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IIR 11-105 – HSR&D Study

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IIR 11-105
Health Policy Implication of Dual Enrollment in the VA and Medicare Advantage
Amal Nitin Trivedi MD MPH
Providence VA Medical Center, Providence, RI
Providence, RI
Funding Period: April 2013 - September 2015

BACKGROUND/RATIONALE:
In the United States, eligible adults may choose to enroll simultaneously in two distinct managed care systems: the MA program administered by the Centers for Medicare and Medicaid Services and the VA Healthcare System, administered by the Veterans Health Administration. Although the VA may collect reimbursements for care provided to VA users enrolled in private health plans, federal law prohibits the VA from collecting any reimbursements from Medicare-financed health plans. Dual enrollment may produce redundant federal payments and fragmentation of care for enrollees with complex chronic medical conditions. Few studies have quantified the clinical and economic consequences of dual enrollment in VA and MA.

OBJECTIVE(S):
This study will provide a comprehensive national assessment of the use
of VA and non-VA health services, VA-financed costs, and quality of care for all VA enrollees who are dually enrolled in a Medicare Advantage (MA) plan. Our primary objectives are: (1) to assess the utilization and VA-financed costs of health care services for VA health care system users who are simultaneously enrolled in a Medicare Advantage plan; (2) to compare the quality of diabetes, cardiovascular, and cancer screening care among the following three groups of veterans who are dually enrolled in VA and MA: veterans who exclusively receive care in the VA, veterans who receive care in both VA and MA, and veterans who exclusively receive care in MA; (3) to understand the effect of fragmented financing on the quality of care among dual enrollees in VA and Medicare Advantage.

METHODS:
We will merge 12 national VA and Medicare clinical and administrative datasets from 2004 through 2013 to derive the population of all VA enrollees who were simultaneously enrolled in a Medicare Advantage plan. For this cohort, we will assess the distribution of ambulatory and acute inpatient care in the VA and Medicare Advantage, the total costs of VA-financed care using average-cost methods, and the effect of fragmented financing on the quality of care for dually enrolled veterans using both instrumental variable and propensity-score approaches.

FINDINGS/RESULTS:
Our findings indicate that 12% of all VA users in CY2012 were simultaneously enrolled in an MA plan and that the VA spent $3.6 billion (approximately 10% of its operating budget) on health services for this population.

The proportion of VA-Medicare dual enrollees who were in Medicare Advantage increased from 13% in 2006 to 22% in 2012.

Of the 6643 dually enrolled individuals in our sample who were eligible for EPRP indicators, 1637 (24.6%) exclusively received outpatient care in he. The remaining 5006 (75.4% received outpatient services in both the VA and MA. We found no significant diferences in intermediate outcomes between VA-only and dual user populations. Differences ranged from a 3.2 percentage point (95% CI: -1.8 to 8.2) greater rate of controlled cholesterol among VA-only users with coronary heart disease to a 2.2 percentage point (95% CI: -2.4 to 6.6) greater rate of controlled blood pressure among dual users with diabetes.


IMPACT:
The coordination of financing and service delivery across these two managed care systems is of vital interest to VA and other federal policymakers. The goal of this project is to inform federal policy regarding the financing and delivery of health care for persons who are dually enrolled in the VA and MA. Understanding how privately-insured veterans use health services, their quality of care, and their reliance on VA health care will be of increasing importance following the implementations of the Affordable Care Act. Based on our study, the General Accounting Office investigated the economic implications of dual enrollment in VA and MA and will issue a final report. The Director of the VA National Center on Homelessness has also expressed interest in the dual use of services among homeless Veterans. We are engaging in an extension of this work to the homeless population.

PUBLICATIONS:

Journal Articles

  1. Trivedi AN, Wilson IB, Charlton ME, Kizer KW. Agreement Between HEDIS Performance Assessments in the VA and Medicare Advantage: Is Quality in the Eye of the Beholder? Inquiry : A Journal of Medical Care Organization, Provision and Financing. 2016 Mar 31; 53:doi: 10.1177/0046958016638804.
  2. Cooper AL, Jiang L, Yoon J, Charlton ME, Wilson IB, Mor V, Kizer KW, Trivedi AN. Dual-System Use and Intermediate Health Outcomes among Veterans Enrolled in Medicare Advantage Plans. Health services research. 2015 Dec 1; 50(6):1868-90.
  3. Trivedi AN, Grebla RC, Jiang L, Yoon J, Mor V, Kizer KW. Duplicate federal payments for dual enrollees in Medicare Advantage plans and the Veterans Affairs health care system. JAMA. 2012 Jul 4; 308(1):67-72.
VA Cyberseminars

  1. Charlton ME, Rosenthal GE, Turvey CL. Dual Use of VA and Non-VA Services by Veterans in PACT. [Cyberseminar]. 2013 May 15.
Conference Presentations

  1. Cooper A, Jiang L, Yoon J, Charlton ME, Mor V, Kizer K, Trivedi A. Association of Multiple System Use with Health Outcomes among Veterans Enrolled in Medicare Advantage Plans. Poster session presented at: AcademyHealth Annual Research Meeting; 2013 Jun 24; Baltimore, MD.


DRA: Health Systems, Cancer, Cardiovascular Disease
DRE: Treatment - Observational
Keywords: Cancer, Cardiovascular Disease, Clinical Diagnosis and Screening, Cost-Effectiveness, Efficiency, Quality Improvement, Quality of Care, Utilization
MeSH Terms: none

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