Medicare-Eligible Veterans' Reliance on VA Primary and Specialty Care Decreased Significantly from 2001 through 2004
In the past two decades, VA has transformed itself from a hospital-based system to an outpatient clinic-based system and is now moving to transform primary care into team-based care via Patient-Aligned Care Teams (PACT). A significant portion of Veterans who use the VA healthcare system also have health coverage through Medicare; however, few studies have examined changes in Veterans' use of outpatient care over time and the potential impact on care coordination in the PACT model. This study assessed longitudinal changes in patterns of cross-system healthcare use in VA and Medicare among 15,520 Medicare-eligible Veterans, who had used VA primary care in FY00. Using VA and Medicare data, investigators specifically examined reliance on VA primary and specialty care, tracking these visit types through FY04. Investigators also assessed factors related to the use of VA and Medicare.
- During the study period (FY01-FY04), Veterans made 869,000 primary and specialty care visits; 39% of all visits occurred within VA, with almost three times more specialty care visits than primary care visits each year. However, a majority of specialty care and nearly half of all primary care for Medicare-eligible Veterans was provided outside VA over this time period.
- Reliance on both VA primary and specialty care decreased substantially over the study period but the decrease was greatest in specialty care: whereas 52% of all specialty care visits occurred in VA in FY01, this fell to 31% in FY04. Over the same period, the proportion of all primary care visits that occurred in VA fell from 68% in FY01 to 57% in FY04. By FY04, only 20% of Medicare-eligible Veterans were completely reliant on Medicare for primary care (i.e. had 90% or more of their primary care visits with a Medicare provider) but 47% were completely reliant on Medicare for specialty care.
- Among Medicare-eligible Veterans, use of Medicare primary care increased among patients who were older, had a greater burden of illness, were served by a VA community-based outpatient clinic, or lived farther from a VA facility.
Patient reductions in reliance on VA primary and specialty care suggest increasingly fragmented care and more difficult care coordination. Increasing use of non-VA services may complicate implementation of the PACT model, but also may emphasize new opportunities for care coordination initiatives within PACT.
- This study does not include data on Veterans' use of other health insurance coverage, i.e., Medicaid and private insurance.
- The study examined healthcare use before Medicare Part D, and precedes the influx of returning Veterans from Iraq and Afghanistan.
This study was funded by HSR&D (IIR 04-292). Dr. Liu is part of HSR&D's Northwest Center for Outcomes Research in Older Adults, Seattle, WA. Dr. Burgess is part of HSR&D's Center for Organization, Leadership and Management Research, Boston, MA.
Liu C-F, Manning W, Burgess J, et al. Reliance on VA Outpatient Care by Medicare-Eligible Veterans. Medical Care June 16, 2011;e-pub ahead of print.