Eve A. Kerr, MD, MPH; Robert B. Gerzoff, MS; Sarah L. Krein, PhD, RN; Joseph V. Selby, MD, MPH; John D. Piette, PhD; J. David Curb, MD, MPH; William H. Herman, MD, MPH; David G. Marrero, PhD; K.M. Venkat Narayan, MD, MSc, MBA; Monika M. Safford, MD; Theodore Thompson, MS; Carol M. Mangione, MD, MSPH
Kerr EA, Gerzoff RB, Krein SL, Selby JV, Piette JD, Curb JD, et al. Diabetes Care Quality in the Veterans Affairs Health Care System and Commercial Managed Care: The TRIAD Study. Ann Intern Med. 2004;141:272-281. doi: 10.7326/0003-4819-141-4-200408170-00007
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Published: Ann Intern Med. 2004;141(4):272-281.
*Patients receiving care in one of the Translating Research into Action for Diabetes (TRIAD) study health plans or Department of Veterans Affairs (VA) health care systems and who had diabetes diagnosis based on the following criteria: a diagnostic code for diabetes (for example, 2 or more outpatient visits with an associated diabetes code [International Classification of Diseases, Ninth Revision, 250. ] or 1 or more inpatient stays with an associated diabetes code); a laboratory value suggestive of diabetes (for example, 2 or more hemoglobin A1c tests or diagnostic levels of hemoglobin A or fasting blood glucose); or a prescription for medications for diabetes (for example, insulin or an oral antidiabetic agent). †At the time of the survey, patients who met the initial criteria were included only if they verified that they had diabetes and received most of their diabetes care through the participating TRIAD health plan or a participating VA facility. CMC = commercial managed care.
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Michael A. Patmas, MD, MMM, FACP.
Providence Medical Center. Portland, Oregon.
August 19, 2004
VA vs. "Managed Care"
Kerr and colleagues article in the August 17, 2004 issue of AIM comparing diabetes care in the VA system with "managed care" reflects a deep misunderstanding of what is meant by managed care. Further, their conclusion is self serving and misleading to the readership. The VA system is, in fact, the largest managed care organization in the country. Analagous to a staff model HMO, the VA benefits from having enterprise wide electronic medical records, employed physicians with restrictive formularies and direct control over the practice patterns of those doctors through mandated use of practice guidelines. Commercial managed care plans rely upon contracted physicians who are generally in private practice, are unlikely to have electronic records and are much less under the control of the plan. To draw comparisons between these two widely disparate types of managed care organizations and conclude that a federally sponsored national health care organization would be superior to "managed care" is disingenuous. They should have included a comparison of both models to a completely unmanaged fee for service setting, data for which is available. The VA system is a managed care organization in every sense of the word. If the VA's clinical outcomes are indeed better, they likely stem from the higher intensity of management of care afforded by having greater control over employed physicians. The more accurate conclusion is that managed care improves diabetes quality measures over unmanaged care and that those improvements are related to the intensity of management afforded by the specific model of managed care. Kerr and colleagues attempt to discredit managed care actually makes the case for it. Michael A. Patmas, MD, MMM, FACP. Providence Portland Medical Center Portland, OR. 97213
Eve A. Kerr
VA Ann Arbor Healthcare System and the University of Michigan
October 13, 2004
Re: VA compared to Commercial Managed Care
As we mentioned in our article, the VA's transformation was indeed based on many managed care principles, and as the largest integrated healthcare system in the nation, it could, as Dr. Patmas suggests, be considered the nation's largest managed care organization (1). This is precisely what makes the comparison between diabetes quality in commercial managed care and in the VA so interesting - - one can begin to think about the elements unique to VA that may have further enhanced quality beyond the strategies espoused in the commercial managed care plans. While comparisons between VA and non-managed care systems had previously been published (2), this was the first study to compare diabetes quality in VA to that in high-performing commercial managed care organizations. The plans that participated in the TRIAD study reflected a full spectrum of practice arrangements, including group and staff model plans with employed physicians, network model plans with large and small contracted group practices, and individual practice associations (IPAs). As we noted in the manuscript, when the VA system was compared only to the TRIAD study staff model plans with electronic medical records the findings, were essentially the same. The authors of this article have a variety of affiliations, including of academic institutions, the VA and managed care organizations. Indeed, we made no attempt to discredit managed care, which performed very well in this study by all commercial standards. Rather, we called for further research to examine how specific organizational factors, such as the intensity of management, influence care quality and for a deeper understanding of which VA investments may be worth translating to commercial managed care. These types of investigations could serve to improve care quality for many patients with diabetes, whether they get care in federally sponsored or in commercial managed care organizations.
Cardiology, Coronary Risk Factors, Diabetes, Endocrine and Metabolism, Healthcare Delivery and Policy.
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