VA health economist and team strive to make agency more efficient, effective
August 13, 2020
By Mike Richman
VA Research Communications
"Ultimately, by making VA more effective and efficient, our work benefits Veterans."
Dr. Austin Frakt is one of VA’s leading voices on improving the efficiency and effectiveness of the agency’s policies and programs.
Frakt, a health economist at the VA Boston Healthcare system, heads the Partnered Evidence-Based Policy Resource Center (PEPReC). The program provides rigorous data analysis to support key policy, planning, and management initiatives and program evaluations on such topics as access to care, productivity, supply and demand, resource targeting, and the quality and value of treatment. PEPReC also helps monitor and evaluate impacts of major agency investments, such VA’s new electronic health record system (CERNER).
At a time when demands on the VA budget are growing fast, VA policymakers and managers are tasked with improving access to and quality of VA care. They also facilitate Veterans’ choices of non-VA care through initiatives such as the VA MISSION Act. There is thus an urgent need for evidence-based policy, planning, and management to accurately forecast the demand for VA care; deploy resources where they are most needed; monitor performance, including access to care; and make sound decisions about new investments. That’s where PEPReC plays a critical role.
Dr. Austin Frakt directs VA's Partnered Evidence-Based Policy Resource Center.
Dr. Austin Frakt directs VA's Partnered Evidence-Based Policy Resource Center.
In addition to his VA responsibilities, Frakt writes about U.S. health care trends for The New York Times and is co-editor in chief of The Incidental Economist, a health services research blog. His research interests include the interaction between economics and health care policy in Medicare and VA, with a focus on patient choice, insurer and health system decision making, health and market outcomes, and cost-effectiveness.
He’s also an associate professor in the Department of Health Law, Policy, and Management at Boston University’s School of Public Health and is a senior research scientist at the Harvard T.H. Chan School of Public Health.
Frakt spoke with VA Research Currents:
Tell us a bit about the history of PEPReC.
PEPReC grew out of a smaller VA health economics research group that I had been a part of since 2003—Health Care Financing & Economics (HCFE). It was led by Dr. Ann Hendricks, followed by Dr. Steven Pizer. Steve is now PEPReC’s chief economist and a professor at the Boston University School of Public Health. When HCFE became PEPReC, it was first led by Dr. Julia Prentice. I took over in 2017.
I enjoy working collaboratively with and learning from close colleagues Dr. Melissa Garrido, PEPReC’s associate director, and Steven Pizer. Drs. Garrido and Pizer and I are supported by a very talented team of junior investigators, data and policy analysts, and administrative staff that keep everything going. As is true of all good things and important institutions, this is a team effort. I did not build and could not sustain PEPReC on my own.
How does your group’s work improve the lives of Veterans?
Although we are not involved in clinical work, most of our studies are focused on improving the lives of Veterans, either directly or indirectly. For example, we are now studying Veteran access to care, opioid use management, and suicide prevention. For the most part, our work helps refine policy and the management of programs. Ultimately, by making VA more effective and efficient, our work benefits Veterans.
How does health economics figure in the work of PEPReC?
Because PEPReC is run by health economists and grew out of a health economics research group, PEPReC’s work is quantitative. Moreover, we strive to learn how changes to VA programs causally impact VA care and outcomes. Health economics—and economics in general—has a body of methods for causal estimation, particularly in circumstances where a randomized evaluation is not feasible. Though we are also engaged in randomized program evaluations, my expertise with these observational methods, and to a larger degree the expertise of my PEPReC colleagues, is the backbone of much of our work.
Please give some examples of PEPReC’s projects.
There is major overlap in our projects that isn’t apparent from the outside. For instance, one of our overarching themes is studying Veterans’ access to care. In support of the VA MISSION Act, which gives Veterans greater access to health care in VA facilities and in the community, we developed a novel approach to measuring access to primary care through statistical modeling using the economic principles of supply and demand. The model enabled PEPReC to rank 128 VA medical centers according to their ability to meet the demand of their enrolled Veterans for VA care. The model will be refined annually based on new and improved data and feedback from national and local VA leaders. Some of our work for VA’s Office of Policy and Planning and its Office of Finance looks at budget impact assessments of alternative access standards required by the MISSION Act. For the Office of Community Care, PEPReC developed a method to calculate wait times for community care.
What are some of the challenges you face in your work?
The most challenging type of issue we encounter on many operations-partnered projects is matching scientific rigor with the necessities of operations. This requires flexibility on both sides and a lot of creative thinking and communication. There is a lot of behind-the-scenes-work to just get these kinds of projects underway and keep them on the rails. That never makes it into scholarly publications.
Some of your projects involve randomized program evaluations (RPEs). What are RPEs and why are they important?
Randomized program evaluations (RPEs) are considered the best approach to estimate the effect of a program or strategy because they control for observable and unobservable characteristics of subjects. The RPEs we are involved in rigorously evaluate VA health care initiatives. They are aimed at improving the care Veterans receive and the efficiency with which it is delivered. We help researchers during the design phase of the project and with data analysis and evaluation.
In an RPE led by Dr. Mark Reger of the VA Puget Sound Health Care System, PEPReC is leading the design and quantitative analysis of the randomized evaluation of a VA suicide prevention program that involves caring letters. Caring letters are a series of nine letters sent over one year that list VA resources and express support to Veterans who call the Veterans Crisis Line. In partnership with investigators from VA’s Quality Enhancement Research Initiative (QUERI) and VA’s Office of Mental Health and Suicide Prevention, PEPReC plans to evaluate whether letters signed by a peer rather than a provider are more likely to improve mental health outcomes for letter recipients.
Another RPE focuses on reducing the risks of opioid prescriptions. The Stratification Tool for Opioid Risk Mitigation (STORM), developed by the Office of Mental Health and Suicide Prevention, is a dashboard to help inform VA clinicians of opioid-prescribed patients at high risk of adverse events. Features of the dashboard were rolled out across VA medical centers in a randomized fashion in 2018 and 2019. PEPReC’s ongoing evaluation is assessing the effects of STORM on care management, the use of mitigation strategies to reduce adverse events from opioid prescriptions, and adverse event rates.
Our immediate goal is to promote the use of rigorous evidence in urgent, high-impact VA policy and management decisions. We do that by partnering with national program offices and research groups on the design of evaluations and valid performance metrics. We also carry out key evaluations and technical assistance projects that fall into our priority areas, including access to care, opioid risk mitigation, suicide prevention, clinic efficiency, and MISSION Act implementation.
We hope to someday expand our activities as part of VA's implementation of the Foundations for Evidence-Based Policymaking Act, which requires ongoing reporting to the Office of Management and Budget on learning agendas and evaluation plans. In partnership with the VA Office of Enterprise Integration and QUERI leaders, we are developing the first generation of these reports, along with procedures and materials to facilitate future targeted evidence generation projects that rapidly link researchers with high-priority national program and policy issues.
What motivates you to blog about U.S. health care issues?
I write to help me understand. I simply can’t work out what I think is the truth about health care issues unless I write it out. My favorite issues to write about are those I haven’t written about before. I’m always seeking to expand the breadth of issues I have some facility with. I love new challenges.
Most recently, I started writing about racism and its consequences for health. That topic and many others that I write about affect Americans broadly, not just Veterans. Though there are Veteran and VA-specific issues—and VA is a unique population and health care system—few general aspects of health care are relevant only to Veterans. So when I write about an American health care issue like racism, I’m still writing about topics of relevance to Veterans.