Health Services Research & Development

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Changes in Outpatient Care-Seeking by Medicare-Eligible Veterans of Care

Medicare-eligible Veterans are unique in being able to obtain care from two public health insurance programs (VA and Medicare) depending on convenience, relative prices, health care needs, availability of services and other factors. A significant proportion of Medicare-eligible Veterans obtain outpatient or inpatient care in both systems, which can complicate continuity of care, care coordination, and medication management. Care that is fragmented due to dual use of VA and Medicare may result in under-use or over-use in services, which could adversely impact health outcomes of Veterans. Furthermore, VA performance metrics may be affected by missing non-VA services.

Numerous studies have examined age-eligible Veterans' use of inpatient services, but fewer studies have examined Veterans' use of outpatient care or how utilization patterns change over time. This article summarizes findings from an examination of changes in VA and Medicare outpatient utilization in fiscal years (FY) 2001 through 2004 from a nationally representative sample of Medicare-eligible Veterans who used the Veterans Administration's primary care services in FY2000.

Medicare-eligible Veterans obtained more primary care from VA than from Medicare in 2001 through 2004, but they obtained more specialty care from Medicare than from VA.1 These Veterans used much more specialty care than primary care, and their reliance on VA services declined consistently for both types of care. The number of VA primary care visits per person decreased from 2.4 in FY2001 to 1.9 in FY2004, whereas Medicare visits per person increased over time from 1.3 in FY2001 to 1.6 in FY2004. The number of Medicare specialty care visits per person increased from 6.7 in FY2001 to 8.8 in FY2004, more than offsetting a modest decline in VA specialty care visits from 4.1 per person in FY2001 to 3.7 per person in FY2004. Medicare-eligible Veterans obtained most of their outpatient mental health services in VA in all years.

For these patients, VA primary care providers are essentially co-managing dual users of VA and Medicare services with non-VA primary care providers. However, VA and non-VA providers currently lack clinical information that is integrated across health systems in order to co-manage effectively. The complexity of care coordination among VA and non-VA providers could present additional challenges as VA's systemwide implementation of Patient Aligned Care Teams (PACT), a patient-centered medical home model, evolves to address the needs of these patients. Dual use also creates opportunities to develop and test care coordination initiatives within PACT.

There are important variations in VA reliance by Medicare eligibility (age or disability) and usual source of primary care in VA (community-based outpatient clinic (CBOC) or VA medical center (VAMC)). Age-eligible and disability-eligible Veterans sought primary care and mental health care most commonly in VA, but these Veterans most often sought specialty care in both systems.2 Disability-eligible Veterans were more reliant on VA for primary care, specialty care, and mental health care than age-eligible Veterans throughout FY2001-2004. Greater VA reliance for primary care and specialty care visits by disability-eligible Veterans is most likely related to their greater health needs.

Veterans obtaining primary care at CBOCs used less VA primary care and specialty care over time than Veterans obtaining VAMC-based primary care, but used more primary care and specialty care covered by Medicare.3 By FY2004, many VAMC-based Veterans and most CBOC-based Veterans obtained at least some primary and specialty care outside the VA. Increasing access to VA primary care in community settings via CBOCs may unintentionally result in fragmented care arising from dual use of VA and Medicare services.

These analyses from 2001 through 2004 showed that reliance on VA outpatient care decreased over time for Veterans of all types, particularly for primary care and specialty care. Unsurprisingly, Veterans obtaining mental health care relied on VA for such care. Research is needed to improve our understanding of whether reliance on VA has changed since the introduction of Medicare Part D in 2006. Most research to date on dual use of VA and non-VA services focuses on age-eligible Veterans in the Medicare fee-for-service program; additional subgroups of Medicare-eligible Veterans merit further examination, including Medicare Advantage enrollees, disability-eligible Veterans, and Veterans enrolled in Medicaid. Future research also needs to assess the impact of PACT on processes and outcomes of care for Medicare-eligible Veterans.

The quality of research and subsequent policymaking related to dual users could be enhanced through a partnership between HSR&D and Operations; Operations is aware of the information gaps that need to be filled to improve decision-making, and HSR&D researchers have the measurement and methods expertise needed to fill these gaps.

  1. Liu, C.F. et al. "Reliance on Veterans Affairs Outpatient Care by Medicare-eligible Veterans," Medical Care 2011; 49(10):911-17.
  2. Liu, C.F. et al. "Use of Outpatient Care in VA and Medicare among Disability-eligible and Age-eligible Veteran Patients," BMC Health Services Research 2012; 12(1):51.
  3. Liu, C.F. et al. "Use of Outpatient Care in Veterans Health Administration and Medicare among Veterans Receiving Primary Care in Community-based and Hospital Outpatient Clinics," Health Services Research 2010; 45(5 Pt 1):1268-86.