HERC Spotlight: February 2024
Veterans Health Administration sent this bulletin at 02/20/2024 11:14 AM EST
Health Economics Spotlight
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SpotlightEvaluating the Impact of Informal Caregiving on Health Care Use and Costs: Spotlight on Data and MethodsInformal caregiving is a crucial source of care for many Veterans, potentially supplementing and substituting for VA-provided services. VA has acknowledged the value of this care, as well as the cost of providing care for caregivers, through the Program of Comprehensive Assistance for Family Caregivers (PCAFC), which provides stipend payments and other benefits to caregivers; however, whether and the extent to which informal care receipt results in cost savings to VA is unknown. As part of her HSR Career Development Award, HERC health economist Jo Jacobs led a team of researchers who quantified the monetary savings that results from informal caregiving from the VA perspective. Using a novel dataset and instrumental variables approach, they found that informal caregiving decreased overall two-year expenditures by $26,431 (2023 dollars), with larger effects among those with higher care needs (a two-year reduction of $33,819 in 2023 dollars). Cost reductions were driven by lower inpatient, outpatient, and long-term care utilization. These findings, published in Social Science & Medicine, can be used to understand how the health system cost savings from informal care receipt align with stipend payments under PCAFC. Here, we discuss the data and methods used by Jacobs and team and present resources for researchers. Measuring Receipt of Informal CareWhile informal care receipt has been historically difficult to measure in administrative datasets, Jacobs and team used a unique dataset: the VA-linked Health and Retirement Study (HRS). This longitudinal dataset enables researchers to examine questions requiring measurement of characteristics that are often unobserved or inconsistently observed in electronic health record data. Using the HRS Helper Files, the team identified whether Veterans received informal care from a child or grandchild, as well as the number of hours of care. Learn more about using the VA-linked HRS data in the seminar The VA-Linked Health and Retirement Study: Data Overview and Research Examples by Jacobs and Wyman. |
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VA Cost DataJacobs and team use HERC average cost data to estimate VA costs. HERC average cost data includes encounter-level costs, which are estimated by distributing aggregate-level VA costs to encounter-level VA utilization using non-VA relative value weights. Jacobs and team used both HERC inpatient and outpatient average cost data to estimate VA costs and group encounters into categories of care. Given that 2012 was the last year of available VA-linked HRS data, the team used Fee Basis files to estimate community care costs and inflation adjusted to 2012 and 2023 dollars. |
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Instrumental Variables to Understand Causal EffectsObservational studies estimating causal effects are prone to bias. When the treatment is correlated with other factors not included in the analysis, it’s known as endogeneity. For this research question, “What is the causal effect of informal caregiving on health care use and costs?”, there’s a high likelihood of endogeneity, particularly around factors that impact a family member’s decision to provide informal care. Therefore, Jacobs and team used instrumental variables (IV), a statistical modeling technique that accounts for endogeneity. In Table 3, Jacobs presents the results of the models that don’t account for endogeneity and those that do. Readers can see that results are notably different in the IV analysis, highlighting the importance of correcting for unobserved variables. Researchers can learn more about IV methods in the seminar Instrumental Variables by Kritee Gujral and the Instrumental Variables page on the HERC website. Learn more about the study methods and view the full results online. Jacobs JC, Lo J, Van Houtven CH, Wagner TH. The impact of informal caregiving on U.S. Veterans Health Administration utilization and expenditures. Soc Sci Med. 2024 Jan 24;344:116625. |
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SeminarsUse and Cost of Low-Value Health Services by Veterans in VA and non-VA SettingsHERC Health Economics Seminar Wednesday, February 21 at 2pm ET |
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 Thomas R. Radomski, MD, MS
Core Investigator, Center for Health Equity Research and Promotion (CHERP) |
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 Carolyn T. Thorpe, PhD, MPH
Core Investigator, Center for Health Equity Research and Promotion (CHERP) |
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Low-value care, defined as the use of a health service whose harms or costs outweigh its benefits, is a major driver of wasteful healthcare spending and exerts physical, psychological, and financial harms upon patients. Prior research on the use of individual low-value services suggests that low-value care may also be prevalent within VA. However, Veterans’ comprehensive use and cost of low-value services delivered by VA facilities or through VA Community Care (VACC) programs has not been previously quantified. Moreover, Veterans’ high degree of dual enrollment in VA and Medicare may subject them to care fragmentation and poor care coordination as they transition between VA and non-VA sources of care, placing them at increased risk of receiving low-value health services outside VA. In this seminar, we will characterize the use, related costs, and determinants of Veterans’ use of low-value health services from VA Medical Centers, VA Community Care Programs, and Medicare. Target audience: Health care providers, health services researchers, and clinical administrators and leaders |
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Veterans’ Use of and Outcomes from VA and non-VA HospitalsHERC Health Economics Seminar Wednesday, March 20 at 2pm ET |
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 Jean Yoon, PhD
Health economist, Health Economics Resource Center (HERC) |
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This presentation will summarize research measuring changes in Veterans’ use of VA and non-VA hospitals after the Choice Act and differences in hospital outcomes between VA and non-VA hospitals for several common conditions. This work used VA data linked to state discharge records in 11 states. Target audience: Those interested in Veterans’ use of non-VA care and comparisons between VA and non-VA care. |
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Cost-Effectiveness Analysis Seminar SeriesThe Cost-Effectiveness Analysis seminar series continues through April 2024. The purpose of this series is to introduce researchers to conducting economic evaluations of healthcare interventions in VA. |
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Register |
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Introduction to Markov Models for Cost-Effectiveness Analysis – Part 2 Markov models are used in health technology assessments to simulate the costs and benefits of a disease using transition health states. This two-day seminar will review the basics of the Markov model for pharmacoeconomic analysis. The seminar will also include a tutorial on how to perform a Markov model in Microsoft Excel. The second day of the seminar will go through the steps to construct a Markov model using Microsoft Excel. Audience members will be given access to the seminar files, which will be stored on the seminar’s GitHub site. Missed Part 1? View the archived seminar. |
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Advanced Decision Science Methods This seminar will review topics such as microsimulation, probabilistic sensitivity analysis, model calibration and validation, and introduce value of information. |
CEA Alongside a Clinical Trial Conducting a cost-effectiveness analysis alongside a randomized trial is possible, and with proper planning (and some luck) this approach offers some unique opportunities for health economics research. This presentation describes the steps needed for such an analysis. |
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Budget Impact Analysis for Implementation Science A budget impact analysis (BIA) estimates the cost to a health care system, or other payer, of adopting a new intervention over a short time horizon. A BIA includes implementation costs, intervention costs, and downstream costs. It can be done alongside a clinical trial to estimate the costs of adoption, should the new intervention be found both clinically effective and cost-effective. This cyberseminar will review the methods for a BIA, highlighting recent research in this area. |
Options for Evaluating VA Programs VA operational leaders often approach HERC asking for help conducting a cost-effectiveness analysis or a return on investment analysis of their program. Frequently, through discussion, we identify alternative study designs that better meet their needs. This cyberseminar is designed to describe the available options, so that researchers and operational leaders can more quickly pinpoint the study design that best suits their needs. |
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ResourcesNew Pages on the VHA Data PortalThe VHA Data Portal (VA intranet only) integrates information about VA data and resources for using the data into a single location. It is designed to be a one-stop-shop for data users' needs. VA data users can find 3 new pages on the VHA Data Portal: (All links are only accessible through the VA intranet)
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Data Q&AInflation Adjustment for VA Cost DataIs VA cost data inflation adjusted? All VA cost data (MCA, HERC Average Costs, and OMOP) are nominal values, i.e., the costs are in the year the data represents. Therefore, studies combining data across fiscal years should inflation adjust. How do you inflation adjust cost data? Researchers should typically use a price index to adjust costs, although the methods and index depends on your objectives. The Agency for Healthcare Research and Quality (AHRQ) Medical Expenditure Panel Survey (MEPS) has created a useful guide to help researchers determine the appropriate price index for health care cost data analyses.This guide includes the recommended index based on the analysis objectives as well as actual price indices for use in analyses. The guide "Using Appropriate Price Indices for Analyses of Health Care Expenditures or Income Across Multiple Years" is available on the AHRQ website. Do you have a question about using VA cost data? HERC offers consultations to VA data users on a variety of health economics and data topics. Visit the HERC website to learn more about our consulting service. |
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ResourcesFY23 Nosos Risk Scores AvailableNosos risk scores are now available for FY23. Nosos is the VA-specific risk score designed to predict costs. These annual risk scores reflect all the costs and care in a given year and can be used for risk adjustment in analyses using VA data. Learn more about Nosos in HERC's Guide to the Nosos Risk Adjustment Score. Nosos is available in CDW, and access can be requested through the Data Access Request Tracker (DART) Research Request process or VA's Electronic Permission Access System (ePAS) for operations. Information about DART and ePAS are available on the VHA Data Portal (VA intranet only). |
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