BACKGROUND/RATIONALE:
VA-enrolled Veterans who live in rural states often must travel far to reach health services, whether VA or non-VA. Travel-related access problems may reduce their overall healthcare use as well as increase their likelihood of using both VA and non-VA care, as compared to Veterans in more populated areas. As a result, their care may be less adequate or less coordinated, which may reduce health outcomes and quality of life, or waste resources. To promote care coordination and optimize resource use, it is important to know how VA enrollees use non-VA healthcare, i.e., how much and for which needs. Many studies have examined how Veterans enrolled in both VA healthcare and Medicare/Medicaid use non-VA services, but they are limited to Veterans who are either elderly or seriously disabled. To date, there are few studies of working-age VA enrollees who access non-VA healthcare through commercial insurance. It remains unknown how much Veterans in rural states use non-VA relative to VA care if they have insurance, how distance, priority for VA care, and particular treatment needs relate to VA or non-VA reliance, or how likely patients are to use both VA and non-VA care contemporaneously, risking duplicative services or conflicting treatments.

OBJECTIVE(S):
Our objectives were to 1) acquire administrative treatment data for all VA and insurance-paid non-VA outpatient, inpatient, and pharmacy services obtained during several recent years by VA-enrolled Veterans living in four rural states; 2) determine how use of VA or non-VA care relates to patients' medical conditions and types of services received, travel burden, insurance coverage, and priority to VA care, as well as age, gender, and other demographics; and 3) assess the treatment needs and services obtained by "dual users," as well as their other distinctive characteristics, and compare them to other patients with regard to duplicative or conflicting treatments.

METHODS:
For VA enrollees living in any of four states (Iowa, South Dakota, New Hampshire, and Maine), we acquired administrative treatment data for any VA or non-VA outpatient, inpatient, or pharmacy services they received during 2005-2011. The non-VA data source for Iowa and South Dakota was the Wellmark Insurance Company, the largest commercial health insurer serving these two states. Non-VA data sources for New Hampshire and Maine were state government agencies that manage their All Payer Claims Database repositories, to which all insurers in the state contribute claims data. VA's National Data Systems (NDS) assigned a random unique identification number (UID) to each VA enrollee. NDS provided any VA treatment data (identified only by UID) that these enrollees had during those years; NDS also sent non-VA data managers in each state a list of enrollees' personal identifiers (SSN, DOB, sex) associated with UIDs. The state data sources used enrollees' identifiers to search their data for any matching records, which they provided to us with UIDs but no personal identifiers (the states then deleted all personal identifiers from their records). These data enabled comparisons of VA, non-VA, and dual healthcare users on diagnostic, health status, demographic, travel burden, and use of specific services.

FINDINGS/RESULTS:
VA enrollees who used both VA and non-VA outpatient care had more diagnoses and procedures than other patients. For any common condition, many dual users used VA care, many others used non-VA care, but few dual users were treated for the condition in both. Overall, dual users had treatment visits more often than other patients, but within either care system they were seen less often, particularly if they were rural residents living far from care. For most diagnoses or procedures, rural residence did not affect the likelihood that dual users were treated, but it did lower chances of treatment for visual acuity problems, anxiety, or injury, or of receiving rehabilitation services, behavioral medicine, and some screening and diagnostic tests.

Half of patients who received prescriptions got them from non-VA pharmacies exclusively; another 29% used both VA and non-VA pharmacy services; these dual users also were heavier inpatient and outpatient users. Psychiatric medications, however, were obtained mostly from the VA.

The VA care of many enrollees can be billed to insurance, but for at least one quarter of such patients, insurance claims for their VA care are not submitted.

IMPACT:
Working age Veterans who are enrolled in VA healthcare and also have commercial insurance obtain most of their healthcare (including pharmacy) from non-VA providers. Many dually eligible patients use both VA and non-VA healthcare concurrently, but generally not for the same conditions - for any common condition, in fact, some dual users use VA treatment, others use non-VA care, but few use both. Dual users, particularly those living in rural areas, are seen less often in either care system than single-system users are. To the extent that providers in one care system are unaware of the treatment that dual users receive in another system, the potential for conflicting or inadequate care increases.

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External Links for this Project

NIH Reporter

Grant Number: I01HX000824-01A1
Link: https://reporter.nih.gov/project-details/8398618

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PUBLICATIONS:

Journal Articles

1. West AN, Weeks WB, Charlton ME. Differences Among States in Rural Veterans' Use of VHA and Non-VHA Hospitals. The Journal of rural health : official journal of the American Rural Health Association and the National Rural Health Care Association. 2017 Jan 1; 33(1):32-40. [view]
2. West AN, Charlton ME, Vaughan-Sarrazin M. Dual use of VA and non-VA hospitals by Veterans with multiple hospitalizations. BMC health services research. 2015 Sep 29; 15(1):431. [view]
3. West AN, Charlton ME. Insured Veterans' Use of VA and Non-VA Health Care in a Rural State. The Journal of rural health : official journal of the American Rural Health Association and the National Rural Health Care Association. 2016 Sep 1; 32(4):387-396. [view]
4. Lund BC, Charlton ME, West AN. Pharmacy use by dual-eligible non-elderly veterans with private healthcare insurance. BMC health services research. 2016 Sep 23; 16(1):515. [view]
5. Charlton ME, Mengeling MA, Schlichting JA, Jiang L, Turvey C, Trivedi AN, Kizer KW, West AN. Veteran Use of Health Care Systems in Rural States: Comparing VA and Non-VA Health Care Use Among Privately Insured Veterans Under Age 65. The Journal of rural health : official journal of the American Rural Health Association and the National Rural Health Care Association. 2016 Sep 1; 32(4):407-417. [view]

DRA: Health Systems Science
DRE: none
Keywords: none
MeSH Terms: none