Neurotrauma can be life-threatening and often results in lifelong disability and secondary complications. Neurotrauma primarily includes traumatic brain injury (TBI) and/or a spinal cord injury or disorder (SCI&D). Veterans with SCI may experience complications such as pressure ulcers, respiratory diseases, and urinary tract infections. Additionally, as Veterans with neurotrauma age, they experience many of the same chronic conditions as other Veterans. Veterans with severe and moderate TBI often require extensive daily assistance and are at high risk of complications. Use of multiple healthcare systems (e.g., VA in addition to Medicare and/or Medicaid) by Veterans has implications for access, coordination of care and duplication of services. Understanding the patterns of utilization and costs of care in and outside VA provides crucial information for planning for the long-term health needs of Veterans with new injuries (OIF/OEF) and for those with longer durations of injury.
The primary objective of this study was to examine VA, Medicare and Medicaid utilization and costs for veterans with neurotrauma. Specific objectives were: to determine the proportion of Veterans with neurotrauma who utilize VA healthcare services who are Medicare users, Medicaid users, and VA only users; to describe characteristics of VA only users and multi-system users; and to describe healthcare utilization, setting and cost of VA, Medicare and Medicaid services for eligible VA users. The secondary objective was to compare the patterns healthcare use and costs of Veterans with neurotrauma who obtained their injuries during OEF/OIF with other Veterans with neurotrauma.
The study was retrospective and included available VA, Medicare and Medicaid demographic, utilization and cost data starting in calendar year 1999. We obtained Medicare and Medicaid data from VIReC and VA data from Medical SAS files, VA SCD registry data, NPPD and DSS datasets. Cost data were obtained from DSS and HERC. Data for veterans with new injuries (OEF/OIF) were also obtained from chart reviews. We described the frequency of single and multi-system use and examined the association between multi-system use and outcomes using logistic regressions.
There were 15,422 Veterans with SCI&D and 91,155 Veterans with TBI who met the inclusion criteria for the study. Because of the extensive number of analyses, we have highlighted a few key results in this report. In 2006 there were 9724 Veterans with SCI&D and 33940 with TBI with complete data. In 2006, among Veterans with SCI, 0.9% used Medicaid only, 1.1% used Medicare only and 63.0% used VA healthcare systems exclusively. Nearly a third of Veterans with SCI&D were multi-system users (35.0%). In 2006, among Veterans with TBI, 0.9% were Medicaid only users, 1.1 % were Medicare only users and 63% were VA healthcare systems only users. Thirty-four percent were multiple system users.
The youngest group of Veterans with SCI&D was those who used VA and Medicaid concurrently (52 years old). The oldest group was those who used Medicare and Medicaid concurrently (61 years old). The mean age of those with triple use was 56 years old. In calendar year 2006, all cause mortality for the cohort of Veterans with SCI was 4.7%. For Veterans with SCI&D who used any Medicaid-covered service, there was a 2.4 (95% CI: 1.8 - 3.2, p <0.001) increased adjusted odds of death in the year following use compared to those without use any Medicaid services. Multi-system users also had significantly lower odds of death compared to those who were VA only users (OR=0.33, 95% CI: 0.26 - 0.43). Overall, 51.5% of Veterans were hospitalized in 2006. Those who used any Medicare or Medicaid services were at least 2 times more likely to be hospitalized compare to VA only users (OR=2.4, 95% CI: 2.2-2.6, p<0.001).
Veterans with SCI&D had substantial VA healthcare costs. In FY 2008, the average VA healthcare costs for Veterans with traumatic injury were approximately $49,000, while average costs for Veterans with non-traumatic injuries were about $45,000. While injury etiology (traumatic vs. non-traumatic) was not a statistically significant predictor of total cost after adjusting for patient characteristics, Veterans who were married or lived in more rural settings had lower healthcare costs, while Veterans with comorbid conditions had higher costs. One example of a condition that is associated with high healthcare costs for individuals with SCI&D is pressure ulcers. Patients with a new diagnosis for pressure ulcer had significantly more VA utilization over a 12 month period compared to those who did not have pressure ulcers. They averaged approximately 52 more inpatient days. They also had more outpatient encounters. After adjusting for covariates, total costs to treat SCI patients with pressure ulcers were significantly higher than costs for those without pressure ulcers ($100,935 vs. $27,914; P < 0.001).
While many Veterans with mild TBI will have symptoms that resolve quickly, some will have symptoms that persist. A review of 250 medical charts for OEF/OIF Veterans with TBI found that 75% reported history of headaches and 92% reported sleep disturbances. Thirty-two percent of these Veterans were referred to a Neurology clinic for their headaches. Of the 32% with Neurology referrals, 30% did not attend the appointment. A large majority of those who did attend Neurology clinics were given CTs or MRIs (93%).
Neurotrauma accounts for a small but significant number of veterans who receive care in VA (both new and chronic injuries). Many will require lifelong care. Veterans with neurotrauma are at high risk for illness complications and typically require highly specialized services. While overlap and duplication of services could result in substantial costs for the federal government, lack of coordination may result in gaps in care that compromise the health and quality of life of Veterans. Describing the use and costs of VA, Medicare and Medicaid services by Veterans with neurotrauma provides crucial information for planning and providing healthcare services for this population. The substantial number of Veterans with neurotrauma who are using multiple healthcare systems highlights the importance of continued efforts to develop effective strategies to coordinate care.
- Rogers TJ, Smith BM, Weaver FM, Ganesh S, Saban KL, Stroupe KT, Martinez RN, Evans CT, Pape TL. Healthcare utilization following mild traumatic brain injury in female veterans. Brain injury. 2014 Jun 19; 28(11):1406-12.
- Fischer MJ, Krishnamoorthi VR, Smith BM, Evans CT, St Andre JR, Ganesh S, Huo Z, Stroupe KT. Prevalence of chronic kidney disease in patients with spinal cord injuries/disorders. American Journal of Nephrology. 2013 Jun 10; 36(6):542-8.
- Ullrich PM, Smith BM, Poggensee L, Evans CT, Stroupe KT, Weaver FM, Burns SP. Pain and post-traumatic stress disorder symptoms during inpatient rehabilitation among operation enduring freedom/operation iraqi freedom veterans with spinal cord injury. Archives of physical medicine and rehabilitation. 2013 Jan 1; 94(1):80-5.
- Patil VK, St Andre JR, Crisan E, Smith BM, Evans CT, Steiner ML, Pape TL. Prevalence and treatment of headaches in veterans with mild traumatic brain injury. Headache. 2011 Jul 1; 51(7):1112-21.
- Stroupe KT, Manheim LM, Evans (Mayfield) C, Guihan M, Ho C, Li K, Cowper Ripley DC, Hogan TP, St. Andre JR, Huo Z, Smith BM. Cost of Treating Pressure Ulcers for Veterans with Spinal Cord Injury. Topics in spinal cord injury rehabilitation. 2011 Apr 1; 16(4):62-73.
- St. Andre JR, Smith BM, Stroupe KT, Burns SP, Evans CT, Cowper Ripley DC, Li K, Huo Z, Hogan TP, Weaver FM. A Comparison of Costs and Health Care Utilization for Veterans with Traumatic and Nontraumatic Spinal Cord Injury. Topics in spinal cord injury rehabilitation. 2011 Mar 1; 16(4):27-42.
- Pizer SD, Frakt AB, Iezzoni LI. Uninsured adults with chronic conditions or disabilities: gaps in public insurance programs. Health affairs (Project Hope). 2009 Nov 1; 28(6):w1141-50.
- Rogers T, Smith BM, Stroupe KT, Evans (Mayfield) C, Pape TL. Healthcare utilization in the year after moderate or severe traumatic brain injury. Poster session presented at: AcademyHealth Annual Research Meeting; 2014 Jun 8; San Diego, CA.
- Rogers T, Smith BM, Weaver FM, Saban KL, Stroupe KT, Martinez RM, Evans (Mayfield) C, Pape TL. Healthcare Utilization following mild traumatic brain injury in women Veterans. Poster session presented at: AcademyHealth Annual Research Meeting; 2014 Jun 8; San Diego, CA.
- Ganesh SP, Weaver FM, Smith BM. Chronic Obstructive Pulmonary Disease in Veterans with Spinal Cord Injury, From 2004-2008. Poster session presented at: Association of Academic Physiatrists Annual Meeting; 2011 Apr 15; Phoenix, AZ.
- Krishnamoorthi VR, Stroupe KT, Smith BM, Evans (Mayfield) C, St. Andre JR, Ganesh SP, Huo Z, Li K, Fischer M. Chronic Kidney Disease in Veterans with Spinal Cord Injury. Paper presented at: VA HSR&D National Meeting; 2011 Feb 16; National Harbor, MD.
- Stroupe KT, Manheim LM, Evans (Mayfield) C, Guihan M, Ho C, Li K, Cowper-Ripley D, Hogan TP, St. Andre JR, Huo Z, Smith BM. Cost of Treating Pressure Ulcers for Veterans with Spinal Cord Injury. Poster session presented at: VA HSR&D National Meeting; 2011 Feb 16; National Harbor, MD.
Health Systems, Brain and Spinal Cord Injuries and Disorders
Treatment - Observational
Access, Cancer, Cost-Effectiveness, Implementation, Management, Practice Patterns/Trends, Spinal Cord Injury, TBI, Traumatic Brain Injury, Utilization, Utilization patterns