Health Services Research & Development

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Research into Veterans' Dual Use of Healthcare Coverage

August 2016


Millions of Veterans are eligible for healthcare services covered by their Veterans Administration (VA) benefits, and by other insurance, such as Medicare or a private healthcare plan. As a result, many Veterans use more than one healthcare option for different services, referred to as dual use.

With dual use, Veterans may experience positive healthcare interactions where providers connect and share important information. However, having and using healthcare coverage through more than one benefit plan may result in challenges ranging from poorly coordinated care to duplicated prescriptions to increased costs. Therefore, providing evidence-based data that supports all of a Veteran's options for care becomes increasingly important.

Investigators with VA's Health Services Research and Development (HSR&D) Service conduct research that examines many aspects of dual use, including health outcomes, health policy, and economic impact. The following studies represent just a few of the completed and ongoing HSR&D-funded research around the practice of Veterans' dual use.

Health Policy Implication of Dual Enrollment in the VA and Medicare Advantage

Many Veterans receive healthcare coverage through both the VA Healthcare System and a Medicare Advantage (MA) health plan. (The Centers for Medicare & Medicaid Service administer MA plans through contracts with private insurers.) While VA may collect reimbursements for care provided to VA users enrolled in private health plans, federal law prohibits VA from collecting any reimbursements from Medicare-financed health plans. As a result, this dual enrollment may result in redundant federal reimbursement for healthcare services. Further, when Veterans seek care both within and outside of VA, the potential exists for that care to be uncoordinated or fragmented. In this study, investigators conducted a comprehensive, national assessment of the economic and clinical consequences of dual enrollment in VA and MA.

Investigators looked at 12 national VA and Medicare clinical and administrative datasets from 2004 through 2013 to determine the total population of all VA enrollees who were simultaneously enrolled in a Medicare Advantage plan. Results showed:

  • Of 6,643 individuals who were dually enrolled in VA and MA, 1,637 (25%) exclusively received VA outpatient care, with an average of 27 annual VA outpatient visits. The remaining 5,006 (75%) received outpatient services in both VA and MA, and on average had 15 annual VA outpatient visits and 9 annual MA outpatient visits.
  • VA-only users were more likely to be younger (69 years vs. 71) and non-white (21% vs. 11%) than dual VA-MA users, and were also more likely to have high VA priority enrollment status (77% vs. 60%) and to be enrolled in Medicaid (2% vs. 1%) or a special needs plan (8% vs. 6%).
  • On average, VA-only users had more comorbid conditions than dual VA-MA users (4.7 conditions vs. 3.8).1

Implications: These study data have considerably advanced the evidence base around financing and delivery of healthcare for Veterans who are dually enrolled in VA and MA. Study results were leveraged by the General Accounting Office in an investigation of the economic implications of dual enrollment in VA and MA.

Principal Investigator: Amal Trivedi, MD, MPH, is an investigator with HSR&D's Center of Innovation in Long-Term Services and Supports for Vulnerable Veterans in Providence, RI.

Cooper AL, Jiang L, Yoon J, Charlton ME, Wilson IB, Mor V, Kizer KW, Trivedi AN. Dual-System Use and Intermediate Health Outcomes among Veterans Enrolled in Medicare Advantage Plans. Health Services Research. 2015 Dec 1; 50(6):1868-90.

Dual Use of VA and Non-VA Healthcare Services among Veterans Younger than 65

Veterans living in rural areas who are enrolled in VA care typically travel some distance in order to reach a healthcare provider. These kinds of travel-related access to care challenges can have wide-reaching impact, including: reduced overall use of care, lack of coordination in care, poorer health outcomes, and an increased likelihood of using non-VA care—particularly when compared to Veterans dwelling in more populated areas. To promote care coordination and optimize resource use, it is important to know how VA enrollees use non-VA healthcare, i.e., how much and for which needs. While many investigations have looked at dual use among VA and Medicare-eligible Veterans, less evidence exists regarding working-age, rural-dwelling VA enrollees who use non-VA healthcare through commercial insurance.

In this study, investigators looked at administrative data from 2001-2011 that was associated with VA enrollees (under age 65) living in Iowa, South Dakota, New Hampshire, and Maine in order to determine how use of VA or non-VA care relates to Veterans' medical conditions, types of services received, their travel burden, insurance coverage, and priority for VA care. Investigators also assessed the treatment needs and services obtained by dual users as compared to other Veterans with regard to duplicated or conflicting treatment.

Results indicated that rural-dwelling Veterans under age 65 who are dual users (enrolled in VA healthcare and a commercial healthcare plan) obtain most of their healthcare from non-VA providers. Further, these dual users had more diagnoses and procedures than other patients. Further, many dually-eligible patients used both VA and non-VA healthcare concurrently, but generally not for the same conditions. Overall, dual users had treatment visits more often than other patients, but within either care system they were seen less often, particularly if they were rural residents living far from care. For most diagnoses or procedures, rural residence did not affect the likelihood that dual users were treated, but it did lower the chances of treatment for visual acuity problems, anxiety, or injury, or of receiving rehabilitation services, behavioral medicine, and some screening and diagnostic tests.

Implications: For Veterans under age 65 who engage in dual use, this study has considerable implications, particularly with regard to the potential for conflicting or inadequate care

Principal Investigator: Alan West, PhD, is an HSR&D investigator and health scientist at the White River Junction VA Medical Center, and is a staff member with VA's Office of Rural Health, Eastern Region.

West AN, Charlton ME, Vaughan-Sarrazin M. Dual use of VA and non-VA hospitals by Veterans with multiple hospitalizations. BMC Health Services Research. 2015 Sep 29;15:431.

Dual Use of VA and Medicare Drug Benefits and Unsafe Prescribing in Veterans with Dementia

VA estimates that more than 570,000 Veterans have dementia, and of those, approximately 40 percent seek care in VA medical facilities. Care coordination for persons with dementia is challenging for healthcare systems under the best of circumstances. The average dementia patient has four comorbid illnesses, receives care from five different providers, and uses an average of six different prescription medications. These coordination challenges are exacerbated in Medicare-eligible Veterans who receive care through both Medicare and VA. While dual eligibility for healthcare coverage may offer Veterans greater flexibility for accessing medical care, seeking prescriptions across uncoordinated systems may increase the risk of unsafe medication prescribing —particularly in Veterans who may have difficulty relaying complex information across VA and non-VA providers.

In this ongoing study, investigators are using both quantitative and qualitative data to look at several aspects of dual use among Veterans diagnosed with dementia, including: describing patterns of outpatient medication use for those with VA-coverage only, those with Medicare Part D-only, and those who use both; identifying risk factors for dual use and evaluating the effect of dual use on potentially harmful medications in the elderly; and exploring Veteran, caregiver, and VA provider perspectives on reasons for and risks associated with dual use.

Investigators looked at a national cohort of VA outpatient users with dementia (N=80,017)2. Using a retrospective cohort design with linked VA and Medicare utilization and prescription data for a three-year period (2007-2010), results showed:

  • 78% of VA outpatient users obtained all their medications from VA only,
  • 20% obtained medications from both VA and Medicare Part D (dual-users), and
  • 2% obtained all medications from Medicare Part D only.

Investigators also found that being a non-Hispanic Black, having more generous VA drug benefits (lower VA priority score), receipt of home-based primary care, and original Medicare entitlement due to disability were all associated with lower odds of being a dual-user. Preliminary results also suggest dual-users may be at greater risk of exposure to a range of potentially unsafe medications.

Implications: Results to date provide valuable insight into which Veterans are most likely to engage in dual use of VA and Medicare prescription drug benefits. Investigators expect final study results to improve the knowledge base around outcomes associated with receiving prescriptions through VA and Medicare in Veterans with dementia. This additional data should support both VA prescribing policy and pharmacy care coordination practices for this Veteran population.

Principal Investigator: Joshua Thorpe, PhD, MPH, is an investigator with HSR&D's Center for Health Equity Research and Promotion (CHERP) Pittsburgh, and Associate Director of Analytics and Research in VA's Center for Comprehensive End-of-Life Care.

Dual Health Systems Users: Strategies to Implement Optimal Care Coordination

Dual use—when Veterans seek care from both VA and other covered providers—is prevalent, with estimates ranging from 30 to 75 percent. Historically, the majority of dual use occurred among Veterans who were also eligible for Medicare. Dual use is expected to grow as more Veterans become eligible for Medicare and as federal legislation continues to expand Veterans' options for receiving care in the community. As VA increases its investment in providing Veterans with greater access to care in the community, research that expands the evidence base around the processes and outcomes of dual use is needed.

In this study, investigators are training Veteran participants to:

  • Use both their VA (MyHealtheVet) and non-VA online patient portals to engage in a bi-directional exchange of health information between VA and community providers; and
  • Enroll in the Veterans Health Information Exchange, or VLER, program if they choose.

Investigators are also educating community providers about VA health information exchange and care coordination using a "co-management toolkit." Finally, Veteran participants are being asked to develop a list of all their VA and community providers, and to indicate what roles they believe each provider plays on their health team. Primary outcomes will focus on Veteran and provider satisfaction, as well as care quality indicators such as medication list concordance and reduction in duplicate lab tests.

Implications: While study data are still being compiled, investigators expect this work to support care coordination programs, promote greater VA provider engagement, improve information sharing processes, and enhance overall quality care for Veterans with dual use.

Principal Investigator: Carolyn Turvey, PhD, MS, is an investigator with HSR&D's Center for Comprehensive Access & Delivery Research & Evaluation (CADRE) in Iowa City, IA.

Turvey C, et al. Blue Button Use by Patients to Access and Share Health Record Information Using the Department of Veterans Affairs' Online Patient Portal, Journal of the American Medical Informatics Association 2014; 21(4): 657-63.

Safety of Opioid Use among Veterans Receiving Care in Multiple Health System

As a key component of pain management, almost 25% of VA patients receive prescriptions for opioid medications. VA has adopted several strategies to mitigate the risks of opioid-related adverse events, but these efforts focus almost entirely on monitoring prescriptions dispensed within VA. However, many Veterans have other forms of health insurance, and can access healthcare and prescriptions in non-VA settings. In this ongoing study, investigators are addressing a knowledge gap by describing patterns of opioid use from VA and non-VA sources among Veterans receiving care in VA. Investigators are also evaluating the impact of dual use of VA and non-VA opioid medications on opioid safety and opioid-related, serious adverse events, and are exploring provider and other stakeholder perspectives on identifying and managing dual use of opioid medications in Veterans, including describing their experiences with Prescription Drug Monitoring Programs (PDMPs).

Implications: Ensuring safe and effective use of prescribed opioids by Veterans is a major strategic goal for VA. It is expected that this study will further the evidence base for and understanding of Veterans' prescription opioid use from non-VA sources. By expanding the knowledge base on dual opioid use, as well as the influences on dual use and its effects on safety, VA can design more effective policies and interventions around prescription opioid use for pain management. The information gathered on provider perspectives on managing dual use of opioids, specifically their experiences using PDMPs, will be valuable as VA expands requirements for providers to use PDMPs when they prescribe opioid medications.

Principal Investigator: Walid F. Gellad, MD, MPH, is an investigator with HSR&D's Center for Health Equity Research and Promotion (CHERP) in Pittsburgh, PA.

Radomski TR, Zhao X, Thorpe CT, Thorpe JM, Good CB, Mor MK, Fine MJ, Gellad WF. VA and Medicare Utilization Among Dually Enrolled Veterans with Type 2 Diabetes: A Latent Class Analysis. Journal of General Internal Medicine. 2016 May 1;31(5):524-31

Gellad, WF. The Veterans Choice Act and Dual Health System Use. Journal of General Internal Medicine. 2016 February;31(2):153-154.



[1] Dual-System Use and Intermediate Health Outcomes among Veterans Enrolled in Medicare Advantage Plans (http://onlinelibrary.wiley.com/doi/10.1111/1475-6773.12303/full)

[2] Schleiden L, Thorpe CT, Gellad WF, Good CB, Hanlon JT, Mor MK, Pleis JR, Van Houtven CH, Thorpe JM. Outpatient Medication Use Across VA Only, Part D Only, and Dual Drug Benefit User Groups in Medicare-Eligible Veterans with Dementia. Poster Session, AcademyHealth Annual Research Meeting; 2016 Jun 27; Boston, MA