Use of Outpatient Care in Veterans Health Administration and Medicare among Veterans Receiving Primary Care in Community-Based and Hospital Outpatient Clinics

Authors

  • Chuan-Fen Liu,

    1. Northwest Center for Outcomes Research in Older Adults, Department of Veterans Affairs, HSR&D, VA Puget Sound Health Care System, 1100 Olive Way, Suite 1400, Seattle, WA 98101
    2. Department of Health Services, University of Washington, Seattle, WA
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    • Address correspondence to Chuan-Fen Liu, Ph.D., M.P.H., Northwest Center for Outcomes Research in Older Adults, Department of Veterans Affairs, HSR&D, VA Puget Sound Health Care System, 1100 Olive Way, Suite 1400, Seattle, WA 98101; e-mail: chuan-fen.liu@va.gov. Chuan-Fen Liu, Ph.D., M.P.H., is with the Department of Health Services, University of Washington, Seattle, WA. Michael Chapko, Ph.D., and Nancy D. Sharp, Ph.D., are with the Northwest Center for Outcomes Research in Older Adults, Department of Veterans Affairs, Seattle, WA, and are also with the Department of Health Services, University of Washington, Seattle, WA. Chris L. Bryson, M.D., M.S., is with the Northwest Center for Outcomes Research in Older Adults, Department of Veterans Affairs, Seattle, WA, and also with the Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, WA. James F. Burgess Jr., Ph.D., is with the Center for Organization, Leadership & Management Research, Department of Veterans Affairs, Boston, MA, and also with the Department of Health Policy and Management, School of Public Health, Boston University, Boston, MA. John C. Fortney, Ph.D., is with the South Central Mental Health Illness Research and Education and Clinical Center, North Little Rock, AR, is also with the HSR&D Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, AR, and also with Division of Health Service Research, Department of Psychiatry and Behavioral Sciences, University of Arkansas for Medical Sciences, North Little Rock, AR. Mark Perkins, Pharm.D., is with the Northwest Center for Outcomes Research in Older Adults, Department of Veterans Affairs, Seattle, WA. Matthew L. Maciejewski, Ph.D., is with the Center for Health Services Research in Primary Care, Department of Veterans Affairs, Durham, NC, and also with the Division of General Internal Medicine, Department of Medicine, Duke University Medical Center, Durham, NC.

  • Michael Chapko,

    1. Department of Health Services, University of Washington, Seattle, WA
    2. Northwest Center for Outcomes Research in Older Adults, Department of Veterans Affairs, Seattle, WA
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  • Chris L. Bryson,

    1. Northwest Center for Outcomes Research in Older Adults, Department of Veterans Affairs, Seattle, WA
    2. Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, WA
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  • James F. Burgess Jr.,

    1. Center for Organization, Leadership & Management Research, Department of Veterans Affairs, Boston, MA
    2. Department of Health Policy and Management, School of Public Health, Boston University, Boston, MA
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  • John C. Fortney,

    1. South Central Mental Health Illness Research and Education and Clinical Center, North Little Rock, AR
    2. HSR&D Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, AR
    3. Division of Health Service Research, Department of Psychiatry and Behavioral Sciences, University of Arkansas for Medical Sciences, North Little Rock, AR
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  • Mark Perkins,

    1. Northwest Center for Outcomes Research in Older Adults, Department of Veterans Affairs, Seattle, WA
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  • Nancy D. Sharp,

    1. Department of Health Services, University of Washington, Seattle, WA
    2. Northwest Center for Outcomes Research in Older Adults, Department of Veterans Affairs, Seattle, WA
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  • Matthew L. Maciejewski

    1. Center for Health Services Research in Primary Care, Department of Veterans Affairs, Durham, NC
    2. Division of General Internal Medicine, Department of Medicine, Duke University Medical Center, Durham, NC
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Abstract

Objective. To examine differences in use of Veterans Health Administration (VA) and Medicare outpatient services by VA primary care patients.

Data Sources/Study Setting. VA administrative and Medicare claims data from 2001 to 2004.

Study Design. Retrospective cohort study of outpatient service use by 8,964 community-based and 6,556 hospital-based VA primary care patients.

Principal Findings. A significant proportion of VA patients used Medicare-reimbursed primary care (>30 percent) and specialty care (>60 percent), but not mental health care (3–4 percent). Community-based patients had 17 percent fewer VA primary care visits (p<.001), 9 percent more Medicare-reimbursed visits (p<.001), and 6 percent fewer total visits (p<.05) than hospital-based patients. Community-based patients had 22 percent fewer VA specialty care visits (p<.0001) and 21 percent more Medicare-reimbursed specialty care visits (p<.0001) than hospital-based patients, but no difference in total visits (p=.80).

Conclusions. Medicare-eligible VA primary care patients followed over 4 consecutive years used significant primary care and specialty care outside of VA. Community-based patients offset decreased VA use with increased service use paid by Medicare, suggesting that increasing access to VA primary care via community clinics may fragment veteran care in unintended ways. Coordination of care between VA and non-VA providers and health care systems is essential to improve the quality and continuity of care.

Ancillary