RO Morgan, Houston Center for Quality of Care and Utilization Studies, Houston VAMC; BA Virnig, University of Minnesota; I Huang, Houston Center for Quality of Care and Utilization Studies, Houston VAMC; CA DeVito, Miami VA Medical Center

Objectives: Several approaches have been proposed to improve the integration of the VA and Medicare systems for veterans who are dually eligible. The more expansive of these approaches include provisions that would allow the VA to be reimbursed under Medicare+Choice or Medicare fee-for-service (FFS) for services provided to low VA service-priority, Medicare eligible veterans. It is unclear how this type of expansion might affect demand on the VA system. Thus, the objective of these analyses was to estimate the impact of expanding the availability of VA services to all Medicare eligible veterans on anticipated use of the VA system. Further, we determined if changes in anticipated use were related to veterans’ characteristics (age, income, distance from VA facilities, health status, perceptions of VA care quality) or type of Medicare enrollment (e.g., FFS versus HMO).

Methods: Data came from the South Florida Health and Health Services Use Survey conducted in early 1999. Data used here are for the 683 male VA-users and 483 male veteran "non-users" who completed the survey. "Non-users" were veterans with no VA use in the prior five years. Logistic regression, multiple regression, and contingency table analyses were used to examine the relationship between VA user status and veterans’ characteristics on reported likelihood of future VA use.

Results: Controlling for other model predictors, VA users were much more likely than non-users to anticipate using VA services over the next year (p <= .0001), as were veterans in poorer health (p <= .001), lower income veterans (p <= .008), and veterans who perceived the VA as providing higher quality care (p <= .0001). Medicare HMO enrollment lowered the level of anticipated use for VA users, but did not affect anticipated use for non-users (p <= .008 for the interaction between HMO enrollment and VA user status). Anticipated use increased dramatically among VA non-users when they were asked if they would use VA services if "VA facilities were open to any veteran with Medicare" (p <= .0001). There was no difference between FFS and HMO enrolled VA non-users in change in anticipated use, but HMO enrolled VA users increased significantly more than FFS enrolled VA users (p <= .02). Age, income, distance to VA facilities, health status, and attitudes regarding VA care quality did not appear significantly related to change in anticipated use.

Conclusions: Expanding VA coverage to include all Medicare eligible veterans dramatically increases anticipated use by VA non-users, while also increasing anticipated use by HMO enrolled VA users. Increases in anticipated use appear related to change in eligibility rather than to age, income, distance from VA facilities, veterans’ perceived health status, or perceptions of VA quality.

Impact: Extension of VA services to veterans who currently have low service-priorities is likely to significantly increase demand on the VA system. Given the demographic and health status differences between current VA users and non-users, it is probable that new VA system users would seek a different spectrum of services than current VA users.