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IIR 13-313 – HSR&D Study

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IIR 13-313
Understanding Dual Use in VA and Medicaid for Potential Impacts Under the ACA
Jean Yoon PhD MHS
VA Palo Alto Health Care System, Palo Alto, CA
Palo Alto, CA
Funding Period: October 2014 - March 2016

BACKGROUND/RATIONALE:
Past research examined the use of VA services by VA enrollees covered by other insurance programs that can help inform the potential impact of new insurance options for veterans under the ACA. However, gaps in the literature remain, so the existing evidence may not provide accurate assessments of potential changes under new insurance expansions. While studies looked at predictors and levels of VA and non-VA use of services among VA enrollees with other insurance coverage, the majority of the evidence focused on Medicare-eligible veterans since they are the largest group of dual enrollees and account for approximately 51% of current VA enrollees. Much more limited research has focused on VA enrollees covered by Medicaid.

OBJECTIVE(S):
The primary objective of this project was to examine dual use among nonelderly VA enrollees who acquire Medicaid coverage since states are adopting Medicaid expansion plans, among other options, to cover previously uninsured residents. This study assessed the impact of new Medicaid coverage on use of VA and Medicaid care and health care spending, both overall and separately for specific types of services, for nonelderly VA enrollees between CY2006 and FY2010 and determined how the use and costs of VA care following Medicaid coverage varies by patient demographic and clinical characteristics and state Medicaid policy factors.

METHODS:
We used VA-Medicaid linked files to obtain VA and Medicaid utilization and costs for inpatient, outpatient, and pharmacy care. After identifying nonelderly veterans newly enrolled in Medicaid, we measured patients' utilization and costs of VA one year prior to Medicaid enrollment and their VA and Medicaid utilization for two years following Medicaid enrollment. Outpatient visits were estimated separately for primary care, specialty care, obstetric care, and mental health and substance abuse care. Inpatient stays were estimated separately for medical/surgical and psychiatric

FINDINGS/RESULTS:
In a cohort of 19,890 nonelderly veterans who did not have Medicare, VA outpatient and inpatient utilization levels were similar before and after enrolling in Medicaid. Overall VA outpatient reliance was 0.65, and VA inpatient reliance was 0.53 after Medicaid enrollment. Factors significantly associated with greater VA reliance included sociodemographic factors, having a service-connected disability, comorbidity, and higher state Medicaid reimbursement. Factors significantly associated with less VA reliance included months enrolled in Medicaid, managed care enrollment, Medicaid eligibility type, longer drive time to VA care, greater generosity in Medicaid eligibility, and better Medicaid quality. Dual enrollees had a mean of 10 primary care, 11 specialty care, and 22 mental health care visits to a VA provider after enrolling Medicaid. Dual enrollees had a mean of 1 primary care, to a Medicaid provider, 2 specialty care, and 2.5 mental health visits to a Medicaid provider after enrolling in Medicaid.

IMPACT:
This study provided information to our partners regarding the limited changes in VA utilization after enrollment in Medicaid for prior users of VA care. The demand for mental health services was an important factor for reliance on VA care.

PUBLICATIONS:

Conference Presentations

  1. Vanneman ME, Dally SK, Phibbs CS, Trivedi AN, Yoon J. Use of VA outpatient services for Veterans with behavioral health conditions after enrolling in Medicaid. Poster session presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 10; Philadelphia, PA.
  2. Yoon J, Vanneman ME, Dally SK, Trivedi AN, Phibbs CS. Use of VA and Medicaid Services for Dual Enrollees. Poster session presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 9; Philadelphia, PA.


DRA: Health Systems
DRE: Treatment - Observational
Keywords: Cost-Effectiveness, Organizational Planning, Utilization
MeSH Terms: none