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Health Services Research & Development

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2008 HSR&D National Meeting Abstract

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National Meeting 2008

3075 — Access to Care and Sectoral Choice: Do Dually Eligible Veterans with Psychiatric Problems Use VA and Medicare Services as Substitutes or Complements?

Carey K ( Bedford COE), Montez M (Boston University School of Public Health), Rosen A (Bedford COE), Christiansen C (Boston University School of Public Health), Loveland S (Bedford COE), Ettner S (University of California Los Angeles)

Objectives:
To examine how service accessibility measured by geographic distance affects service sector choices for veterans who are dually eligible for VA and Medicare services and who are diagnosed with mental health and/or substance abuse (MH/SA) disorders.

Methods:
We identified dually eligible veterans who had either an inpatient or outpatient MH/SA diagnosis in the VA system during FY’99. We estimated one- and two-part regression models to explain the effects of geographic distance on both VA and Medicare total and MH/SA costs. Primary VA data sources were the Patient Treatment, Extended Care, and Outpatient Clinic files. VA cost data were obtained from 1) inpatient and outpatient cost files developed by the VA Health Economics and Resource Center and 2) outpatient VA Decision Support System files. Medicare data sources were the denominator, MEDPAR, Provider-of-Service, Outpatient Standard Analytic and Physician/Supplier Standard Analytic files. Additional sources included the Area Resource File and Census Bureau data.

Results:
Results provide evidence for substitution between the VA and Medicare, demonstrating that poorer geographic access to VA inpatient and outpatient clinics decreased VA expenditures but increased Medicare expenditures, while poorer access to Medicare-certified general and psychiatric hospitals decreased Medicare expenditures but increased VA expenditures. Practitioner density did not appear to affect the choice of sector.

Implications:
As geographic distance to VA medical facility increases, Medicare plays an increasingly important role in providing mental health services to veterans.

Impacts:
There is an increasing incidence of mental health problems among our newest veterans and an association between severe physical injury in this population and the prevalence of mental health diagnoses. Many of the newly disabled veterans will become dually eligible for VA and Medicare services. VA is currently grappling with the very difficult task of meeting the needs of returning OEF/OIF soldiers under conditions of strained resources. Results generated here suggest that distance from both inpatient and outpatient care may be an important factor for younger veterans in choosing to seek mental health care in VA. If returning veterans become eligible for Medicare on disability basis, the behavioral health services offered by Medicare may not compensate adequately for poor access to these services within VA.


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