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15. VA Utilization and Patient Insurance Coverage: Variation Across VISNs
AM Hendricks, Center for Health Quality, Outcomes & Economic; JA Gardner, Center for Health Quality, Outcomes & Economic; Y Shen, Center for Health Quality, Outcomes & Economic; S Zhang, Center for Health Quality, Outcomes & Economic; LE Kazis, Center for Health Quality, Outcomes & Economic
Objectives: To demonstrate differences in the amounts and types of care received by VA patients with and without private health insurance and quantify overestimates of potential collections from third-party payers in prior forecasts.
Methods: We compared self-reports of Medigap and private health insurance coverage in the utilization module of the 1999 Large Survey of Veterans (n=152,258) with FY 1999 billing data from VA’s Revenue Office and self-reports of Medicare enrollment with rates from merged VA and Medicare utilization data. We compiled inpatient discharges and days of care by DRG (from the Patient Treatment Files) and outpatient procedures (Outpatient Visit and Clinic Stop Files) and valued them using VA’s reasonable charges for billing third-party payers.
Results: Survey respondents’ self-reported insurance status shows a high degree of validation from VA’s own billing information (90% of those billed in FY 1999 reported having billable insurance in that year). The self-reported rates of dual-eligibility in VA and Medicare are also similar to those from merged utilization data for 2 VISNs by age (< 65, >=65) and across VISNs as reported nationally. Based on self-reports, 47% of VA patients have third-party private health insurance: 53% of patients enrolled in Medicare have Medigap; 40% of those who are not in Medicare have private insurance. Controlling for Medicare status (which is due to age or disability), VA patients with private insurance tend to have better health status than other veterans (e.g., PCS scores are 3.6 points higher for patients with insurance compared to those without regardless of age (p < .001) and MCS scores are at least 5.0 points higher (p < .001). Patients with private insurance are admitted to VA hospitals less frequently (2.7% vs. 5.1% of the dual-enrolled; 11.6% vs. 14.7% of VA patients who are not in Medicare; p < .01) and have fewer outpatient visits (9.7 vs. 15.1 of the dual-enrolled; 8.2 vs. 13.9 of VA patients not in Medicare; p < .001) and procedures than those without other coverage. The value of VA inpatient care is equal for Medicare enrollees with and without Medigap (~$27,000 per inpatient per year), but two thirds more for non-Medicare VA enrollees without insurance ($22,502 per inpatient per year) as those with insurance ($13,541 pipy). Outpatient care for enrollees with private insurance has about half the value as that for enrollees without private insurance (about $2,000 compared to $3,800). Potential third party collections are now estimated to be roughly half of prior estimates, but this varies across VISNs.
Conclusions: Efforts to forecast VA alternative revenues from third party insurers have relied on estimates of the percent of veteran patients who have billable insurance (Medigap and other private insurance) based on the 1988 and 1992 National Surveys of Veterans. These forecasts have assumed an equal distribution of utilization between veterans with and without billable insurance and have overstated the potential amount to be collected from third party payers.
Impact: These results should lead to substantial adjustments in the target amounts for third-party collections across the VISNs.