BACKGROUND/RATIONALE:
Health maintenance organization (HMO) enrollment by dually eligible (Veterans Affairs [VA], Medicare) veterans raises concerns about management of care and increasing costs. Although co-utilization of VA and Medicare fee-for-service (FFS) care has been well described, Medicare HMOs differ from Medicare FFS in the scope of services covered and how access is managed. Further, changes implemented under the Balanced Budget Act (BBA) may significantly impact the availability of Medicare HMOs, particularly for low income and minority individuals. It is unclear how these changes will affect use of VA services by HMO enrolled veterans.

OBJECTIVE(S):
This study has two specific aims: 1) to examine individual-level factors affecting enrollment by minority and low-income veterans in HMO plans, as well as use of medical care and satisfaction with care by these VA users compared to White and higher-income veterans, and to veterans who do not use the VA medical system; and 2) to examine patterns of enrollment in Medicare HMOs by different race/ethnic and income-based sub-groups of VA users, and to describe changes in HMO enrollment by VA users following the implementation of the BBA provisions.

METHODS:
Aim 1 of this study uses a national survey methodology to examine the influence of patient and system level factors on decisions to enroll in Medicare managed care and to use VA and non-VA medical services by community-dwelling veteran males age 65 and older. Aim 2 of this study uses a retrospective examination of combined VA and Medicare administrative files to examine the impact of the Balanced Budget Amendment (BBA) of the extent and pattern of Medicare managed care enrollment by VA users, and of the impact of managed care enrollment on use of VA services.

For Aim 1, we are conducting a population-based survey following the protocol used in our earlier VA funded study (HSRD IIR 95-079). Survey recipients were elderly (age 65+) community-residing males from three racial/ethnic Social Security Administration (SSA) classifications, ‘White’, ‘Black’, and ‘Hispanic’, sampled from a combined VA-Medicare data set. The questionnaire used for this survey was adapted from our earlier survey instrument.

Aim 2 is a cross-sectional and longitudinal analysis of race/ethnic and income variability in Medicare HMO enrollment by elderly Medicare eligible VA users. We are using national VA Medical Center inpatient and outpatient data for the calendar year 2000 merged with the year 2000 national Medicare administrative data. To test for change in Medicare HMO enrollment and use of VA services before and after the BBA, we will also merge VA and Medicare data for 1996 and 1998.

FINDINGS/RESULTS:
All necessary Medicare and VA data sets have been acquired. All survey procedures have been completed. These include, the data request, construction of sampling frame, surname match, design and pre-pilot of survey, conduct of survey mail-out, and data entry and cleaning. The survey size was expanded from 4,300 to 6,450 recipients based on our revised estimates of the differential proportions of veterans among our non-VA using White, Black, and Hispanic survey recipients. Adjusted for deaths and ineligible recipients (e.g., moved with no forwarding address) our overall response rate was 51.7% (3,238 of 6,267). Our analyses are underway and the project’s final report is in preparation.

Based on our database analysis, 15% of White (n=254,469) and Black (n=26,427) and 18% of Hispanic (n=4,700) VA-using veterans were enrolled in a Medicare health plan. More Black and Hispanic enrollees than White enrollees were in plans without a monthly premium (82% and 84% versus 69%, respectively; p<.0001) and offering some drug coverage (90% and 95% versus 79%, respectively; p<.0001). Furthermore, Black and Hispanic enrollees were more likely to have lower physician co-payments (p<.0001) and at least 1 of the 4 supplemental benefits (p<.0001). Thus, the majority of VA-using veterans enrolled in a Medicare health plan in CY2000 paid nothing or less than $50 for monthly premiums, had drug coverage and other supplemental benefits. Compared to White enrollees, Black and Hispanic enrollees were more likely to be in plans without monthly premiums and with lower physician co-payments, higher prescription drug coverage and more supplemental benefits.

Based on our survey findings, regardless of their VA-using status, respondents’ intention-to-use the VA was higher for low-income veterans compared to higher income veterans, and was two-fold higher for Blacks compared to Whites. Among VA-using veterans, Hispanics reported higher interest in using the VA than Whites. While among VA non-using veterans, Medicare HMO enrollees were twice as likely as FFS enrollees to report intention-to-use the VA. Significant variations were also observed among the six metropolitan areas. All findings were significant at p<=0.05. This suggests that If VA healthcare was available to all Medicare-enrolled veterans, there is likely to be wide geographical variation and substantial differences among ethnic/racial groups and veterans at different income levels in intent-to-use VA services.

Methodologically, the Hispanic surname match used to improve identification of Hispanic recipients worked extremely well. At the population level, the proportion of Hispanic males identified using our surname match procedure very closely closely approximated the proportions estimated by the 2000 U.S. Census. These findings have been published in the journal Medical Care (Morgan RO, Wei I, Virnig BA. Use of surname matching to identify elderly Hispanic males in combined Medicare/VA data files. 2004; Medical Care).

IMPACT:
This study will provide the first comprehensive examination of both individual and system level factors affecting use of VA services by veterans enrolled in Medicare HMOs.

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External Links for this Project

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PUBLICATIONS:

Conference Presentations

1. Morgan R, Duque M, DeVito C. Low Intensity Exercise and Falls Risk Among a Clinically Defined Sample of At-Risk Elders. Paper presented at: VA HSR&D National Meeting; 2002 Sep 1; Washington, DC. [view]
2. Morgan R, Huang I. Use of surname matching to identify elderly Hispanic males in combined Medicare/VA data files. Paper presented at: VA HSR&D National Meeting; 2002 Sep 1; Washington, DC. [view]

DRA: Health Systems
DRE: Epidemiology
Keywords: Ethnic/cultural, Managed care, VA/non-VA comparisons
MeSH Terms: none