Diabetes Care in the Veterans Affairs System and in Managed Care

IN RESPONSE:

As we mentioned in our article, the VA's transformation was indeed based on many managed care principles, and as the largest integrated health care system in the United States, it could, as Dr. Patmas suggests, be considered the nation's largest managed care organization. This is precisely what makes the comparison between diabetes care quality in commercial managed care and in the VA so interesting—one can begin to think about the elements unique to the 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 (1), our study was, to our knowledge, the first to compare diabetes quality in the VA with that in high-performing commercial managed care organizations. The plans that participated in the Translating Research into Action for Diabetes (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. As we noted in our article, when the VA system was compared only with the TRIAD study staff-model plans that used electronic medical records, the findings were essentially the same. The authors of our article have a variety of affiliations, including academic institutions, the VA, and managed care organizations. Indeed, we made no attempt to discredit managed care, which performed very well in our 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 improve care quality for many patients with diabetes, whether they receive care in federally sponsored or commercial managed care organizations.