Predicting Demand for Veterans' Health Care: An Assessment of the VA's Forecasting Tools
The U.S. Department of Veterans Affairs (VA) is charged with providing comprehensive health care to more than 7 million enrolled veterans. To budget and plan for meeting the medical needs of this population, the VA relies on a forecasting model known as the Enrollee Health Care Projection Model (EHCPM), which predicts future demand for veterans' health care services. Is the EHCPM adequate for the task? The VA asked RAND to evaluate the model. Led by RAND researcher Katherine Harris, the evaluation focused on the model's adequacy for short-term budget planning and monitoring as well as for longer-term policy planning.
The results suggest that the EHCPM is useful for short-term budgeting purposes in a stable policy environment but less so for longer-range planning. Two features limit the model's long-range predictive accuracy. First, the model does not account for three key drivers of long-term demand for VA care: the value of the VA medical benefit versus other options; the size, capacity, and location of VA medical facilities; and the impact of military conflicts on demand. Second, the model treats the VA's cost structure like that of a fee-for-service payer, such as Medicare or a commercial insurer, whose costs are variable. Thus, if a substantial proportion of the VA's costs are fixed rather than variable, projected expenditures will be unrealistic. Nonetheless, the model is structured in a way that would allow modifications to address these limitations without disrupting its usefulness for near-term budget planning. However, these modifications would require substantial investments to expand the VA's ongoing survey efforts and to develop new costing methodologies that account for fixed costs. If such investments are not feasible, the VA should consider simplifying the current model, drawing more exclusively on its own data resources. A simpler model would perform as well as the current one and would be more transparent to users.
Avoiding the "Greenhouse Effect": Helping to Ensure that Health Interventions Work in Communities
Health interventions have the potential to reduce the burden of many chronic health problems. But in many cases, interventions are not introduced into the communities that can most benefit from them. Such interventions suffer from a "greenhouse effect": They work well on paper or in controlled trials but less well in the often-chaotic community settings for which they are intended. Over the past several years, RAND Health researchers have been involved in a series of community-based participatory research (or CBPR) efforts that are transferring the promise of evidence-based research directly to communities.
The role that a community potentially plays in research reflects a continuum of approaches that range from research conducted in community settings but without the direct or formal involvement of the community in decisionmaking (community-placed research) to that in which community leaders seek out research and other partners to help develop, implement, and advocate for programs and activities they believe to be necessary and important (community-driven research). Most of RAND Health's work has been in the middle of the spectrum—community-partnered work—where there is equal authority for all participants, representing the community and academia, over all research and program planning aspects. The goal is to achieve more valid work in terms of being relevant to, and consistent with, community values in a process of joint discovery of ideas, approaches, and methods that goes beyond where current evidence might take us.
Key examples of RAND's community-partnered work include Witness for Wellness, a multi-stakeholder, academic-community partnership initiative that strives to combine principles from evidence-based research on depression with community expertise and direction in historically underserved minority communities in Los Angeles with an eye toward reducing stigma around depression and improving depression care. A second effort has focused on efforts to develop and transfer the proven benefits of evidence-based RAND-partnered research within a community setting—Cognitive-Based Intervention for Trauma in Schools—a program to help children cope with violence. A third effort involves a community-centered coalition to address asthma disparities in Puerto Rico—Alianza Contra el Asma. And more recently, RAND Health has been collaborating with REACH NOLA, a community-based participatory research and action partnership working to improve community health and access to quality health care in post-Katrina New Orleans. In all these CBPR efforts (and in others as well), RAND Health researchers have been on the ground, working in partnership with key stakeholders in communities to transfer the benefits of evidence-based health interventions by incorporating the unique perspectives of community members on what it takes to make interventions responsive to community needs and constraints.
RAND Health Marks 40 Years of Research and Analysis
Originally chartered in 1948 to conduct policy analysis for the U.S. military, the RAND Corporation broadened the focus of its research in the late 1950s to examine social policy issues, such as education, criminal and civil justice, and health. RAND consolidated its health-related research in 1968 by using its own funds to establish the Health Sciences Program. Today, RAND Health is the largest research division within RAND and one of the largest private health research groups in the world. To mark our 40th anniversary, we will highlight throughout the year 40 of RAND Health's greatest hits: studies or streams of research conducted over the past four decades that best reflect the breadth and scope of our work and have made the greatest contribution to shaping health care policy, advancing health research, and improving the health of individuals around the world.
Each week, we will highlight one of these 40 studies or special topics on the RAND Health Web page (www.rand.org/health/). Our first highlight for the Web, planned for the final week of January, will feature COMPARE (which stands for Comprehensive Assessment of Reform Efforts). The COMPARE initiative is intended to provide information and tools that help policymakers, the media, and other interested parties understand, design, and evaluate health policies. After three years of work, COMPARE had its live public launch this week (www.randcompare.org). Stay tuned for February's Health Congressional Newsletter, which will feature COMPARE and provide more information on the project.
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RESEARCHER PROFILE
Katherine M. Harris
Katherine M. Harris PhD, is a Health Economist and Health Services Researcher at the RAND Corporation. She has led and participated in studies exploring the organization, delivery, and outcomes of medical and behavioral health services and has expertise in health care consumer behavior, mental health and substance abuse treatment, and primary and preventive health care. Ms. Harris has participated in a number of studies through RAND's military health program including the recent report, Review and Evaluation of the VA Enrollee Health Care Projection Model. In addition, she has also recently published work examining the DoD's Health IT system, the Armed Forces Health Longitudinal Technology Application (AHLTA).
Read more work by Ms. Harris »
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RAND CONGRESSIONAL RESOURCES STAFF
Lindsey Kozberg
Vice President, Office of External Affairs
Shirley Ruhe
Director, Office of Congressional Relations
Kristy Anderson
Health Legislative Analyst
RAND Office of Congressional Relations
(703) 413-1100 x5395
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