Where Do Women Veterans Get Their Inpatient Care?

PURPOSE: In this study we explore women veterans' use of Veterans Administration (VA) and private sector inpatient services. METHODS: Using a comprehensive dataset of VA and private hospital admissions, we identified 1,409 female patients who were enrolled in the VA system and had an inpatient admission between 1998 and 2000 in either the VA or the private sector. For Major Diagnostic Categories (MDCs) with >20 admits in each sector, we compared care provided in the private sector with care provided in the VA with respect to patient characteristics and resource utilization. In addition, we determined payment sources for women who used the private sector for inpatient care. FINDINGS: Women who used the VA were younger (mean, 54 vs. 60 years; p < .001) and more likely to be service connected (39% vs. 24%; p < .001), African American (25% vs. 13%; p < .001), and urban dwelling (81% vs. 75%; p < .01). Women veterans were significantly more reliant on the VA system for mental diseases, alcohol and drug use, and skin/subcutaneous/breast diseases. For every MDC examined, VA hospitals had longer mean lengths of stay. Among VA eligible women <65 years old using the private sector, 56% used private insurance, 15% used Medicare, 14% used Medicaid, and 9% did not have insurance. CONCLUSIONS: In New York, female veterans admitted to VA hospitals differed from women admitted to private hospitals by patient characteristics, admission reason, and admission resource consumption. Many younger women who used the private sector were reliant on other government agencies (Medicaid or Medicare) or out-of-pocket payments for their inpatient care.     

Veterans Health Administration and Medicare Outpatient Health Care Utilization by Older Rural and Urban New England Veterans

CONTEXT: Older veterans often use both the Veterans Health Administration (VHA) and Medicare to obtain health care services. PURPOSE: The authors sought to compare outpatient medical service utilization of Medicare-enrolled rural veterans with their urban counterparts in New England. METHODS: The authors combined VHA and Medicare databases and identified veterans who were age 65 and older and enrolled in Medicare fee-for-service plans, and they obtained records of all their VHA services in New England between 1997 and 1999. The authors used ZIP codes to designate rural or urban residence and categorized outpatient utilization into primary care, individual mental health care, non-mental health specialty care, or emergency room care. FINDINGS: Compared with their urban counterparts, veterans living in rural settings used significantly fewer VHA and Medicare-funded primary care, specialist care, and mental health care visits in all 3 years examined (P<.001 for all). Compared with urban veterans, veterans living in rural settings used fewer VHA emergency department services in 1998 and 1999 but more Medicare-funded emergency department visits in 1997. The authors found some evidence of substitution of Medicare for VHA emergency visits in rural veterans, but no other evidence of like-service substitution. Rural veterans were more reliant on Medicare for primary care and on VHA services for specialty and mental health care. CONCLUSIONS: These findings suggest that rural access to federally funded health care is restricted relative to urban access. Older veterans may choose different systems of care for different health care services. With poor access to primary care, rural veterans may substitute emergency room visits for routine care.     

Practical and Policy Implications of Using Different Rural-Urban Classification Systems: A Case Study of Inpatient Service Utilization Among Veterans Administration Users

ABSTRACT:  Context: Several classification systems exist for defining rural areas, which may lead to different interpretations of rural health services data. Purpose: To compare rural classification systems on their implications for estimating Veterans Administration (VA) utilization. Methods: Using 7 classification systems, we counted VA health care enrollees who lived in each category, and number admitted to VA hospitals or non-VA hospitals under Medicare. For dual VA-Medicare enrollees over age 65, we compared VA and private sector hospitalizations on numbers of admissions and bed-days of care. We compared VA enrollees' relative proportions across rural to urban categories for each classification system and evaluated discordance between systems at the veterans-integrated service networks (VISN) level. Findings: Enrollment and inpatient utilization counts for rural veterans vary considerably from one classification system to another, though the systems generally agree that admission rates, length of stay, and reliance on the VA for care are lower for rural veterans. Among older dual VA and Medicare enrollees, rural residents rely on non-VA facilities more, though this effect also varies widely depending on the classification scheme. VISNs vary greatly in the proportions of patients who are rural residents, and in the degree to which classification systems are discordant in designating patients as rural. Conclusions: Decisions about allocating VA health care resources to target "rural" patients may be affected greatly by the rural classification system chosen, and the impact of this choice will affect some hospital networks much more than others.     

Provider incentives and access to dental care: Evaluating NHS reforms in England

Changes were made to the management and delivery of primary dental care in the NHS in England in 2006 aimed at improving access to NHS dental services among populations with low use. These included: (i) commissioning of NHS dental services by primary care trusts (ii) replacing item of service patient charges by Course of Treatment cost bands and (iii) changing the remuneration of dentists providing NHS dental care. Using longitudinal data from the 1991-2008 waves of the British Household Panel Survey, we estimate the effects of these changes on the levels and distribution of dental care in the population and on the public–private mix of primary dental care services in England using dynamic probit models. We find evidence of a decrease in NHS use, driven by reductions in use among populations with previously good access to care and a positive effect of the reforms on consumer transitions from NHS to private practice. Our results highlight the potential (unintended) consequences of reforming public health care systems. It appears that contrary to expanding NHS access, the dental reforms contracted NHS use amongst those with previously good access. This contraction relied upon the ability of the private sector to absorb this group.     

Use of VA and Medicare services by dually eligible veterans with psychiatric problems

Objective. To examine how service accessibility measured by geographic distance affects service sector choices for veterans who are dually eligible for veterans affairs (VA) and Medicare services and who are diagnosed with mental health and/or substance abuse (MH/SA) disorders.
Data Sources. Primary VA data sources were the Patient Treatment (acute care), Extended Care (long-term care), and Outpatient Clinic files. VA cost data were obtained from (1) inpatient and outpatient cost files developed by the VA Health Economics and Resource Center and (2) outpatient VA Decision Support System files. Medicare data sources were the denominator, Medicare Provider Analysis Review (MEDPAR), Provider-of-Service, Outpatient Standard Analytic and Physician/Supplier Standard Analytic files. Additional sources included the Area Resource File and Census Bureau data.
Study Design. We identified dually eligible veterans who had either an inpatient or outpatient MH/SA diagnosis in the VA system during fiscal year (FY)'99. We then estimated one- and two-part regression models to explain the effects of geographic distance on both VA and Medicare total and MH/SA costs.
Principal Findings. Results provide evidence for substitution between the VA and Medicare, demonstrating that poorer geographic access to VA inpatient and outpatient clinics decreased VA expenditures but increased Medicare expenditures, while poorer access to Medicare-certified general and psychiatric hospitals decreased Medicare expenditures but increased VA expenditures.
Conclusions. As geographic distance to VA medical facility increases, Medicare plays an increasingly important role in providing mental health services to veterans.     

Health Care Expenditures for Urban and Rural Veterans in Veterans Health Administration Care

Objective. To compare Veterans Health Administration (VA) patients, non-VA-using veterans, and nonveterans, separated by urban/rural residence and age group, on their use of major categories of medical care and payment sources.
Data Source. Expenditures for health care–using men in Medical Expenditure Panel Surveys from 1996 through 2004.
Study Design. Retrospective, cross-sectional analysis.
Data Collection/Extraction Methods. Controlling for demographics, health status, and insurance, we compared groups on population-weighted expenditures for inpatient, hospital-based outpatient, office-based, pharmacy, and other care, by major payers (self/family, private insurance, Medicare, other sources, and VA).
Results. VA users received most of their health care outside of the VA system, paid through private insurance or Medicare; self-payments were substantial. VA users under 65 reported worse health if they were rural residents but also lower expenditures overall and less care through private insurance.
Conclusions. VA health care users get most of their medical care from non-VA providers. Working-age VA users have less insurance coverage and rely more on VA care if they live in rural areas.     

The Impact of Private Insurance Coverage on Veterans' Use of VA Care: Insurance and Selection Effects

Objective. To examine private insurance coverage and its impact on use of Veterans Health Administration (VA) care among VA enrollees without Medicare coverage.
Data Sources. The 1999 National Health Survey of Veteran Enrollees merged with VA administrative data, with other information drawn from American Hospital Association data and the Area Resource File.
Study Design. We modeled VA enrollees' decision of having private insurance coverage and its impact on use of VA care controlling for sociodemographic information, patients' health status, VA priority status and access to VA and non-VA alternatives. We estimated the true impact of insurance on the use of VA care by teasing out potential selection bias. Bias came from two sources: a security selection effect (sicker enrollees purchase private insurance for extra security and use more VA and non-VA care) and a preference selection effect (VA enrollees who prefer non-VA care may purchase private insurance and use less VA care).
Principal Findings. VA enrollees with private insurance coverage were less likely to use VA care. Security selection dominated preference selection and naïve models that did not control for selection effects consistently underestimated the insurance effect.
Conclusions. Our results indicate that prior research, which has not controlled for insurance selection effects, may have underestimated the potential impact of any private insurance policy change, which may in turn affect VA enrollees' private insurance coverage and consequently their use of VA care. From the decline in private insurance coverage from 1999 to 2002, we projected an increase of 29,400 patients and 158 million dollars for VA health care services.     

Health care utilisation in India

India has a plurality of health care systems as well as different systems of medicine. The government and local administrations provide public health care in hospitals and clinics. Public health care in rural areas is concentrated on prevention and promotion services to the detriment of curative services. The rural primary health centers are woefully underutilized because they fail to provide their clients with the desired amount of attention and medication and because they have inconvenient locations and long waiting times. Public hospitals provide 60% of all hospitalizations, while the private sector provides 75% of all routine care. The private sector is composed of an equal number of qualified doctors and unqualified practitioners, with a greater ratio of unqualified to qualified existing in less developed states. In rural areas, qualified doctors are clustered in areas where government services are available. With a population barely able to meet its nutritional needs, India needs universalization of health care provision to assure equity in health care access and availability instead of a large number of doctors who are profiting from the sicknesses of the poor.     

Mortality of Department of Veterans Affairs patients undergoing coronary revascularization in private sector hospitals

OBJECTIVE: A limitation of studies comparing outcomes of Veterans Affairs (VA) and private sector hospitals is uncertainty about the methods of accounting for risk factors in VA populations. This study estimates whether use of VA services is a marker for increased risk by comparing outcomes of VA users and other patients undergoing coronary revascularization in private sector hospitals. DATA SOURCES: Males 67 years and older undergoing coronary artery bypass graft (CABG; n=687,936) surgery or percutaneous coronary intervention (PCI; n=664,124) during 1996-2002 were identified from Medicare administrative data. Patients using VA services during the 2 years preceding the Medicare admission were identified using VA administrative files. STUDY DESIGN: Thirty-, 90-, and 365-day mortality were compared in patients who did and did not use VA services, adjusting for demographic and clinical risk factors using generalized estimating equations and propensity score analysis. RESULTS: Adjusted mortality after CABG was higher (p<.001) in VA users compared with nonusers at 30, 90, and 365 days: odds ratio (OR)=1.07 (95 percent confidence interval [CI], 1.03-1.11), 1.07 (95 percent CI, 1.04-1.10), and 1.09 (95 percent CI, 1.06-1.12), respectively. For PCI, mortality at 30 and 90 days was similar (p>.05) for VA users and nonusers, but was higher at 365 days (OR=1.09; 95 percent CI, 1.06-1.12). The increased risk of death in VA users was limited to patients with service-connected disabilities or low incomes. Odds of death for VA users were slightly lower using samples matched by propensity scores. CONCLUSIONS: A small difference in risk-adjusted outcomes for VA users and nonusers undergoing revascularization in private sector hospitals was found. This difference reflects unmeasured severity in VA users undergoing revascularization in private sector hospitals.     

Shifting the financial burden: the VA ambulatory care discharge policy.

The Department of Veterans Affairs is a primary source of health care services for many of the nation's uninsured and underinsured. Changes in congressionally mandated eligibility criteria and limited increases in appropriations have forced the Department to adopt a policy of discharging chronic but stable outpatients who have been treated for non-service-connected health conditions. Survey data from one VA medical center suggest that many, but not all, of those discharged: 1) have either Medicare or private insurance coverage; 2) have not sought or found alternative physician services in their local communities; 3) have discontinued taking previously prescribed medications; 4) report worsened health status since discharge; and, 5) have been hospitalized. In general, discharged patients from the lowest income group report the greatest financial access barriers. Preliminary analyses of the discharge policy suggest the potential for decreased access to needed medical services due to financial factors and cost-shifting from the VA to patients and other federal, state and local payers and providers.     

An evaluation of universal vouchers as a demand-side subsidy to change primary care utilization: A retrospective analysis of longitudinal services utilisation and voucher claims data from a survey cohort in Hong Kong

To incentivize private primary care utilization and reduce reliance on public healthcare services, Elderly Healthcare Voucher Scheme has been implemented to provide a voucher entitlement to entire older resident population for subsidising their purchase of unspecified primary healthcare services in the private sector. Our study assessed whether voucher usage is associated with reduced utilization of public healthcare services. We retrieved the public healthcare services utilization and voucher transaction data of a survey cohort of 551 participants, who were age eligible for the scheme since 2009, over the period 2009–2015. Our results showed that voucher usage was not associated with reduced utilization of public healthcare services and has encouraged dual utilization of public and private healthcare. It may be due to a generated supply-induced demand and price inflation. The finding suggests the voucher is specifically designed to address the health systems issues to achieve the effective policy objectives. Defining the specific services to be provided and the prices at which they should be offered based on the needs of specified populations is a fundamental design parameter which needs to be incorporated. The alternatives of whether primary care services should be expanded and provided in the public sector or purchased using supply/demand side instruments should be considered taking the context and goals of the health system into account.     

Health status of veterans found ineligible for ongoing outpatient care

In patient's declared ineligible for longitudinal outpatient care in the Veterans Administration (VA) health care system, it is unclear how health status changes after discharge from the VA or how many patients find a regular provider of care in the private sector. Among 65 patients declared ineligible for longitudinal care at the Gainesville VA Medical Center (GVAMC), 28 (43%) continued to use this facility as their primary source of general medical care. Patients who lived within 50 miles of GVAMC or had used this facility frequently in the past were more likely to return to GVAMC for their general care. In the 37 patients who no longer used GVAMC for general care, 42% could not identify a regular provider of care outside GVAMC nine months after their discharge from this facility. Thirty-six percent had not seen a non-VA physician during this time, and 44% felt their health had worsened since they were released from GVAMC. A large number of patients who are declared ineligible for longitudinal care in the VA system continue to use the VA system for primary care. Among those who stop using the VA, many do not receive any medical care or obtain a regular care provider within the first nine months after their release from the VA system.John Meuleman, M.D. is with the Veterans Administration Medical Center, Geriatric Research, Education and Clinical Center (182), Gainesville, FL 32602.Marcia Mounts, M.D. is a Fellow at the Geriatric Medicine Program of the Veterans Administration Medical Center in Gainesville, FL 32602.     

'Where is the public health sector?' Public and private sector healthcare provision in Madhya Pradesh, India

OBJECTIVE: This paper aims to empirically demonstrate the size and composition of the private health care sector in one of India's largest provinces, Madhya Pradesh. METHODOLOGY: It is based on a field survey of all health care providers in Madhya Pradesh (60.4 million in 52,117 villages and 394 towns). Seventy-five percent of the population is rural and 37% live below poverty line. This survey was done as part of the development of a health management information system. FINDINGS: The distribution of health care providers in the province with regard to sector of work (public/private), rural-urban location, qualification, commercial orientation and institutional set-up are described. Of the 24,807 qualified doctors mapped in the survey, 18,757 (75.6%) work in the private sector. Fifteen thousand one hundred forty-two (80%) of these private physicians work in urban areas. The 72.1% (67793) of all qualified paramedical staff work in the private sector, mostly in rural areas. CONCLUSION: The paper empirically demonstrates the dominant heterogeneous private health sector and the overall the disparity in healthcare provision in rural and urban areas. It argues for a new role for the public health sector, one of constructive oversight over the entire health sector (public and private) balanced with direct provision of services where necessary. It emphasizes the need to build strong public private partnerships to ensure equitable access to healthcare for all.     

Is travel distance a barrier to veterans' use of VA hospitals for medical surgical care?

Lengthy travel distances may explain why relatively few veterans in the United States use VA hospitals for inpatient medical/surgical care. We used two approaches to distinguish the effect of distance on VA use from other factors such as access to alternatives and veterans' characteristics. The first approach describes how disparities in travel distance to the VA are related to other characteristics of geographic areas. The second approach involved a multivariate analysis of VA use in postal zip code areas (ZCAs). We used several sources of data to estimate the number of veterans who had priority access to the VA so that use rates could be estimated. Access to hospitals was characterized by estimated travel distance to inpatient providers that typically serve each ZCA. The results demonstrate that travel distance to the VA is variable, with veterans in rural areas traveling much farther for VA care than veterans in areas of high population density. However, Medicare recipients also travel farther in areas of low population density. In some areas veterans must travel lengthy distances for VA care because VA hospitals which were built over the past few decades are not located close to areas in which veterans reside in the 1990s. The disparities in travel distance suggest inequitable access to the VA. Use of the VA decreases with increases in travel distance only up to about 15 miles, after which use is relatively insensitive to further increases in distance. The multivariate analyses indicate that those over 65 are less sensitive to distance than younger veterans, even though those over 65 are Medicare eligible and therefore have inexpensive access to alternatives. The results suggest that proximity to a VA hospital is only one of many factors determining VA use. Further research is indicated to develop an appropriate response to the needs of the small but apparently dedicated group of VA users who are traveling very long distances to obtain VA care.     

Adequate Access to Posthospital Home Health Services: Differences Between Urban and Rural Areas

The health care environment in rural areas changed dramatically in the 1980s. Policy-makers are concerned that these changes have reduced access to care among residents of rural areas. This study measures adequate access to Medicare home health services and determines whether it differs for urban and rural beneficiaries. Adequate access to care is measured by whether a patient with a specific health condition received a level of skilled services predetermined as appropriate for that condition. The predetermined levels of care were developed in an earlier study and were found to correlate with adverse outcomes. This study focused on patients with diabetes mellitus and surgical hip procedures to concentrate on access to skilled nursing services and physical therapy services. To conduct the analysis, a data base was constructed that included both patient utilization and health status data, drawing on three different data sources: Medicare hospital claims data, Medicare home health bill record data, and home health plan of treatment data from patients' utilization review forms (forms 485 and 486). The analysis samples consisted of 404 patients with diabetes and 876 patients who had surgical hip procedures. Significant differences were found between urban and rural areas in access to home health services. The largest differences were found in access to physical therapy services, but differences in access to skilled nursing services also exist. The data suggest that the availability of skilled care services may cause these differences.     

Native American Vietnam-era Veterans’ Access to VA Healthcare: Vulnerability and Resilience in Two Montana Reservation Communities

As a growing segment of the military, Native Americans are expected to increase enrollment in Department of Veterans Affairs (VA) healthcare. Currently, 20% of Native American veterans are aged 65–74, which means they served during the Vietnam era. This study explores the experiences of rural American Indian veterans from two Montana reservations with accessing VA health services. Utilizing detailed data obtained in focus group and individual interviews, we examine the experiences, attitudes, barriers and needs of rural Vietnam-era veterans. Analyses indicate that while Native American Vietnam-era veterans experienced a poor reception returning to the US after military service, they had more positive receptions in their home reservation communities. However, reintegration was often impeded by poor local opportunity structures and limited resources. As they have aged and turned to the VA for healthcare, these veterans have encountered barriers such as lack of information regarding eligibility and services, qualifying for care, excessive distances to health services, the cost of travel, and poor quality of assistance from VA personnel. Despite variations in their resources, tribal community efforts to honor veterans have begun to facilitate better access to healthcare. Focusing on the roles and importance of place–based resources, this study clarifies challenges and obstacles that Native American Vietnam-era veterans experience with accessing VA health services in rural, reservation communities. Additionally, findings show how tribal efforts are facilitating access as they begin to implement the 2010 agreement between the VA and Indian Health Services to better serve Native veterans.     

Unmet healthcare needs in Ireland: Analysis using the EU-SILC survey

The analysis used the 2013 Survey of Income and Living Conditions to examine the extent and causes of unmet need for healthcare services in Ireland. The analysis found that almost four per cent of participants reported an unmet need for medical care. Overall, lower income groups, those with poorer health status and those without free primary care and/or private insurance were more likely to report an unmet healthcare need. The impact of income on the likelihood of reporting an unmet need was particularly strong for those without free primary care and/or private insurance, suggesting a role for the health system in eradicating income based inequalities in unmet need. Factors associated with the healthcare system – cost and waiting lists – accounted for the majority of unmet needs. Those with largely free public healthcare entitlement were more likely than all other eligibility categories to report that their unmet need was due to waiting lists (rather than cost). While not possible to explicitly examine in this analysis, it is probable that unmet need due to cost is picking up on the relatively high out-of-pocket payments for primary care for those who must pay for GP visits; while unmet need due to waiting is identifying the relatively long waiting times within the acute hospital sector for those within the public system.     

Substance abuse as a predictor of VA medical care utilization among vietnam veterans

The primary objective was to determine whether Vietnam veterans who had alcohol or drug use problems prior to, during, or immediately after the war used Veterans Administration (VA) health care services more intensively during the next two decades than Vietnam veterans without these behaviors. The secondary objective was to identify predictors of VA health services utilization among data collected at service discharge. Logistic and ordinary least squares regression were used to model the effect of predisposing, enabling, and need factors on utilization of VA health services (N=571). Results show that Vietnam veterans who had substance use problems either before or immediately after Vietnam used VA health care services more intensively during the next two decades than Vietnam veterans without these behaviors. Depression and psychiatric care seeking were also important predictors. More research is needed to evaluate the impact of health system characteristics and private sector use on the predictive ability of the models.The views expressed in this article are those of the authors and should not be construed as reflecting the official position of St. Louis University, Washington University, or the Department of Veterans Affairs. This article was a poster presentation at the annual meeting of the Association for Health Services Research, June 15–17, 1997, Chicago.     

Relationship between Clinical Conditions and Use of Veterans Affairs Health Care among Medicare-Enrolled Veterans

Objective. To determine how reliance on Veterans Affairs (VA) for medical care among veterans enrolled in Medicare is affected by medical conditions, access, and patient characteristics. Data Sources/Study Setting. Department of Veterans Affairs. Study Design. We examined reliance on the VA for inpatient, outpatient, and overall medical care among all VA users in fiscal years 2003 and 2004 who were also enrolled in Medicare. We calculated the marginal effects of patient factors on VA reliance using fractional logistic regression; we also analyzed overall VA reliance separately for under‐65 and age‐65+ groups. The primary focus of this analysis was the relationship between aggregated condition categories (ACCs), which represent medical conditions, and reliance on the VA. Principal Findings. Mean VA reliance was significantly higher in the under‐65 population than in the age‐65+ group (0.800 versus 0.531). Lower differential distance to the VA, and higher VA‐determined priority for health care, predicted higher VA reliance. Most individual ACCs were negatively associated with VA reliance, though substance abuse and mental health disorders were significantly associated with increased reliance on VA care. Conditions of the eyes and ears/nose/throat had positive marginal effect on VA reliance for the under 65, while diabetes was positive for age 65+. Among inpatients, veterans with ACCs for mental health conditions, eye conditions, amputations, or infectious and parasitic conditions had higher likelihood of a VA hospitalization than inpatients without these conditions. Conclusions. Many dually enrolled Veterans use both Medicare and VA health care. Age, accessibility, and priority level for VA services have a clear relationship with VA reliance. Because dual use is common, coordination of care among health care settings for such patients should be a policy priority.