HERC: VA Community Care
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VA Community Care

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Overview

VA Community Care data files report financial and limited clinical information on non-VA care that was paid by a VA facility, including care provided to Veterans at military facilities. The files exclude most care provided through sharing agreements at university affiliates and services at state Veterans homes. As VA has expanded access to community care with the passage of the Veterans Access, Choice, and Accountability Act (VACAA; also called “Choice”, Fiscal Year (FY) 2015-2017) and the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act (FY2019-present), the types and content of community care data available has also grown. There are three primary sources of VA Community Care data: Fee Basis Claims System (FBCS), the Corporate Data Warehouse (CDW) Purchased Care Domain, and the Program Integrity Tool (PIT). Third Party Administrator (TPA) Monthly Choice tables are a fourth data source for investigation specifically focused on care received through VACAA.

Data Sources

Prior to FY2015, the primary source of VA Community Care data was known as Fee Basis Data or Purchased Care data. These data are available in the VA Corporate Data Warehouse (CDW) in the Purchased Care domain or as SAS Fee files. Beginning in 2013, VA introduced the Non-VA Care Program Integrity Tools (PIT) system, which is a comprehensive set of tools that aggregates many sources of data to check for fraud, waste, and abuse in the VA Community Care program. PIT is now considered to be the primary source for understanding VA Community Care. For all analyses using data for FY19 or earlier, we highly suggest using both Fee/Purchased care data and PIT data for the most complete understanding of VA Community Care use (see preliminary results from the Women's Health Evaluation Initiative (WHEI) “Preliminary Investigation of Outpatient Community Care Use Among Veteran VHA Patients, FY18”).

For more information on the differences between the sources, see the VIReC Researcher's Notebook: Overview of Three Community Care Data Sources (VA intranet only: http://vaww.virec.research.va.gov/Notebook/RNB/RNB17-CDW-Community-Care-Data-Sources-CY20.pdf).

Fee Basis Claims System (FBCS): FBCS is a nationwide claims management system. The FBCS schema is available as CDW raw data, meaning that users will need to plan for additional time for cleaning the data. Researchers looking for clinical data can use the “obligation number” variable to identify care related to the Veterans Choice Program in the Fee Basis or FBCS Data. NOTE: It is our understanding that starting January 2021, the FBCS application will no longer be used. Claims and other FBCS data will be found in PIT or Community Care Referral & Authorization domains. See the FBCS page (CDW Raw) on the CDW SharePoint site (VA intranet only: https://vaww.cdw.va.gov/bisl/Database/SitePages/Raw%20Extractor.aspx) for more information.

CDW Purchased Care domain and SAS Fee Files: Data in the CDW Purchased Care domain and SAS Fee Files comes from VistA. These databases were the primary source of VA Community Care data before the onset of PIT. These databases have similar, although not identical data. See the HERC Fee Basis Guidebook for an overview of similarities and differences between the two (Note: As of April 2019, the HERC Fee Basis Guidebook is no longer being udpated). A detailed overview of the CDW Purchased Care domain is available the VIReC Factbook: Corporate Data Warehouse (CDW) Purchased Care Service Domain (VA intranet only: http://vaww.virec.research.va.gov/CDW/Factbook/FB-CDW-Purchased-Care-Authorized-Domain.pdf). With the shift to PIT, the purchased care domain has become the source mainly for dental claims and contract nursing claims (http://vaww.virec.research.va.gov/Notebook/RNB/RNB17-CDW-Community-Care-Data-Sources-CY20.pdf). As of June 2019, the SAS Fee files are no longer being updated.

Program Integrity Tool (PIT): The PIT system is the consolidated source for understanding VA Office of Community Care (OCC) data. PIT collects VA OCC claims data from multiple sources for the purposes of identifying fraud, waste, and abuse. The data is subsequently transmitted for storage in CDW. PIT provides comprehensive data on all Veteran family member programs, and Choice and MISSION Act utilization.

Other VA Community Care data sources:

Third Party Administrator (TPA) Monthly Choice tables: Those interested in evaluating the administrative process, such as clinic wait times, can find detailed records in the TPA Monthly Choice tables, which can be found within the VACAA schema in CDW Raw. The VACAA tables are “live,” which means that the data are constantly updated. The TPA tables do not contain clinical information, such as diagnosis and procedure codes.

Figure 1. General overview of VA data streams. Courtesy of Richard Pham.

Figure 1. General overview of VA data streams

Overlap of Community Care Data Sources

Prior to FY20, we recommend that PIT data be analyzed in combination with Purchased Care/Fee data for a complete understanding of VA Community Care utilization and costs. Starting January 1, 2020, all Community Care data will be found in PIT or the CDW Purchased Care Domain (CDW FEE schema).

Data Access

Operations users can request access to data using the VHA NDS Access for Health Operations ePAS Form. Researchers can request data access through the DART research request process. For more information, visit the VHA Data Portal (VA intranet-only: http://vaww.vhadataportal.med.va.gov/).

History of VA Community Care

VA Directive 1663 allows VA medical centers to contract for clinical and related services with affiliated medical schools, faculty groups, hospitals, and other providers. These contracts, also called sharing agreements, are developed under several circumstances: when a clinical service cannot be provided by one VA facility and the patient cannot be transferred to another VA facility; when VA cannot recruit a needed clinician; when it is determined not to be in the best interest of the VA to hire, such as when only a portion of a clinician’s time is needed; in order to reach market-rate pay for certain highly paid subspecialists; and when it is cost-effective to share a service or space with another entity rather than to develop stand-alone capacity for VA.

Most care provided through sharing agreements does not appear in VA utilization databases. One exception is services purchased from the Department of Defense (DoD), which are recorded in the Fee Basis Claims System (FBCS) database. The data capture system is imperfect at present, although this may be remedied by a VISTA patch currently being developed. Another exception would be care provided at a VA facility by a contract provider. In such cases the provider uses VISTA and the encounter is recorded as usual. There is no plan to record sharing care from other sources in Community Care files or other utilization databases available to researchers.

A regulation change in FY2007 made it difficult for VA stations to enter into sharing agreements. Their number fell precipitously as local officials moved to purchase contract care through the VA Community Care program instead. These events may have caused an anomalous increase in non-VA medical care. Due to the considerably larger scope of VA Community Care contracts, however – more than $3 billion in FY2008 – the increase due to the FY2007 regulation change may not be noticeable. Changes in the contracting process since FY2007 have led to a substantial return to the use of sharing agreements throughout the system.

The VA Financial Management System (FMS) records spending by fiscal year, location, budget object code (BOC), and cost center. The data are stored in files at the Austin IT Center. FMS data is useful for determining summary figures, but they cannot be tied to care for individual patients. Most BOCs pertaining to contract care fall in the range of 2560-2636. Exceptions include 2674, 2692, and 2693, which contain a mixture of contract and non-contract care, and 4110 and 4120, which include payments for services related to medical care, to cemeteries, and to other veteran benefits. Most contract care falls within cost centers in the 8300 series. Again, there are exceptions, such as 8204, 8222, and 8272. The current policies defining BOCs and cost centers may be found by visiting https://www.va.gov/vapubs and searching by keyword.

Sharing agreements with DoD facilities are recorded under a single BOC. Using the vendor files in the FBCS data one could locate all paid claims for sharing care provided by DoD. The resulting figure would be less than actual spending due to incomplete reporting. FMS will not suffer from incomplete reporting, however, and so the difference between FMS and FBCS totals for DoD care should indicate the level of underreporting in the FBCS files.

In response to health care issues faced by VHA, Congress passed into law the Veterans Access, Choice and Accountability Act of 2014 (hereafter referred to as the Choice Act). The Choice Act provides care to Veterans who are unable to be scheduled for an appointment within 30 days of their preferred visit date or who live more than a specified distance from the nearest VA medical facility. Care provided under the Choice Act is considered part of VA Community Care and in FY2015 (the first year of the program), data is included in the FBCS database. Beginning in FY2016, care provided under the Choice Act can be found in separate files housed in the VA Corporate Data Warehouse (CDW). It is estimated that there are approximately 1.7 million Choice care claims processed each month and that Choice care claims account for approximately $5-8 billion annually. The Choice Act was replaced by the Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act of 2018 in June 2019.

Resources

Last updated: April 22, 2020