2030. Does Establishing CBOCs
in Underserved Areas Impact Patterns of Utilization and Costs?
JC Fortney, Center for Mental Health and Outcomes Research, Central
Arkansas Veterans Healthcare System, ML Maciejewski, Northwest Center for
Outcomes Research in Older Adults, VHA Puget Sound Health Care System, JJ
Warren, Center for Mental Health and Outcomes Research, Central Arkansas
Veterans Healthcare System, JF Burgess, Management Science Group,
Department of Veterans Affairs, Bedford, MA
Objectives: To determine
how the establishment of new Community Based Outpatient Clinics (CBOCs) affects
service utilization and costs.
Methods: A
quasi-experimental pre-post study design was used to estimate the impact of
CBOCs for all existing users and for existing users with six ambulatory care
sensitive conditions: alcohol dependence, angina, COPD, depression, diabetes,
and hypertension. The intervention
group was defined as existing users in the catchment area of 15 new CBOCs, and
the reference group was defined as matched existing users outside CBOC catchment
areas. The intervention group
represents an intent-to-treat population because not all veterans in the
intervention group sought treatment at the CBOCs. Regression analyses were used
to estimate the impact of residing within the CBOC catchment area on utilization
and cost in the post-period, controlling for patient casemix and
utilization/cost in the pre-period.
Results: Existing users
in the intervention group traveled on average 42.9 miles to the closest VHA
facility in the pre-period compared to 19.1 miles in the post-period.
However, relatively few (18.1%) of the existing users in the intervention
group used services at CBOCs. Existing users in four of the seven intervention
groups (all-diagnoses, alcohol, COPD and hypertension) had a somewhat greater
number of primary care encounters than veterans in the reference groups
(p<0.01). However, there were
few differences in the number of specialty outpatient encounters, or inpatient
admissions. Compared to the reference groups, costs were significantly higher
for existing users in three of the seven intervention groups and significantly
lower in one of the seven intervention groups.
Conclusions: Results
indicate that while CBOCs improved geographic access to primary care, relatively
few existing users sought treatment from CBOCs.
Moreover, there were only modest increases in the use of primary care
services and there was no evidence that increased use of primary care services
reduced the use of specialty and inpatient care or decreased overall costs.
Impact: It appears that CBOCs are having only a modest impact on existing users in their catchment areas (mostly in terms of increased primary care encounters). VISN policy makers may have been establishing so many CBOCs in recent years because they attract new low cost users.