Radiotherapy is a treatment provided by the Veterans Health Administration (VHA) to patients as a result of the diagnosis of certain cancers. Radiotherapy services may be provided directly by the VHA, or payment for these services may be made to non-VA providers in the community under certain circumstances (fee-basis or contracted care in non-VA sites). Additionally, veterans that are dually eligible (e.g., VHA and Medicare) may also choose to receive care at non-VA facilities that is paid for by the Medicare program. Understanding these facets will help policy and planners allocate scarce resources.
1. Identify use in radiotherapy services across the VA that are provided in VA (salaried and contracted) and Non-VA (Fee Basis and Medicare) facilities.
2. Identify and track the proportion and magnitude of radiotherapy services for VA enrolled veterans that is paid for by the Medicare program when the veteran is dually eligible.
3. Determine if patient access to VA care is associated with the location of radiation treatment delivery when the veteran is dually eligible.
The VHA, VHA fee basis (VHA-FBC), and Medicare datasets were screened for a cohort of veterans who received radiation therapy services during calendar year 2008. Radiation therapy patients were identified by having either a CPT code in the range of 77261-77799 and 79005-79999 or an ICD-9-CM procedure code in the range of 92.21-92.39. We excluded patients younger than 65 at the time of their enrollment. The primary dependent variable was utilization of radiation therapy services in the VHA either through VHA radiation therapy clinics, or VHA-FBC, with reference to Medicare. We used both logistic and multinomial logistic regression models. Our main independent variables measuring access included specifications for both distance to healthcare and the town classification. Distance was measured in miles as a Euclidean distance between the location of healthcare facility and the centroid of the zip code of the patient's residence. Distance was categorized into 5 intervals (0-5, 6-10, 11-20, 21-39, 40+ miles) with those residing 40 or miles as the reference group. Rural Urban Commuting Area (RUCA) codes, version 2.0 were used to identify type of town by patient zip code. To facilitate analysis we used the University of Washington Categorization-A that collapses the 33 RUCA codes into four groups (urban, large rural city/town, small rural town, isolated small rural town) and used the isolated small rural town as the reference group. Financial incentives may also impact the utilization of VHA services. We created 4 groups for our analysis: priority 1 and 4 (catastrophically disabled), priority 2, 3, and 6 (moderate disability), priority 5 (Medicaid assistance/low income), and priority 7 and 8 (no service-connected disability) which served as the reference group. Adjusted odds ratios (OR) and 95% confidence intervals (CI) are presented. All analyses were conducted with Statistical Analysis Software (SAS ), Version 9.2, Cary, NC.
During calendar year 2008, we identified 45,914 VHA and Medicare enrollees that received radiation care. Among these dually-enrolled patients, 35,513 (77.4%) received radiation care through the Medicare program. The VHA and VHA-FBC program comprised 4,646 (10.1%) and 5,755 (12.5%), respectively. Men made up over 98% of Medicare, VHA and VHA-FBC radiation therapy patients. There were more black patients that used the VHA (11.1%) than VHA-FBC (6.0%) and Medicare (5.7%). Patients' priority level had the greatest odds in determining radiation therapy program utilization. Relative to patients with no service-connected disability, those classified as catastrophically disabled (OR: 5.62 [95% CI: 5.05-6.25]) or Medicaid assistance/low income (OR: 6.42 [95% CI: 5.90-6.98]) were nearly five to six times more likely to utilize VHA radiation therapy services. More than twenty percent of VHA patients were within 5 miles of a VHA facility compared to 8.8% of patients who ultimately chose to use Medicare providers for radiotherapy services (P<0.0001). Just over 45% of Medicare patients were 40 miles or more to a VHA facility compared to 27.4% of VHA patients (P<0.0001). Patients who utilized the VHA-FBC program also tended to be closer to VHA facilities compared to those who utilized Medicare services. Based on RUCA town classification, VHA patients tended to live in more urban areas than Medicare patients. More Medicare patients resided in large rural cities, small rural towns and isolated small rural towns than VHA patients. Similarly the VHA-FBC radiation therapy patients resided in more rural towns than that of VHA patients. There were large differences in the priority status categorization of both VHA and VHA-FBC patients compared to Medicare patients. Over 53% of Medicare patients were non-service-connected disability compared to 18.7% for the VHA and 20.3% for VHA-FBC (P<0.0001). Over half of VHA patients were classified as Medicaid assistance and low income compared to 23% Medicare (P<0.0001). Both VHA and VHA-FBC were nearly twofold greater in the number of patients classified as catastrophically disabled. Younger patients in the age group 65-69 with reference to the oldest age group (age 80+) were nearly four times more likely to utilize the VHA over Medicare for radiation therapy (OR:3.96 [95% CI: 3.61-4.35]) and age showed a declining effect. As expected, patients residing within 5 miles of a VHA facility with reference to those residing 40 or more miles were more than four times more likely to utilize VHA radiation care (OR:4.32 [95% CI: 3.88-4.81]) and likelihood of VHA utilization declined with distance. Results for RUCA classification were mixed. When isolated small rural towns served as the reference group, patients residing in urban towns (OR:0.76 [95% CI: 0.66-0.88]) and large rural cities (OR:0.73 [95% CI: 0.62-0.86]) were 24 to 27% less likely to utilize VHA radiation care. For VHA-FBC urban dwelling patients the odds were smaller (OR:0.53 [95% CI: 0.47-0.60]).
The VA estimates that the need for radiology and nuclear medicine services will increase. The results of this study are consistent with the findings from the several VHA annual surveys that have found the strongest factors associated with reliance on the VHA were veteran priority level and Medicaid insurance status. This study demonstrates that a significant proportion of radiation therapy for cancer care to dually eligible veterans occurs outside the VHA healthcare system.
- French DD, Bradham DD, Campbell RR, Haggstrom DA, Myers LJ, Chumbler NR, Hagan MP. Factors associated with program utilization of radiation therapy treatment for VHA and medicare dually enrolled patients. Journal of community health. 2012 Aug 1; 37(4):882-7.
- French DD, Margo CE, Campbell RR. Comparison of complication rates in veterans receiving cataract surgery through the Veterans Health Administration and Medicare. Medical care. 2012 Jul 1; 50(7):620-6.