Health and ambulatory care use among Native American veterans

In 1995, the Veterans Health Administration reorganized its health services structure to emphasize ambulatory care. Successful health care planning and improving access to ambulatory care services now depends upon a better understanding of health care needs and outpatient services. Because the veteran population is heterogeneous, it is important to understand the health, access issues, and utilization of ambulatory care services in order to develop effective strategies and interventions to ensure access to and utilization of ambulatory care. Drawing on a focus group methodology with 86 Native American veterans, representing 34 tribes, this study is a qualitative examination of the health, access, use of the Department of Veterans Affairs Health Care services, barriers to health care, and satisfaction with care experienced by Native American veterans. Results reveal problems in accessing care, receiving appropriate care, and coordinating care within the VA health care system. Policy and program recommendations include increasing outreach and education efforts regarding the availability of benefits and services, improving coordination of services between the Indian Health Service and the VA, and reemphasizing the importance of patient-centered care.     

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.     

Comparing the health status of male and female veterans who use VA health care: results from the VA Women's Health Project

BACKGROUND: In recent years the number of women serving in the military has increased substantially, resulting in more demand for VA services by women veterans. This paper describes the characteristics and health status of women veterans who use VA ambulatory services. METHODS: Respondents in the VA Women's Health Project (n = 719) represent a randomly selected subsample from all women who had an ambulatory visit between July 1, 1994 and June 30, 1995 at a large tertiary care VA facility in the Boston area. Summary statistics on eight dimensions of health status (using the SF-36) for women veterans who use VA ambulatory care are provided. Comparisons are made between women veterans and men veterans who use VA services. RESULTS: Women veterans reported consistently low scores on health status across multiple dimensions, reflecting considerable health needs. Among veterans using VA services, women were younger, better educated, and less likely to be married than male veterans. Women veterans who use VA ambulatory services scored lower on every scale except physical functioning and general health perceptions when compared to male VA users. There were more pronounced differences for women on scales measuring emotional health. CONCLUSIONS: Health status among women veterans is moderate to poor. Important differences in health status are observed between men and women who use VA services which have implications for improving health care to women veterans at VA facilities. These findings strongly indicate that increased mental health services need to be available for women veterans seeking VA health care.     

Veterans using and uninsured veterans not using Veterans Affairs (VA) health care

OBJECTIVES: The objectives of this study were to: (1) examine veteran reliance on health services provided by the Veterans Health Administration (VA), (2) describe the characteristics of veterans who receive VA care, and (3) report rates of uninsurance among veterans and characteristics of uninsured veterans. METHODS: The authors analyzed data from the 2000 Behavioral Risk Factor Surveillance System. Using bivariate and multivariate analyses, the association of veteran's demographic characteristics, health insurance coverage, and use of VA services were examined. Veterans not reporting VA coverage and having no other source of health insurance were considered uninsured. RESULTS: Among veteran respondents, 6.2% reported receiving all of their health care at the VA, 6.9% reported receiving some of their health care at the VA, and 86.9% did not use VA health care. Poor, less-educated, and minority veterans were more likely to receive all of their health care at the VA. Veterans younger than age 65 who utilized the VA for all of their health care also reported coverage with either private insurance (42.6%) or Medicare (36.3%). Of the veterans younger than age 65, 8.6% (population estimate: 1.3 million individuals) were uninsured. Uninsured veterans were less likely to be able to afford a doctor or see a doctor within the last year. CONCLUSIONS: Veterans who utilized the VA for all of their health care were more likely to be from disadvantaged groups. A large number of veterans who could use VA services were uninsured. They should be targeted for VA enrollment given the detrimental clinical effects of being uninsured.     

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.     

Physical and Mental Health and Access to Care Among Nonmetropolitan Veterans Health Administration Patients Younger Than 65 Years

CONTEXT: The 4.5 million military veterans treated by the Veterans Health Administration (VA) are believed to experience poorer physical and mental health than nonveterans. Furthermore, nonmetropolitan residents have less access to medical services, whether or not they are veterans in VA care. A direct comparison of metropolitan and nonmetropolitan veterans and nonveterans on a national health survey has not been reported, so it is not known whether nonmetropolitan VA patients experience similar medical need or access as other nonmetropolitan residents. PURPOSE: We sought to compare the perceptions of health status and access to care among metropolitan and nonmetropolitan veterans in VA care, other veterans, and nonveterans in a large national sample surveyed under the same conditions. METHODS: Male respondents to the 2000 Behavioral Risk Factor Surveillance System health survey were divided into veterans or nonveterans, VA users or nonusers, metropolitan or nonmetropolitan residents, and 1 of 3 age groups (18-44, 45-64, and 65(+)). Responses to questions about current health status, health coverage, and access to care were submitted to chi-square analyses or analyses of variance, using SUDAAN software to compute survey error variance. FINDINGS: Nonmetropolitan VA patients younger than 65 years consistently reported the worst physical and mental health status and reduced access to care. CONCLUSIONS: VA can anticipate increasing demand for mental and physical health care among rural veterans younger than 65 years.     

Geographical proximity and health care utilization in veterans with SCI&D in the USA

In the USA, substantial geographic variation in health care utilization exists in the Department of Veterans Affairs (VA) health care system. Utilization of health care services is especially important for veterans with spinal cord injuries and disorders (SCI&D) who are often at high risk for secondary complications related to their SCI&D. Due to impaired mobility, access to health care for veterans with SCI&D may be even more challenging. The goal of this cross-sectional study was to describe health care utilization relative to SCI&D veteran residential geographic proximity to VA health care facilities. A negative binomial regression model was used to examine VA outpatient utilization. Veterans with SCI&D utilized outpatient services less frequently when VA facilities were farther away from their residences (p<0.000). Female (p<0.000), older (p<0.000), and non-white veterans (p<0.000), and veterans with history of respiratory (p<0.000), kidney/urinary tract (p<0.005), circulatory (p<0.000), or digestive system diseases (p<0.003) were more likely to utilize outpatient care during the study period. A Poisson model was used to examine inpatient utilization. Inpatient utilization decreased when travel distance to VA facility increased (p<0.000). Contrary to outpatient, age did not significantly affect veterans' likelihood of using inpatient health care. Marital status, gender, race, and level of injury were not related to inpatient utilization. However, history of prior illnesses including respiratory (p<0.000), kidney/urinary tract (p<0.000), circulatory (p<0.005), digestive system (p<0.015), or skin/subcutaneous tissue/breast-related illnesses (p<0.000) were associated with a greater likelihood of inpatient utilization. Geographic proximity and other factors on health care use must be considered in order to meet the health care demand patterns of veterans with SCI&D.     

Utilization of VA and Medicare services by Medicare-eligible veterans: the impact of additional access points in a rural setting

The Veterans Health Administration (VA) has recently established community-based outpatient clinics (CBOCs) to improve access to primary care. In our study we sought to understand the relationship between the degree to which older, Medicare-eligible veterans use CBOCs and their utilization of health services through both the VA and Medicare. We wanted to limit our analysis to a largely rural setting in which patients have greater healthcare needs and where we expected to find that the availability of CBOCs significantly improved access to VA healthcare. Therefore, we identified 47,209 patients who lived in the largely rural states of northern New England and were enrolied in the VA in 1997, 1998, and 1999. We used a merged VA/Medicare dataset to determine utilization in the VA and the private sector and to categorize patients into three segments: those who used only CBOCs for VA primary care, those who used only VA medical centers for VA primary care, and those who used both. For all three groups, we found that VA patients obtained an increasing amount of their care in the private sector, which was funded by Medicare. VA patients who obtained all of their VA primary care services through CBOCs relied on the private sector for most of their specialty and inpatient care needs. Our findings suggest that, in this rural New England setting, improved access to VA care through CBOCs appears to provide complementary, not substitutive, services. Analyses of the efficiency of adding access points to healthcare systems should be conducted, with particular emphasis on examining the possibilities of encroachment, worsened coordination of care, and potential health services overuse.     

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.     

Women Veterans’ Attrition from the VA Health Care System

PurposePatient attrition from the Veterans Health Administration (VA) health care system could undercut its mission to ensure care for eligible veterans. Attrition of women veterans could exacerbate their minority status and impede systemic efforts to provide high-quality care. We obtained women veterans’ perspectives on why they left or continued to use VA health care.MethodsA sampling frame of new women veteran VA patients was stratified by those who discontinued (attriters) and those who continued (non-attriters) using VA care. Semistructured interviews were conducted from 2017 to 2018. Transcribed interviews were coded for women's decision-making, contexts, and recommendations related to health care use.ResultsFifty-one women veterans (25 attriters and 26 non-attriters) completed interviews. Reasons for attrition included challenging patient care experiences (e.g., provider turnover, claim processing challenges) and the availability of private health insurance. Personal experiences with VA care (e.g., gender-specific care) were impactful in women's decision to use VA. The affordability of VA care was influential for both groups to stay connected to services. More than one-third of women originally categorized as attriters described subsequently reentering or planning to reenter VA care. Suggestions to decrease attrition included increasing outreach, improving access, and continuing to tailor care delivery to women veterans' needs.ConclusionsUnderstanding the drivers of patients’ decisions to use or not use the VA is critical for the development of strategies to improve retention of current patients and optimize health outcomes for veterans. Women veterans described complex reasons why they left or continued using VA, with cost/affordability playing an important role even in considerations of returning to VA after a long hiatus.     

The organization and delivery of women's health care in Department of Veterans Affairs Medical Center.

Congressional eligibility reforms have profoundly changed the array of services to be made available to women veterans in Department of Veterans Affairs (VA) health care facilities. These include access not only to primary and specialty care services already afforded VA users, but also to a full spectrum of gender-specific services, including prenatal, obstetric, and infertility services never before provided in VA settings. The implications of this legislative mandate for delivering care to women veterans are poorly understood, as little or no information has been available about how care for women veterans is organized. This article reports on the first national assessment of variations in the organization of care for women veterans.     

Changes in characteristics of veterans using the VHA health care system between 1996 and 1999

Background  

The Department of Veterans Affairs' Veterans Health Administration (VHA) provides a health care safety net to veterans. This study examined changes in characteristics of veterans using the VHA health care system between 1996 and 1999 when VHA implemented major organizational changes to improve access of ambulatory care and to provide care to more veterans.     

The veterans healthcare system: preparing for the twenty-first century

Since its establishment in 1946, the veterans healthcare system has greatly expanded in both size and responsibility. It is now the largest integrated healthcare system in the United States, the nation's largest provider of graduate medical and other health professionals training, and one of the largest research enterprises in America. It is also the nation's largest provider of services to homeless persons, an essential provider in the public healthcare safety net, and an increasingly important element in the federal response to disasters and national emergencies. Patterned after what was considered the best in American healthcare, for most of the past 50 years the Department of Veterans Affairs (VA) healthcare has focused primarily on acute inpatient care, high technology, and medical specialization. Now, in response to societal and industrywide forces, the Veterans Health Administration (VHA) is reengineering the veterans healthcare system, changing the operational and management structure from individual hospitals to 22 integrated service networks and transitioning the system to one that is grounded in ambulatory and primary care. This article briefly describes the history and functions of the veterans healthcare system, its service population, and key aspects of its restructuring.     

Primary care satellite clinics and improved access to general and mental health services

OBJECTIVES: To evaluate the relationship between the implementation of community-based primary care clinics and improved access to general health care and/or mental health care, in both the general population and among people with disabling mental illness. STUDY SETTING: The 69 new community-based primary care clinics in underserved areas, established by the Department of Veterans Affairs (VA) between the last quarter of FY 1995 and the second quarter of FY 1998, including the 21 new clinics with a specialty mental health care component. DATA SOURCES: VA inpatient and outpatient workload files, 1990 U.S. Census data, and VA Compensation and Pension files were used to determine the proportion of all veterans, and the proportion of disabled veterans, living in each U.S. county who used VA general health care services and VA mental health services before and after these clinics began operation. DESIGN: Analysis of covariance was used to compare changes, from late FY 1995 through early FY 1998, in access to VA services in counties in which new primary care clinics were located, in counties in which clinics that included specialized mental health components were located, and for comparison, in other U.S. counties, adjusting for potentially confounding factors. KEY FINDINGS: Counties in which new clinics were located showed a significant increase from the FY 1995-FY 1998 study dates in the proportion of veterans who used general VA health care services. This increase was almost twice as large as that observed in comparison counties (4.2% vs. 2.5%: F = 12.6, df = 1,3118, p = .0004). However, the introduction of these clinics was not associated with a greater use of specialty VA mental health services in the general veteran population, or of either general health care services or mental health services among veterans who received VA compensation for psychiatric disorders. In contrast, in counties with new clinics that included a mental health component the proportion of veterans who used VA mental health services increased to almost three times the proportion in comparison counties (0.87% vs. 0.31%: F = 8.3, df = 1,3091, p = .004). CONCLUSIONS: Community-based primary care clinics can improve access to general health care services, but a specialty mental health care component appears to be needed to improve access to mental health services.     

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.     

Utilization and Intensity of Outpatient Care Related to Military Sexual Trauma for Veterans from Afghanistan and Iraq

Little research has examined factors associated with the utilization of outpatient health care services related to sexual assault experiences. The Veterans Health Administration provides free outpatient treatment services to veterans who report military sexual trauma (MST); this system provides a unique opportunity to examine factors related to the utilization of mental health and non-mental health outpatient services by patients with sexual trauma. The current study examined sociodemographic, military service factors, and primary diagnoses related to utilization and utilization intensity of MST-related care among 4,458 Operation Enduring Freedom/Operation Iraqi Freedom Veterans in a 1-year period after reporting an experience of MST. Of the veterans who reported MST, 75.9% received MST-related care. The most notable factor that influenced receipt and intensity of MST-related care was gender, where male veterans used less care than female veterans. These results have important treatment implications for both veteran and civilian sexual trauma survivors.