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Publication Briefs

Prior to the Choice Act Elderly Medicare-Enrolled Veterans Increased their Use of VA Healthcare versus Medicare

In an era of increasing community care options, understanding how Medicare-enrolled Veterans choose between VA and Medicare can help policy-makers predict expected use of VA and non-VA care. No research has assessed system-level changes in VA reliance on outpatient care among Medicare-enrolled Veterans over an extended period and across an extensive array of outpatient service types. Thus, this study examined long-term trends in reliance on VA outpatient care at the system level among elderly Medicare-enrolled Veterans from FY2003 to FY2014. Using VA and Medicare data, investigators examined four visit types (primary care, mental health, specialty care, and surgery) and seven high-volume medical subspecialties (cardiology, ophthalmology, critical care/pulmonology, nephrology, dermatology, gastroenterology, and hematology oncology).


  • The number of elderly Veterans enrolled in VA and Fee-for-Service (FFS) Medicare was 1.7 million in 2003, decreasing to 1.5 million in 2014.
  • Medicare-enrolled Veterans, who had a choice of using VA or Medicare providers, steadily increased their reliance on VA outpatient services (all categories) prior to the Choice Act.
  • Elderly Medicare-enrolled Veterans received most of their mental healthcare from VA (75% in 2003 to 77% in 2014), while receiving most of their primary care (76% in 2003, 65% in 2014), specialty care (86% in 2003, 78% in 2014), and surgical care (85% in 2003, 78% in 2014) through Medicare.
  • The increase in VA reliance was driven by a decrease in Medicare-only users, and an increase in VA-only users. Among users during the study period, the proportion of VA-only users increased in primary care (28% to 40%), mental health (80% to 88%), specialty care (18% to 26%), and surgical care (18% to 28%). Similar trends were seen in seven high-volume medical subspecialties.


  • Despite the recent controversies of access to VA care, elderly Medicare-enrolled Veterans were increasingly reliant on VA outpatient care across a diverse range of services at the life stage of growing healthcare needs. This may reflect their greater satisfaction with VA care.
  • Future research should explore the reasons for the increase in VA reliance to help VA inform policy planning around the provision of outpatient services, including the decision to expand internal VA capacity versus non-VA community care programs.


  • This study did not include Veterans younger than age 65 who used Medicare due to disability.

This study was funded by the Office of Primary Care through the PACT Demonstration Laboratory Initiative, HSR&D (IIR 10-150), and Dr. Wong is supported by an HSR&D Career Development Award. Drs. Liu, Wong and Hebert are part of HSR&D's Center of Innovation for Veteran-Centered and Value-Driven Care in Seattle, WA.

PubMed Logo Liu C-F, Batten A, Wong E, Fihn S, and Hebert P. Fee-for-Service Medicare-Enrolled Elderly Veterans are Increasingly Voting with their Feet to Use More VA and Less Medicare, 2003-2014. Health Services Research. Epub ahead of print; August 27, 2018.

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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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