Investigators Establish Typology for Veterans with Diabetes who Utilize Both VA Healthcare and Medicare

BACKGROUND:
Dual healthcare use is anticipated to increase as the Affordable Care Act and Veterans Choice Act enhance Veterans' access to care outside VA, and as more Veterans qualify for Medicare. However, dual use may lead to fragmented care and worse outcomes. This retrospective cohort study sought to establish a typology of VA and Medicare utilization among dually-enrolled Veterans with type 2 diabetes, to better understand specific patterns of dual use. Using data from VA and the Centers for Medicare and Medicaid Services, investigators identified 316,775 community-dwelling Veterans age >65 with type 2 diabetes who were dually-enrolled in VA and Medicare from FY2008 – FY2009. Using latent class analysis, investigators identified classes of Veterans based upon their probability of using VA and Medicare diabetes care services, including patient visits, laboratory tests, glucose test strips, and medications. They compared the amount of healthcare use between classes and identified key factors associated with latent class membership (i.e. demographics, Medicaid enrollment, priority group, and distance to the nearest VA).

FINDINGS:

• Four classes were identified that represent the most common ways dually-enrolled Veterans receive diabetes care:
  • Veterans in Class 1 (n= 170,750; 54%) had high probabilities of VA use and low probabilities of Medicare use across all facets of diabetes services.
  • Veterans in Class 2 (n= 54, 606; 17%) had a high probability of VA use across all care and a high probability of Medicare use for outpatient visits (88%) and lab tests (48%).
  • Veterans in Class 3 (n=69,158; 22%) had a nearly 0% probability of receiving glucose test strips from VA, but a 70% probability of receiving them through Medicare.
  • Veterans in Class 4 (n= 22,261; 7%) had a 50% probability of receiving a diabetes medication through VA, but nearly a 100% probability of receiving one through Medicare.
• Veterans who lived 40 or more miles from VA facilities had greater odds of being VA + Medicare test strip users (Class 3) or VA + Medicare prescription users (Class 4). Medicaid eligibility predicted membership in class 4.

IMPLICATIONS:

• Veterans with diabetes can be grouped into four distinct classes of dual health system use. This classification has applications for identifying patients facing differential risk from care fragmentation.
• By recognizing common characteristics associated with dual users in classes at greatest risk of care fragmentation, (e.g., dual medication users), study findings may be integrated into decision-support tools to help coordinate the care of certain Veterans, and actively address drivers of dual use.

LIMITATIONS:

• Data were from FY08-09 and only considered the dual use of Veterans enrolled in VA and fee-for-service Medicare, thus may not reflect patterns of dual use that may have emerged with more recent policies.

AUTHOR/FUNDING INFORMATION:
This study was supported through Dr. Gellad's HSR&D Career Development Award (CDA 09-207). All authors are part of HSR&D's Center for Health Equity Research & Promotion (CHERP), Pittsburgh and Philadelphia, PA.

Radomski T, Zhao X, Thorpe C, Thorpe J, Good C, Mor M, Fine M, and Gellad W. VA and Medicare Utilization among Dually-Enrolled Veterans with Type 2 Diabetes: A Latent Class Analysis. Journal of General Internal Medicine. February 22, 2016;e-pub ahead of print.