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2023 HSR&D/QUERI National Conference Abstract

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1183 — Community Care Emergency Room Use and Specialty Care Leakage from Veterans Health Administration Hospitals

Lead/Presenter: Kertu Tenso
All Authors: Palani S (Partnered Evidence-Based Policy Resource Center), Palani S (Partnered Evidence-Based Policy Resource Center) Garrido MM (Partnered Evidence-Based Policy Resource Center) Tenso K (Partnered Evidence-Based Policy Resource Center) Figueroa S (Partnered Evidence-Based Policy Resource Center) Pizer SD (Partnered Evidence-Based Policy Resource Center)

The Veterans Health Administration (VA) is a healthcare system that provides care to Veterans at its own medical centers and pays for services provided at hospitals outside its system. Care leakage, proportion of care received by VA beneficiaries from non-VA providers, can result in high healthcare cost to the VA, inefficient care delivery and poor health outcomes. Although emergency room visits (ED) to non-VA providers are believed to be a major source of specialty care leakage, the degree to which it occurs in practice is unknown. We investigated this association between Veterans’ non-VA emergency room visits and specialty care leakage to non-VA providers.

We used VA administrative and claims data from 2017 to 2019. VA-enrolled Veterans with at least one ED visit (either VA ED or non-VA ED) were included in the sample. Veterans’ first ED visit in 2018 was used as the index visit. The outcome variables – proportion of all specialty care visits and associated relative value units (RVUs ) (VA + non-VA) accounted for by non-VA providers within 30, 60, and 90 days from the index visit were calculated for each Veteran. Ordinary least square regression estimates are biased as unobserved patient characteristics can affect both non-VA ED and specialty care utilization simultaneously. For example, sicker patients are more likely to have more ED visits and specialty care visits at the same time. To isolate and estimate the effect of ED visit on specialty care visits, we used instrumental variables (IV) regression in which VA ED capacity is used as an instrument to estimate the likelihood of non-VA ED visit which is unaffected by any unobservable patient characteristics. We estimated the impact of non-VA ED visit on subsequent specialty care utilization using this IV model controlling for patient characteristics and facility fixed effects.

Of 1,235,936 Veterans with ED visits in 2018, 280,297 (22.7 %) Veterans had at least one non-VA ED visit with an average of 2.0 visits (SD = 2.37). The average proportion of non-VA specialty care visits within 30, 60, and 90 days among Veterans who had at least one non-VA ED was 44%, 40% and 37% respectively. We observed a positive association between non-VA ED visit and the proportion of specialty care visits in non-VA clinics. Compared to patients with no non-VA ED visits, patients with a non-VA ED visit had 36%, 34% and 32% more non-VA specialty care visits within 30, 60, and 90 days of ED index visit respectively. Compared to patients with no non-VA ED visits, patients with a non-VA ED visit had 35%, 33% and 31% more non-VA specialty care RVUs within 30, 60 and 90 days of ED index visit respectively.

Veterans who have a non-VA ED visit have a greater proportion of subsequent specialty care visits and associated RVUs in non-VA hospitals than Veterans with a VA ED visit. This relationship persists when we examine Veterans whose decision to go to a non-VA ED is influenced by VA ED capacity rather than general preferences for non-VA care.

To our knowledge, this is the first study to demonstrate that out-of-system emergency department use increases subsequent specialty care utilization in out-of-system hospitals. Health systems like VA and others may wish to minimize the out-of-system or out-of-network specialty care visits of their beneficiaries, because they have less control over the content, cost, and quality of out-of-system care. The findings may be of interest to managers of VA and other integrated healthcare systems who intend to reduce care leakage from their systems.