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Publication Briefs

Increasing Access to VA Primary Care via Community Clinics May Alter Veterans’ Use of Healthcare


  • VA primary care patients who were eligible for Medicare used significant primary care and specialty care outside of VA over a four-year period (’01-’04). A significant proportion used Medicare-reimbursed primary care (>30%) and specialty care (>60%), but not mental health care (3-4%).
  • Community-based VA patients used less VA care (17% fewer primary care visits, 22% fewer specialty care visits) and more Medicare service use (9% more primary care visits, 21% more specialty care visits), suggesting possible unintended fragmentation of care.
  • Hospital-based VA patients were more likely than community-based patients to obtain primary care and specialty care only at VA.
  • Dual use of VA and Medicare specialty care was the most common care pattern and the most fragmented among both community and hospital-based patients.
  • Mental healthcare services were not fragmented, as most patients used VA only for these services.
  • Use of Medicare only for outpatient primary and specialty care increased over the 4-year study, while use of VA only for these services decreased.

Over the past two decades, VA has reorganized from an inpatient care to an outpatient care-oriented healthcare system. By March 2009, VA had 773 community clinics at locations distinct from VA hospital outpatient clinics, greatly expanding access to primary care for Veterans. In a series of evaluations, satisfaction and quality of care were found to be comparable between community-based and hospital-based patients. However, these studies did not characterize overall healthcare use among Veterans because non-VA services were not included. Therefore, this retrospective cohort study examined trends in primary care, specialty care, and mental health services use in VA and Medicare among Medicare-eligible Veterans who obtained primary care in 72 VA hospital clinics and 108 VA community clinics. Using VA, Medicare, and US Census data, investigators analyzed health services use for 8,964 Veterans who received community-based primary care and 6,556 Veterans who received hospital-based primary care from 2001-2004.


  • This study did not include data on Veterans receiving healthcare outside of VA and/or Medicare, such as Medicaid and private insurance.
  • These results show Veterans’ experience from ’01 to ’04, before Medicare Part D.
  • The study cohort precedes the influx of OEF/OIF Veterans, which has resulted in large increases in VA budgets and provision of more specialty care aimed at younger Veterans.


  • Results suggest that increasing access to VA primary care via community clinics may fragment care for Veterans eligible for Medicare in unintended ways. Thus, coordination of care between VA and non-VA providers and healthcare systems is essential to improve quality and continuity of care.

This study was funded by HSR&D (IIR 04-292). Drs. Liu, Chapko, and Bryson are part of HSR&D’s Northwest Center for Outcomes Research in Older Adults, Seattle, WA.

PubMed Logo Liu C-F, Chapko M, Bryson C, et al. Use of Outpatient Care in VA and Medicare among Veterans Receiving Primary Care in Community-Based and Hospital Outpatient Clinics. Health Services Research October 2010;45(5 Pt 1):1268-86.

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What are HSR Publication Briefs?

HSR requires notification by HSR-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR published articles. Visit the HSR citations database for a complete listing of HSR articles and presentations.

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