Quantity and quality of care in primary care services

Abstract

The Veterans Health Administration (VHA) is a national healthcare system that provides a safety net for veterans. When economic conditions worsen, more veterans may turn to VHA services because VHA care is cheaper compared to private care. U.S. healthcare systems must balance three completing elements: cost, access, and quality. U¬nder a fixed budget system, such as the VHA, hospitals must choose between increasing patients' access to care and higher quality of care. This study focuses on two types of care quality-patient experience and patient health. This study evaluates the impact of changes in regional economic conditions, which could shift the demand for care at safety-net hospitals and its quality of care. In Study 1, I explore the direct relationship between changes in regional market factors that affect people's health insurance coverage and affluence, and patient-provider communication. As patient experience is associated with patient health outcomes, in Study 2, I expand upon my findings from Study 1 to explore the relationship between changes regional economic conditions and patient health outcomes. Finally, there are methodological challenges to measuring the trade-off between quantity (i.e., access to care) and quality of care since they are endogenous. Utilizing the findings from the first two studies, in Study 3, I take an instrumental variable approach to measure the trade-off between the number of primary care visits and two quality of care measures-patient experience and patient health. In Study 1, our findings supported our hypothesis that changes in regional market factors are associated with patient-provider communication scores measured by patient experience surveys. Along with primary care capacity, regional market factors-an increase in employer-sponsored insurance and a decrease in veterans' unemployment rate-were associated with positive patient-provider communication. Study 2 also found associations between economic downturn and negative health outcomes. A lower proportion of health insurance coverage and a decrease in affluence in the region were associated with higher risk of diabetes-related preventable hospitalization or death among older patients with diabetes. In Study 3, I was able to quantify the trade-off between hospitals treating more patients and providing higher quality of care, where a 10% increase in the number of visits would result in a 6.6 percentage point reduction in patient experience and a 0.72 percentage point increase in preventable hospitalization of death among older diabetes patients. This dissertation explored the relationship between changes in regional economic conditions and quality of care, and measured the trade-off between patients' access to care and quality of care in VHA primary care services. A comparison of quality of care measures between hospitals without accounting for changes in regional economic conditions could lead to misaligned resource allocations, as lower quality of care could be influenced by the economic downturn and higher demand for care at safety-net hospitals. This is particularly relevant for safety-net hospitals that could be financially penalized under value-based programs. Also, under bundled payment programs, as hospitals are incentivized to increase the volume of care given the same resources, quality of care could degrade. For the VHA, my dissertation findings provide insights on resource allocation and expansion of access to care for veterans.--Author's abstract