3059 — Use of Outpatient Care in VA and Medicare among VAMC and CBOC Patients

Liu C (Seattle COE), Chapko M (Seattle COE), Burgess J (Boston COE), Bryson C (Seattle COE), Perkins M (Seattle COE), Fortney J (REAP Little Rock), Manning W (University of Chicago), Sharp N (Seattle COE), Maciejewski M (Durham COE)

Objectives:
VA established community-based outpatient clinics (CBOCs) to improve veterans’ access to primary care. Previous studies document that veterans going to CBOCs have lower VA outpatient care utilization than veterans going to VAMC primary care clinics. This study examines whether lower VA outpatient care by Medicare-eligible CBOC and VAMC patients is offset by more Medicare outpatient care.

Methods:
This study included 8,310 CBOC and 12,496 VAMC primary care users who also were eligible for Medicare in FY2000. We obtained primary care, specialty care, and mental health visits from 2001-2004 VA administrative datasets and Medicare claims.

Results:
More than 30% of CBOC and VAMC patients used primary care in Medicare. CBOC patients had fewer VA primary care visits (2.4 versus 3.2) than VAMC patients but more Medicare primary care visits (1.5 versus 1.1), and fewer total primary care visits (3.8 versus 4.3) in 2001. More than 60% of CBOC and VAMC patients used specialty care in Medicare. CBOC patients had fewer specialty care VA visits (4.1 versus 6.3) but more Medicare specialty care visits (6.9 versus 4.6) than VAMC patients, and similar total specialty care visits (11 for both groups) in 2001. There was no difference in the likelihood of Medicare mental health services use between the two groups, but CBOC patients had fewer total mental health care visits than VAMC patients (1.0 versus 1.9) in 2001; the majority of visits occurred in VA for both groups (0.8 versus 1.7). Similar patterns were observed in subsequent years, and regression results were consistent with these descriptive results.

Implications:
Significant proportions of CBOC and VAMC patients use Medicare outpatient services. CBOC patients appear to be offsetting less VA use of primary care and specialty care with more Medicare services.

Impacts:
Increasing non-VA primary and specialty care use may affect continuity of care, chronic disease management, and provider- and system-level performance measures, particularly for CBOC patients. Development of strategies for sharing information between VA and non-VA primary care providers is critical to improving patient care.