) Examine whether adding
readily available VA, CC, and pharmacy data and individual- and community-level SDOH variables improve the
discrimination and calibration of Gagne (an easily modifiable comorbidity measure); 2) Examine whether
adding non-VA system use improves the discrimination and calibration of Gagne; and 3) Compare overall
VA/CC quality at the national and local area levels using “Gagne1” (which includes additional VA and SDOH
data), “Gagne2” (which includes non-VA system use datasets), and the Nosos risk score (an “off-the-shelf” VA
risk adjustment method). We selected two Veteran subgroups to study: Veterans with serious mental illness
(SMI) and Veterans undergoing total hip or total knee arthroplasty (THA/TKA). Both of these subgroups are in
high-cost, high-volume categories of outsourced CC. Quality of care is defined by 4 health outcomes:
emergency department (ED) visits and readmissions for Veterans with SMI, and complications and
readmissions after THA/TKA.
 Methodology: For Aim 1, we will examine the extent to which the coefficients on the Gagne comorbidities
change when additional data sources (CC and pharmacy data) are added to VA utilization data and then when
SDOH variables are added to predict outcomes. We will also compare discrimination and calibration between
Gagne, Gagne1, and Nosos. For Aim 2, we will examine the effect of adding non-VA system use data to
Gagne1 and evaluate their effect on model discrimination and calibration of Gagne2. For Aim 3, we will
compare overall VA/CC quality at the national and local levels using Gagne1, Gagne2, and Nosos.
 Next Steps/Implementation: T...

## Key facts

- **NIH application ID:** 10752618
- **Project number:** 5I01HX003521-02
- **Recipient organization:** VA BOSTON HEALTH CARE SYSTEM
- **Principal Investigator:** AMY K ROSEN
- **Activity code:** I01 (R01, R21, SBIR, etc.)
- **Funding institute:** VA
- **Fiscal year:** 2024
- **Award amount:** —
- **Award type:** 5
- **Project period:** 2022-11-01 → 2026-04-30

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/10752618

## Citation

> US National Institutes of Health, RePORTER application 10752618, Comparing Quality of Care between VA-Delivered and VA-Purchased Care: The Need for Better Risk Adjustment (5I01HX003521-02). Retrieved via AI Analytics 2026-05-24 from https://api.ai-analytics.org/grant/nih/10752618. Licensed CC0.

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