1119 — Reliance on VA Outpatient Care among Medicare-Eligible Veterans from 2004 to 2011

Liu CF, VHA Puget Sound Healthcare System; Wong ES, VHA Puget Sound Healthcare System; Hu E, VHA Puget Sound Healthcare System; Fihn SD, VHA Office of Analytics and Business Intelligence; Hebert PL, VHA Puget Sound Healthcare System;

Objectives:
Dual use of VA and Medicare services increases Veteran choice and access to care, but may have negative effects on continuity and coordination of care. This study described longitudinal time trends in VA outpatient use among Medicare-eligible Veterans in 2004-2011.

Methods:
This was a cross-sectional time series analysis using VA and Medicare administrative data among 7.8 million Veterans enrolled VA primary care, covered by Medicare fee-for-service( parts A and B) from 2004 to 2011. We measured three types of outpatient face-to-face visits per quarter: primary care, medical subspecialty, and mental health. We calculated quarterly VA reliance at the system level as the proportion of total visits (VA+Medicare) that occurred in VA over the prior four quarters. All analyses were stratified by age ( < 65 and 65+).

Results:
The number of Medicare-eligible VA users increased over time (2 million in 2004Q1 and 2.4 million in 2011Q3), however, among VA users, the proportion with Medicare coverage was stable over time (90% for 65+ and 15% for < 65). For 65+, unadjusted time trends indicated VA reliance gradually increased from 2004Q1 2011Q3 in primary care from 57% to 62%, medical subspecialty care from 22% to 28%, and mental health from 81% to 88%. Similar increasing trends were observed from 2004Q1 to 2011Q3 among < 65 in primary care from 76% to 83%, medical subspecialty from 49% to 61%, and mental health from 92% to 96%. The increase in VA reliance resulted from a combination of changes in VA and/or Medicare use. Comparing to 2004 to 2011 for 65+, VA primary care visits were stable overtime, while visits in Medicare decreased by10% in 2011; VA medical subspecialty visits increased by 39%, while visits in Medicare were stable; and there was a much greater increase in mental health visits in VA than that in Medicare (103% versus 16.7%).

Implications:
Reliance on VA outpatient increased during the study period among Medicare-eligible Veterans. VA reliance was highest for mental health care, followed by primary care and medical subspecialty care.

Impacts:
VA is the main source of mental health care and has become an increasingly important source of outpatient care for dual VA-Medicare enrollees.