To address the increasing prevalence of overweight and obesity in veterans, VA has implemented a comprehensive, evidence-based, multidisciplinary weight management program called the MOVE! Weight Management Program for Veterans in all VA medical centers beginning in 2006. In June 2008, VA began waiving the $15 MOVE! clinic visit copayment for Veterans who were not eligible for free VA care due to disability or low income through a change in VA regulations. The impact of the copayment waiver was unknown at the time. Eliminating the MOVE! clinic copayment might increase clinic access for these overweight and obese veterans and, in turn, improve their health outcomes. However, eliminating the copayment also removed a revenue stream for VA Facilities, particularly since MOVE! services, are funded through existing medical center budgets.
In this project, we examined the impact of the regulatory change waiving MOVE! visit copayment by examining the utilization of MOVE! clinic services by newly-exempted veterans in 126 VA facilities. We hypothesized that MOVE! utilization after copayment waiver would increase because overall MOVE! utilization was still increasing at the time of the copayment waiver. We expected that Veterans not eligible for free care would have a disproportionate increase in utilization as compared to Veterans already eligible for free care prior to copayment waiver. We also hypothesized that elimination of the copayment would result in a higher proportion of return visits by Veterans not eligible for free care.
The pilot study addressed three aims:
1) Are more veterans per month being newly seen in MOVE! clinics after the MOVE! copay elimination than in the months before the copay elimination?
2) Is the number of MOVE! visits per veteran greater in the months after the MOVE! copay elimination than in the months before the copay elimination?
3) What is the level of MOVE! implementation at the facility, and does this level change after the copay elimination?
We selected a national sample of overweight and obese veterans who engaged in higher-volume MOVE! programs (>30 users) at 126 VAMCs or Community Based Outpatient Clinics in the months preceding and following the copayment elimination. The pre-period cohort (6/16/2007-6/15/2008) included 44,411 veterans, 17% of whom were not eligible for free VA care, because they were Priority Group 7 and 8 veterans (hereafter referred to as "non-exempt"). The post-period cohort (6/16/2008-6/15/2009) included 64,398 veterans, 16% of whom were not eligible for free VA care.
For this pilot study, we used 2006-2009 Outpatient Care File data to construct the MOVE! clinic utilization outcomes and patient covariates. We also obtained Diagnostic Cost Group (DCG) risk adjustment scores for each patient in the cohort. To address Aim 3, we obtained VA MOVE! Annual Report data collected from all VAMC facilities to measure facility implementation of the MOVE! program.
To examine whether elimination of the copayment was associated with more non-exempt MOVE! users, we estimated a generalized estimating equation (GEE), controlling for pre-period or post-period and clinic-level demographic characteristics (age, gender, race, marital status and DCG score). To examine whether elimination of the copayment was associated with more repeat visits in the 12 months after the first visit, we estimated a GEE. The Aim 3 analysis is ongoing.
As hypothesized, the unadjusted analyses showed that utilization of MOVE! clinics by non-exempt new users increased significantly (pre: 3.6%, post: 5.8%); however, the increase was even higher for exempt new users (pre: 18%, post: 29.9%). GEE results confirmed these findings. GEE found no difference in the number of return visits between exempt and non-exempt veterans. In sum, these results suggest that the MOVE! clinic copayment elimination was not associated with increased utilization by veterans newly exempt from these copayments.
This study describes MOVE! clinic utilization trends before and after the MOVE! copayment waiver. There are at least two responses that Facilities might have had to the MOVE! clinic visit copayment elimination. First, Facilities could have responded to increased demand by Veterans formerly required to pay copayments by increasing their access to MOVE!, which we expected to observe through a market increase in the proportion of all visits that were made by veterans formerly required to pay copayments. Our findings do not support this response. Our findings of no difference in number of visits between exempt and non-exempt Veterans also suggest that a copayment may not have been a significant barrier to MOVE! clinic access for most veterans, which contradicts anecdotes that cost is an important barrier to patients getting and remaining engaged in preventive care. Further the disproportionate increase in MOVE utilization by exempt Veterans after copayment elimination suggests that VA does not need to be concerned about "a run on services" following co-payment elimination.
Second, clinics could respond to the loss of revenue by targeting veterans who might benefit the most from MOVE! clinic attendance. MOVE! clinic staff might have determined that these veterans exempt from copayments due to disability or low income might most benefit from MOVE! clinic attendance. Our results are consistent with this possible explanation. After the elimination of the MOVE! copayment, utilization of MOVE! by non-exempt Veterans increased, but less in magnitude than the increase in utilization by exempt Veterans.
There are several limitations to this study. First, these results do not generalize to low volume MOVE! clinics. Second, we lack data on how many Veterans wanted to attend the MOVE! clinic but were unable to. If a disproportionate share of Veterans required to pay copayments were turned away due to supply limits, these results under-estimate the response to the copayment elimination by Veterans required to pay copayments because we only included Veterans with actual MOVE! clinic utilization in the sample.
VA has eliminated copayments for other prevention-oriented services in the past (e.g., influenza vaccination, breast and cervical cancer screening, smoking cessation treatment) without a formal evaluation of the health and economic impacts of these policy decisions. When the White House's Office of Management and Budget reviewed regulatory changes to eliminate the MOVE! copayment, VA was asked to provide a retrospective evaluation of the impact of the prior copay eliminations but none was available. This pilot study took advantage of this natural experiment to provide the empirical evidence to this very relevant operational question of great interest to senior VA decision makers.
- Maciejewski ML, Yancy WS, Olsen M, Weidenbacher HJ, Abbott D, Weinberger M, Datta S, Kahwati LC. Demand for weight loss counseling after copayment elimination. Preventing chronic disease. 2013 Apr 4; 10:E49.