BACKGROUND/RATIONALE:
Multiple sclerosis (MS) - a chronic, deteriorating neurological condition - affects 400,000 Americans and potentially over 30,000 veterans using VHA. VHA MS Centers of Excellence (MS CoE) were mandated in 2002 to improve veterans' MS care. These veterans' complex care results from uncertainty about diagnosis, treatment and maintenance. Nearly 10% of these veterans with MS access local alternatives or augmentation to VHA-based care with Medicare (gained by SSDI disability status, 2-years after unemployment). However, this may introduce discontinuity.

OBJECTIVE(S):
Our short-term goal was to answer the question, "Does dual-eligibility (VHA & Medicare) improve quality, or threaten patient safety?" This required linking VHA and Medicare databases to survey data, and detecting differences in outcomes related to dual-eligibility.

METHODS:
This study, with primary data collection and a retrospective, longitudinal extant database analysis, examined access, quality, and patient safety through VHA and Medicare extant data and patient self-report. To determine if veterans' use of Medicare services is driven by convenience or augmented healthcare, we merged Medicare and VHA data (1998 to 2009) with our national, randomized survey of MS-veterans, to support longitudinal regression modeling of consumption patterns, controlling for: Medicare eligibility, distance to VHA care, comorbidity and demographics (age, gender, income). A series of "two-part" models (estimating probability of use, and total costs) was planned for total VHA and Medicare care, and the components of inpatient, outpatient, and pharmacy care.
Five original hypotheses focused on dual-eligibles among over 39,000 veterans of all ages. Analyses controlled confounders of: comorbidities, demographics and self-reported disability, MS Sub-type, and duration of MS. The hypotheses were:
1. Dual-eligibility (VHA and Medicare) increases the probability of any healthcare use and the total consumption annually, in veterans with MS.
2. As disability or distance from the "nearest" VHA Medical Center increases, inpatient care from Medicare-covered, non-VHA providers increases.
3. As disability or distances from any VHA outpatient clinic increases, outpatient care from Medicare-covered, non-VHA providers increases.
4. Preventable admissions will be lower among veterans with only VHA-based care, as compared to veterans with both VHA and Medicare covered care.
5. In veterans on Disease Modifying Therapies (DMTs), side effects will be higher among veterans with VHA and Medicare covered care, compared to veterans with only VHA-based care.

FINDINGS/RESULTS:
We surveyed veterans with MS in a 2009 stratified, random mailed-survey of VHA Multiple Sclerosis Surveillance Registry (MSSR) volunteers. VHA data were assembled into a longitudinal file describing 1988 through 2009 VHA use. We estimated the expected annual VHA costs and use rates, including fee-basis care, in a preliminary dataset for 39,115 veterans in a two-part, longitudinal analysis adjusting for: demographics, Medicare-VHA dual eligibility, and comorbidities, service-connectedness, distance to VA settings, and death. Over half (53.4%) of these veterans were from 45 to 65 years old. Only 6.2% were service-connected for MS, indicating that documented symptoms began during active duty. Nearly one-tenth (8.5%) were eligible for Medicare, while less than 1% of cases were eligible for Medicaid, based on these preliminary VHA-only data. Utilization and costs were lower for older and younger groups, compared to middle-aged. Service-connected status and Medicare-VHA dual eligibility were associated with increased expected annual VHA expenditures. This analysis was planned to be repeated after merging with CMS data, for final examination of hypotheses, but was not completed due to CMS data delays.

Three reports (McDowell, et al, NeuroEpi, 2010, 2011, 2012) have been published from the primary data collection (survey of MSSR participants).

IMPACT:
Primary data collection for this project provided important insights to the field of MS, regarding the potential protective role of environmental vitamin D exposure in delaying MS onset, modifying the time to age-related neuro-degeneration symptoms, and delaying progression to disability. (see: McDowell, et al, NeuroEpi, 2010, 2011, 2012).
Multivariate VHA utilization and costs of care analyses found that over half (53.4%) of these veterans were from 45 to 65 years old. 6.2% were service-connected for MS, indicating that documented symptoms began during active duty. Nearly one-tenth (8.5%) were eligible for Medicare, while less than 1% of cases were eligible for Medicaid, based on VHA-only data. VHA utilization and costs were lower for older and younger groups, compared to middle-aged. Service-connected status and Medicare-VHA dual eligibility were associated with increased expected annual VHA expenditures.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. McDowell TY, Amr S, Culpepper WJ, Langenberg P, Royal W, Bever C, Bradham DD. Sun exposure, vitamin D and age at disease onset in relapsing multiple sclerosis. Neuroepidemiology. 2011 Jan 1; 36(1):39-45. [view]
2. McDowell TY, Amr S, Culpepper WJ, Langenberg P, Royal W, Bever C, Bradham DD. Sun exposure, vitamin D intake and progression to disability among veterans with progressive multiple sclerosis. Neuroepidemiology. 2012 Jan 16; 37(1):52-7. [view]
3. McDowell TY, Amr S, Langenberg P, Royal W, Bever C, Culpepper WJ, Bradham DD. Time of birth, residential solar radiation and age at onset of multiple sclerosis. Neuroepidemiology. 2011 Jul 28; 34(4):238-44. [view]

DRA: Health Systems Science, Autoimmune, Allergy, Inflammation, and Immunology, Brain and Spinal Cord Injuries and Disorders
DRE: none
Keywords: Chronic disease (other & unspecified), Neural Mechanisms of Brain Disorders, Quality assessment
MeSH Terms: none