Health Services Research & Development

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What We Need to Know about Dual Use

As noted in the article by Pat Vandenberg et al., about a third of Veterans cared for by the VA also gets care outside of the VA, usually from private Medicare providers. Receiving care from two separate systems is not ideal in today's health care environment (for reasons described in other papers in this issue) but it represents the willing choice of those Veterans and is thus not likely to go away. We need to understand this population and the care they seek for a number of reasons: first, to ensure that their current and future needs are met; and, second, to predict future demands on VHA resources.

The research we need to guide practice and policy falls into at least three general areas. The first area is to understand at a macro level the patterns of dual use so that we can better forecast the future needs of the population for which we care. As the analysis from the Office of Policy and Planning indicates, broad patterns of dual use are influenced by the age and gender mix of the Veteran population, their geographic distribution (rural vs. urban), their health care needs, and external factors such as the state of the economy and availability of insurance. All of these factors are changing, some dramatically. The demobilization of large numbers of active-duty military and impending reductions to the defense budget will create a large new cohort of Veterans, many of them living in rural areas. The implementation of the Affordable Care Act and Medicaid expansion may provide alternatives to VA care for many poorer Veterans.

Some forces will increase the number of eligible Veterans who seek care outside the VA (especially those that increase health care coverage options for Veterans) and some will decrease it (a slow economy with a population of Veterans whose needs are not well met in the private sector). We need to be able to forecast these trends more reliably or we will risk either building capacity we don't need or being unable to meet the demand that develops.

The second area of research is understanding at a micro-level the factors that influence a dually-eligible Veteran to seek care in the VA but to turn outside of the VA for certain aspects of that care. There will always be Veterans who seek acute care at private hospitals because they live too far from the nearest VAMC. But other instances of dual use reflect preferences that are amenable to change, i.e. a decision that the private provider offers better access, convenience, experience of care, or technical quality. The substantial investment the VA is making to promote access in rural areas, expand telehealth, and improve specialty access may reduce the number of Veterans who seek out local specialists. At the same time, by better understanding the choices our Veterans are making and why, we will improve our decision making as to investments that would increase the proportion of times the patient chooses VA for their care.

A third critical area, which has been the emphasis of much of the limited research on dual use to date, is to examine the effects of dual use on quality. If Veterans receiving dual care had identical health outcomes to those getting all their care in the VA, the issue would be one simply of cost and convenience. Unfortunately, studies such as those by Pizer, et al. suggest dual use is associated with worse outcomes. While we can guess at reasons this might be so, we actually don't know the exact mechanisms by which dual use produces worse outcomes and, more importantly, how to mitigate them. Is it, as is often assumed, a result of poor communication and missed handoffs as patients traverse two independent health systems? Or is it related to more complex factors of patient activation and engagement, which may be diminished by fragmented care? The answers matter because the solutions are different. To the extent that poor outcomes are a result of miscommunication between clinicians or with patients, interventions such as regional information exchanges, medication reconciliation, and the Blue Button feature of MyHealtheVet may gradually improve things. But if the underlying problem is that a Veteran feels less connected to care, and thus less involved in effective self-management, because his or her clinicians are not all on one team, the solutions are much more challenging. A principal notion behind the VA investment in Patient Aligned Care Teams was to have a "medical home" that would coordinate comprehensive care. How does one recreate the benefits of "home" for a patient commuting between two residences?

One challenge for initiatives targeting these Veterans is that dual use can make the VA "business case" more complicated. If VA develops a successful program that improves coordination and reduces hospitalization in dual users, the savings may accrue to Medicare rather than to VA. There is no shortage of interesting questions for researchers to tackle and HSR&D is committed to building the knowledge needed to improve the care for this important and growing population. Moreover, the lessons we learn are likely to help us improve communication, coordination, and engagement for all of our patients.