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BACKGROUND/RATIONALE:
Many veterans enrolled in VA healthcare also use private sector care, often more than the VA. Beyond specific medical needs, a veteran's reliance on VA versus non-VA care may depend on factors such as VA priority status, income, and insurance coverage, as well as proximity to needed services, which may be especially problematic for rural veterans. The dual use of medical systems raises several issues, such as continuity of care, the risks of redundant or conflicting treatments, and potential increased costs overall. Medicare coverage, which begins for most at age 65, is a primary factor in healthcare financing, and may increase veterans' use of private sector care. The proportion of VA enrollees who are younger than 65 is growing rapidly, yet we know very little about their reliance on VA versus private sector care. The VA obtains discharge data for all Medicare-funded private sector hospitalizations its enrollees undergo, but not other non-VA admissions. Sources of more comprehensive private sector utilization data, covering veterans of all ages, are very few, and the research literature is small. We propose to acquire administrative discharge data from several states, and national survey data, to fully represent the private sector hospitalizations for all VA enrollees, regardless of age or insurance coverage.
OBJECTIVE(S):
We will address three major research questions: 1) For which major diagnostic or medical service / procedure categories do VA enrollees obtain more inpatient care in the VA or in the private sector?; 2) Within each major diagnostic or service category, how much are insurance coverage, income, rural residence, proximity to care, and other individual characteristics associated with greater reliance on the private sector?; and 3) How well do free, readily obtainable national patient surveys represent the utilization, payers, and costs of veterans' private sector hospitalizations as well as the effects of patient characteristics on private sector reliance? A primary objective is to develop a comprehensive database spanning several recent years of a) discharge information for all VA enrollees living in several states, and b) national health survey data, including perceptions of access and costs, for enrollees' private sector hospitalizations, that will support multiple utilization and quality studies.
METHODS:
This is a retrospective, cross-sectional study comparing existing VA and private sector hospitalization data for VA enrollees. Data sources, spanning several recent years, will be of two types: a) administrative hospital discharge data for all VA and non-VA admissions obtained by VA enrollees living in nine states (including at least 1 million admissions), and b) hospital use and cost data from national surveys of healthcare consumers that include VA users (with several thousand admissions). Comparisons of utilization, health status, and payment information will be conducted for major diagnostic and service categories, accounting for the influences of age, VA priority status, Medicare or other insurance coverage, income, urban or rural residence, and distance to care. Analyses also will compare utilization estimates for major diagnostic and service categories derived from national health surveys to counts from administrative discharge data, to determine how well the inexpensively monitored surveys reflect the more costly discharge data.
FINDINGS/RESULTS:
Several papers have been generated from this project, including the following:
West AN, Weeks WB. Who pays when VA users are hospitalized in the private sector? Evidence from three data sources. Medical Care, 2007, 45, 1003-1007.
Abstract
Background: Older veterans enrolled in VA healthcare receive much of their medical care in the private sector, through Medicare. Less is known about younger VA enrollees' use of the private sector, or its funding. We compare payers for younger and older enrollees' private sector use in three hospitalization datasets.
Research Design: From 1998-2000 private sector discharge data for VA enrollees in New York State, we categorized hospitalizations according to payer (self/family, private insurance, Medicare, Medicaid, other sources). We compared this payer distribution to population-weighted national Medical Expenditure Panel Survey data for 1996-2003 for veterans in VA healthcare. We also compared Medicare utilization in either dataset to hospitalizations for New York veterans, 1998-2000, in the VA-Medicare dataset. Analyses separated patients younger than 65 from those 65 or older.
Results: VA enrollees under 65 obtain roughly half their hospitalizations in the private sector; older enrollees use the private sector at least twice as often as the VA. Datasets generally agree on payer distributions. Though older enrollees rely heavily on Medicare, they also use commercial insurance and self/family payments substantially. Half of younger enrollees' non-VA hospitalizations are paid by private insurance, but Medicare, Medicaid, and self/family each pay for one-quarter to one-third of admissions.
Conclusions: VA enrollees use the private sector for most of their inpatient care, which is funded by multiple sources. Developing a national UB-92/VA dataset would be critical to understanding veterans' use of the private sector for specific diagnoses and procedures, particularly for the fast growing population of younger veterans.
These findings also were presented at this meeting:
West AN, Weeks WB, Bagian JP. Comparing three datasets on payers for the private sector inpatient care of VA patients. American Public Health Association 135th Annual Meeting & Exposition, Washington, DC, November 3-7, 2007.
Another paper was the following:
West AN, West PA, Weeks WB. Disparities in healthcare utilization among rural
veterans who use VA care. AcademyHealth 2008 Annual Research Meeting,
Washington, DC, June 9, 2008.
Abstract
Research Objective: To compare military veterans in VA healthcare with other healthcare-using veterans and non-veterans to assess disparities in healthcare coverage and utilization related to age and residence beyond urban areas.
Study Design: Retrospective study of patient survey data on healthcare utilization and costs, involving both cross-sectional and longitudinal comparisons of distinct subject groups. Statistical procedures applied sample weights and accounted for survey design (PSUs and strata) to yield corrected standard errors for utilization proportions and expenditure means. Trends over time were assessed with regression models. To correct for multiple comparisons, differences were considered statistically significant only if 99% confidence intervals did not overlap.
Population Studied: Adult male respondents who reported using any healthcare (i.e., annual medical expenditures > $0) in any of nine years (1996-2004) of the national Medical Expenditures Panel Survey of the civilian non-institutionalized US population. For comparisons, they were separated into a) veterans who used any VA healthcare, veterans who did not use VA care, or non-veterans; b) men younger or older than 65; and c) men living in urban (MSA) or rural areas. Analyses were limited to males because veterans and VA users are predominantly male.
Principal Findings: Between the earlier and later years, the proportion of veterans receiving VA care increased from less than 30% to nearly 50%, reflecting changes in VA enrollment criteria. In either age group, rural veterans were consistently more likely to be in VA care; those older than 65 showed the highest proportion using VA care each year, and they were the most likely to use at least $1000 of VA care in a year. Average annual medical expenditures for VA users were more than $3000 higher than for other veterans or non-veterans, regardless of age or residence group, reflecting their substantially greater healthcare needs. But the VA's portion of these expenditures averaged only about 15-20% of total expenses; even among veterans who used at least $1000 of VA care per year, VA provided less than half of their total medical care. For VA users older than 65, as for other men in that age group, Medicare paid more than half their expenditures, but private insurance and payments by self or family also were substantial. Among men younger than 65, private insurance was the biggest payer, even among VA users, although rural VA users averaged $1000 less in private insurance payments than their urban counterparts, and overall received less care despite comparable health status. For rural VA users younger than 65, VA has provided a steadily increasing percent of their medical care in recent years (to above 40% of all expenditures in 2004), whereas for other users this percentage has been more stable, around 25%.
Conclusions: VA's share of the healthcare market for veterans has increased, particularly among rural residents, but it still provides a small portion of their total care. Among men younger than 65, rural veterans are at a disadvantage for lack of adequate private insurance coverage.
Another paper is currently under review:
Healthcare Expenditures for Urban and Rural Veterans in VA Care
Abstract
Objective: To compare VA patients, non-VA using veterans, and non-veterans on their use of major categories of medical care and payment sources.
Data source: Medical expenditures for adult healthcare-using males in the Medical Expenditure Panel Surveys from 1996 through 2004, separated into non-veterans, veterans not in VA care, and veterans who received any care from the VA, by residence (urban or rural) and age group (younger or older than 65 years).
Study design: Retrospective, cross-sectional analysis.
Data collection / extraction methods: Controlling for demographics, health status, and insurance coverage, we compared groups on population-weighted annual health care expenditures in major care categories (inpatient, outpatient department / emergency room, office-based, pharmacy, and other care) and by major payer categories (self / family, private insurance, Medicare, other sources, and the VA).
Results: VA users get most of their care through private insurance or Medicare, and their self-payments are substantial. Though they report worse health than urban users, rural VA users under 65 have lower expenditures and get less care through private insurance.
Conclusions: VA healthcare users get most of their medical care from non-VA providers. Working age VA users, however, are relatively more reliant on VA care if they live in rural areas, apparently due to having less commercial insurance coverage.
Additional papers on time trends and expenditures for family members of veterans in VA care are currently in preparation.
IMPACT:
VA enrollees use the private sector for most of their inpatient care, which is funded by multiple sources. VA's share of the healthcare market for veterans has increased, particularly among rural residents, but it still provides a small portion of their total care. Working age VA users, however, are relatively more reliant on VA care if they live in rural areas, apparently due to having less commercial insurance coverage.
PUBLICATIONS:
None at this time.
DRA:
Aging and Age-Related Changes, Health Services and Systems
DRE:
Quality of Care, Resource Use and Cost
Keywords:
Access, Cost, Utilization patterns
MeSH Terms:
none
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