2023 HSR&D/QUERI National Conference

1052 — Payer Shifting After Expansions in Access to Private Care Among Veterans Affairs Health Care System Enrollees

Lead/Presenter: Liam Rose,  Resource Center - HERC
All Authors: Rose LF (Health Economics Resource Center), Tran LD (Health Economics Resource Center) Vashi A (Center for Innovation to Implementation)

Recent policy changes in the Veterans Health Administration (VA) greatly increased access to care purchased from non-VA providers. VA costs have increased dramatically, but it is unknown if this increased access affected overall utilization and payer mix between VA and other health insurance for VA enrollees. We investigate whether the implementation MISSION Act increased overall utilization or induced a shift in primary payer mix for acute care among VA enrollees.

We use a difference-in-differences analysis comparing VA enrollees to the general population before and after the implementation of the MISSION Act in June 2019. We take all emergency department (ED) encounters in the state of New York in 2019 and examine changes in acute care utilization and proportion of encounters paid by specific payers.

Among 5,577,199 ED visits in the sample, 4.9% (n = 253,799) were with VA enrollees. Of these, 44.9 percent of visits were paid by Medicare, 32.8 percent occurred in VA facilities, and 7 percent were paid by private health insurance. There was a 6.4% (2.91 percentage points; std. error = 0.18; p < 0.01) decrease in the proportion of ED visits paid by Medicare among VA enrollees relative to the general population after the implementation of the MISSION Act in June 2019. This decrease was larger for ED visits with a subsequent inpatient admission (-8.4%; 4.87 percentage points; std. error = 0.33; p < 0.01). There was no statistically significant change in the total volume of ED visits (0.06%; std. error = 0.08; p = .45).

VA policy changes intended to increase access to care were associated with a change in the payer of acute care and not associated with a change in the number of encounters.

Evidence of payer shifting is of immediate fiscal concern as VA faces a rapidly growing role as a payer of private sector care. VA’s efforts to expand access to non-VA providers may require substantial additional resources as fiscal burdens are shifted from other health insurance programs to VA.