Association of Multiple System Use with Health Outcomes among Veterans Enrolled in Medicare Advantage Plans

Cooper A, Jiang L, Yoon J, Charlton ME, Mor V, Kizer K, Trivedi A. Association of Multiple System Use with Health Outcomes among Veterans Enrolled in Medicare Advantage Plans. Poster session presented at: AcademyHealth Annual Research Meeting; 2013 Jun 24; Baltimore, MD.

Related HSR&D Project(s)

• IIR 11-105 – Health Policy Implication of Dual Enrollment in the VA and Medicare Advantage

Research Objective: Many veterans enrolled in the VA health care system have alternative sources of insurance coverage and rely on non-VA providers for some portion of their health care needs. Although receiving services across multiple systems may fragment care, little is known about the health consequences of dual use of VA and non-VA care. We characterized the population of veterans who were dually enrolled in both the VA and a Medicare Advantage (MA) plan, and compared the quality of care among those exclusively receiving care in the VA with those receiving care in both managed care systems. Study Design: Using merged VA and MA quality and administrative data, we used propensity score methods to determine the association between dual use and five VA External Peer Review Program quality measures. Outcomes included control of cholesterol, blood pressure and glycosylated hemoglobin among persons with diabetes, cholesterol among persons with coronary heart disease (CHD), and blood pressure among persons with hypertension. Population Studied: 8,226 veterans concurrently enrolled in the VA and an MA plan during 2008 and 2009 with diabetes, hypertension, or CHD. Principal Findings: Of 8,226 dually-enrolled individuals, 2,001 (24.3%) exclusively received outpatient care in the VA. The remaining 6,225 (75.7%) received outpatient services in both the VA and MA. VA-only users were more likely to be younger (68.6 years vs. 71.3), female (9.4% vs. 7.8%), and non-white (20.7% vs. 10.5%) than dual VA-MA users. They were also more likely to have high VA priority enrollment status (77.9% vs. 61.4%). VA-only users had more comorbid conditions than dual VA-MA users (4.5 conditions vs. 3.7), and lived approximately one mile closer to a VA medical center (11.0 miles vs. 11.9) (p < 0.01 for all comparisons). Among dual users, the mean number of annual outpatient visits was 24.4; of this total, 15.7 occurred in VA and 8.7 in MA. In propensity score analyses, intermediate outcomes were comparable for VA-only users (n = 1,971) and matched dual VA-MA users (n = 1,971) (p > 0.05 for all differences). The differences ranged from a 3.9 percent difference (95% CI: -2.0 to 9.8) favoring VA-only users with CHD in the proportion of controlled cholesterol < 100 mg/dL to a 1.1 percent difference (95% CI: -3.8 to 5.1) favoring dual users with diabetes in the proportion of controlled cholesterol < 100 mg/dL. Conclusions: The VA was the primary source of outpatient care in this sample of dual VA-MA enrollees, even among those receiving care in both systems. For the five intermediate outcome measures assessed in this sample, dual use was not associated with poorer patient outcomes. Implications for Policy, Delivery, or Practice: The high intensity of VA outpatient service use among dual users may explain why intermediate health outcomes are comparable to those achieved by VA-only users, despite the potential for multiple system use to fragment care. The Affordable Care Act will expand the number of VA-enrollees with alternative sources of coverage and care. Policymakers and clinicians should promote efforts to coordinate care and share information across VA and non-VA settings, particularly for dually-enrolled veterans with chronic conditions.