IU School of Medicine, Kelley School of Business researchers examine impact of VA community outreach centers
An Indiana University School of Medicine professor is teaming up with IU Kelley School of Business faculty to help the Veterans Affairs (VA) Indiana Healthcare System determine the effectiveness of its Community-Based Outreach Centers (CBOCs), opened to serve the needs of veterans living in rural areas.
“I first worked with veterans as a medical student at IU when I had rotations at the VA Hospital in neurology and internal medicine,” said Gregory Katzman, MD, MBA, professor of clinical radiology and imaging sciences at IU School of Medicine. “The Indianapolis VA places a strong value on both education and research.”
More than 2,400 medical trainees rotate through the doors of Indianapolis’ Richard L. Roudebush VA Medical Center each year, noted Katzman, who became service chief of radiology there in 2019 when he joined the IU School of Medicine faculty. He previously was chief of radiology for the VA Salt Lake City Healthcare System while on faculty with the University of Utah, followed by faculty appointments with the University of Texas and the University of Chicago.
“I’ve spent a total of 11 or 12 years caring for veterans, plus my medical school rotations,” Katzman said. “It’s an interesting population. They’re now more geriatric than the general population, so you see more chronic diseases.”
That makes access to both primary and specialty care important. The Veterans Health Administration (VHA) has long allowed veterans to seek care from community providers on an exceptional basis, but in 2019, it launched the Veterans Community Care Program to expand options for veterans living far from VA medical centers or who could not be seen in a timely manner. Under the new guidelines, the Congressional Budget Office estimates that VHA’s costs for community care grew from $7.9 billion in 2014 to $17.6 billion in 2021, and utilization of care outside the VA system went from 1.3 million to 2.3 million veterans.
Along with budgeting issues, the increased use of private-sector care presents quality-of-care concerns; coordinated care becomes more difficult with providers who have not registered to use the VHA’s information sharing system. Risks of poorly coordinated care include repeated or unnecessary tests and inconsistent medical instructions.
To address these concerns, the VA Indiana Healthcare System has opened several community clinics, most recently in Edinburgh (2016), Shelbyville (2018) and Brownsburg (2021).
“Most of the VA systems around the country had the mindset of ‘build it, and make them come,’” said Katzman of the nation’s large, centralized VA systems. “The Indianapolis system has been pretty progressive in saying we need to go to them.”
While the benefits of community-based centers might seem obvious, the VA wants to make sure these CBOCs are doing what they’re designed to do—increase access to quality care. That’s where Katzman and his collaborators come in.
“We wanted to know what effect they have on rural veterans’ health, and secondarily, does opening a clinic in a rural area impact demand for services at the Indianapolis hospital?” said Rodney Parker, PhD, MSE, associate professor of operations and decision technologies at Kelley School of Business.
The research team also includes Kelley faculty Jonathan Helm, PhD, MS, MEng, and Kurt Bretthauer, PhD, MBA, along with Masoud Kamalahmadi, PhD, MSc, at University of Miami Herbert Business School, who started with the team as an IU Kelley PhD student.
“Our preliminary results show the opening of these CBOCs led to a 4-5% increase in the number of veterans enrolling in the system and the number who used services,” Kamalahmadi said. “That’s a good result. By opening these facilities, we were able to cover more veterans, especially those living in rural areas.”
A surprising result of their study was that opening the community-based centers did not decrease demand at the Indianapolis VA hospital, he added.
“This is potentially due to the limited services provided at CBOCs,” Kamalahmadi said. “The CBOCs allowed physicians to diagnose issues in more patients who might not have been diagnosed in the past because they were too far from the medical center. They diagnose them and then send them to the Indianapolis medical center for services not provided there.”
The next phase of the team’s research will examine trends in patient ZIP codes and delve into which health conditions are driving the most referrals to specialists at the Indianapolis medical center.
“The data suggests that opening an outpatient clinic does result in earlier intervention in veterans’ health by alleviating the hurdle of getting to Indianapolis for care,” Parker said. “Now we need to build a model and look at where the VA might want to build the next CBOC and which specialties should be offered. Indianapolis is also interested in telehealth because building hospitals is expensive.”
The Kelley faculty includes many researchers interested in improving health care operations, which pairs well with Katzman’s interests as a physician with an MBA. He co-leads IU School of Medicine’s Business of Medicine Scholarly Concentration program, offered statewide to medical students interested in learning how to improve medical outcomes, reduce costs and lift staff morale through innovative changes at the enterprise level.
“IU School of Medicine has been fairly visionary in that they have scholarly concentrations in multiple areas that allow medical students to dive deeper into specialty areas of interest,” said Katzman. “For me, I’ve always been interested in cool business operations questions.”
Katzman was eager to collaborate with Kelley researchers, who equally value Katzman’s contributions to the team.
“Greg has been great to work with—he understands our language, and he understand the VA’s language,” Bretthauer said. “We have a lot of skills to analyze data, but sometimes we need guidance to get to the right questions from someone who’s there. There’s a lot of value to add from having a physician on the team.”
Bretthauer said the study could have implications beyond the VA.
“We focused on the VA, but all large health care systems have these issues with access to care,” he said, “so what we’re doing is more powerful than just the VA.”