JB Macdonald, Center for Health Quality, Outcomes, & Economic R; AM Hendricks, Center for Health Quality, Outcomes, & Economic R

Objectives: This project examined the profile of VHA users from baseline FY1996 through FY1998 related to VISN-level factors hypothesized to have provided incentives for change in order to determine the extent to which the VHA safety net changed following reorganization of eligibility, resource allocation, and third-party billing.

Methods: For each study year, we classified patients as using the VHA as a safety net (a "safety net veteran") if 1) they lacked evidence of alternative coverage (<65 and with no bill to an insurer from VHA’s cost recovery office) or 2) they had high mental health use (which is not extensively covered by other payers). We then determined changes in the number of safety net veterans among new patients (no VHA use in the previous three years). We compared changes in the quantity of care provided to safety net veterans to that provided to other veterans in terms of 1) outpatient stops, 2) outpatient stops with a psychiatric code, 3) inpatient bed days and 4) bed days in a psychiatric bed section. We estimated factors accounting for variation in safety net care across VISNs.

Results: Safety net veterans are always more than half of the VHA population (57% in FY1996). Despite the overall growth in the number of VHA patients (from 2.49 million in FY1996 to 2.86 million in FY1998), safety net veterans declined slightly. Safety net patients differed from all patients in that they were 1) more likely to be female (6% compared to 4%), 2) younger (mean age 50) and 3) less likely to be eligible for VHA services on the basis of income (p< .001). Changes in the amounts of care were less for safety net veterans.

Conclusions: Between FY1996-1998 the VHA’s commitment to being a safety net for veterans remained intact. While there has been increased use of the VHA, there has also been an overall increase in the absolute number of safety net veterans treated. Any changes in the amount of care provided to veterans have been less for safety net veterans.

Impact: Because changes in VHA eligibility, resource allocation and third-party billing are so recent, very little research analyzes their effects on VHA health services. Understanding these effects will help the VHA clarify its role as a provider of health care to the most vulnerable veteran populations. In addition, because this analysis includes VHA health and mental health care users of both genders from all age groups and from all regions of the country, effects of VHA changes on certain groups can be determined as well as their reliance on the VHA as a safety net.