We are constantly faced with the decision either to produce an item or service internally or buy it externally from another source. Health care systems are faced with the same dilemma.
Key Factors in the decision-making process may include:
1. Doing a cost-benefit analysis of making or providing the service (lower cost, higher quality, patient-specific needs)
2. Advantages of buying or outsourcing (low volume, unique technical needs patient convivence)
Historically, Veteran Health Affairs ( VHA) navigated the balances related to doing a cost-benefit analysis of making or providing the service (lower cost, higher quality, patient-specific needs) or buying or outsourcing (low volume, unique technical needs patient convivence).
Expansion of primary care and mental health at every medical center and the community-based outpatient clinic was an investment worth making the goal was to make services available everywhere.
Veterans had to travel great distance but it worth it when measured to the level of high-quality medical care they received. For instance, the regionalization of organ transplantation, cardiac procedures, and polytrauma centers were thoughtful decisions that supported specialized expertise. Additionally, community care for obstetrics and radiation oncology were thoughtful motives and acquiring decisions.
A key point to be considered is the middle- ground involved in partnering in buying or make decisions. Here we look at VHA, which comprises of regional variations in supply and demand. VHA has strong partnerships with academic medical centers in training healthcare professionals, and providing veterans with world-class expertise, particularly in highly specialized medical care that would not have been possible without partnerships from academic medical centers.
Veterans access to care has proven to be beneficial through close partnerships with the Department of Defense, Indian Health Service, and other local providers and healthcare systems.
The Veterans CHOICE and MISSION Acts on the “make side’’
The Veterans CHOICE and MISSION Acts have created new opportunities for VHA to evaluate past make or buy decisions and propose new models to advance access to care from both the subjective patient perspective and the objective costs and wait times.
Note the “make” side of the Act enhances capacity by recruiting and retaining health care professionals. VHA has been successful in improving its access to telemedicine through teledermatology, and recently tele hospitalists.
It is key that careful attention must be paid to when providing care so that the level and quality of care can be measured, maintained and improved. The MISSION Act has the potential to facilitate both the make and buy decisions for VHA. We need better provisions to accomplish funding in order to make better buying and making decisions.
The Veterans CHOICE and MISSION Acts on the “buy side’’ a key provision authorizes local provider agreements. The providers are cognizant of the related expertise and capacity is available and where. Third-party providers take great strides to foster relationships in communities. Building these relationships is mutually beneficial for community and VA providers, but most importantly they benefit the patients. The provider and patient education advance the scheduling systems, and improve health information exchange and will help facilitate the buying side of decision making.
One of the objectives behind the provision to establish criteria of providers to Veterans, specialties provided, and local community resources and wait time metrics. Care is needed to ensure we create a cost-effective solution, and simplify complex issues, particularly in rural areas.
In the context of the MISSION ACT, a key question is “How do we deliver specialty care services”, this question requires an approach beyond that of current delivery models. Currently proposed benchmarks continue to reflect the belief that acting within predefined terms timeframes will drive high-quality access and satisfy the needs of patients. This construct is a fallacy because fixed times don’t always align with patient preferences.
VHA Needs A Result Oriented Approach
Notably, the goal of VHA is to deliver highly effective, quality care in efforts to achieve favorable outcomes. Taking this approach into consideration VA needs to develop a conceptual model of specialty care access that is of high quality and cuts through on whimsical timelines
 Kuhn E, et al. “Preliminary Evaluation of PTSD Coach, a Smartphone app for Posttraumatic Stress Symptoms,” Military Medicine 2014; 179: 12-8