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.