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Author List:
Maciejewski ML (Seattle HSR&D)
Liu CF (Seattle HSR&D)
Perkins M (Seattle HSR&D)
Li YF (Seattle HSR&D)
Fortney J (Little Rock HSR&D)
Chapko M (Seattle HSR&D)
Objectives:
: To examine whether veterans obtaining primary care at community-based outpatient clinics (CBOCs) had lower VA utilization and expenditures between 2000 and 2001 than veterans obtaining primary care at VA medical centers (VAMCs); to assess whether these differences were driven by veterans with ambulatory care-sensitive conditions (ACSCs) in these two settings.
Methods:
VA utilization and expenditure data was obtained from Inpatient and Outpatient National Extracts derived from the Decision Support System (DSS). 108 CBOCs were included because they were in operation in 1999, were serving at least 200 veterans, and could be tracked independently in DSS. 26,700 veterans in 108 CBOCs, 27,336 in 72 parent VAMCs, and 12,330 Crossover patients (those that received care at both a CBOC and parent) were included in the final sample. ACSCs were identified via diagnosis codes. Utilization was estimated using negative binomial models and expenditures were estimated using generalized linear one-part or two-part models.
Results:
CBOC patients had lower inpatient, specialty and mental health utilization (p<0.001) but higher primary care utilization (p<0.0001) than patients obtaining primary care at VAMCs. CBOC patients had lower total, outpatient and inpatient expenditures (p<0.0001). This expenditure pattern was also observed in veterans with alcohol, COPD and hypertension conditions. Veterans with angina seen at CBOCs had lower total and inpatient expenditures (p<0.001), but similar outpatient expenditures as comparable veterans seen at VAMCs. Veterans with depression or diabetes seen at CBOCs had lower total and outpatient expenditures (p<0.001), but similar inpatient expenditures.
Implications:
It appears as though CBOCs are helpful in containing total VA expenditures, particularly for patients with ACSCs. It may also be useful to examine CBOCs in greater detail to get into the “black box” of CBOC organizations and cultures to more fully understand why their performance is equal to, if not better than, performance of VAMC primary care clinics.
Impacts:
CBOCs may be an alternative primary care delivery system that can effectively contain VA expenditure growth while ensuring that veterans obtain sufficient primary care.
