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Publication Briefs

Study Shows No Evidence that Dual Use of VA and Medicare Advantage Results in Worse Patient Outcomes

Many Veterans enrolled in VA healthcare have alternative sources of insurance and rely on non-VA providers for some portion of their healthcare. However, relatively little is known about the health consequences of dual use of VA and non-VA care. This study assessed characteristics of Veterans who were dually enrolled in both VA and Medicare Advantage (MA) – managed care plans administered by private health insurance companies that contract with the Centers for Medicare and Medicaid Services. This study also compared quality of care using intermediate quality outcomes among Veterans exclusively receiving outpatient care in VA with Veterans receiving outpatient care in both systems. Using VA and MA data from 2008 and 2009, investigators identified 1,637 Veterans who used VA care only, and 5,006 Veterans who used VA and MA (dual users) – and who were diagnosed with diabetes, hypertension, or coronary heart disease (CHD). Specific intermediate quality outcomes included: blood pressure control (<140/90 mm Hg) among Veterans with hypertension; LDL cholesterol control (<100 mg/dl) among Veterans with CHD; and LDL cholesterol, BP, and glycosylated hemoglobin control (<9.0%) among Veterans with diabetes.


  • For the measures included in this study, no evidence was found that Veterans with dual use of VA and Medicare Advantage experienced either improved or worsened intermediate outcomes compared with Veterans who exclusively used VA healthcare.
  • Outcomes were marginally better for VA-only users on the measures related to hypertension control and CHD control. Conversely, dual VA-MA users experienced slightly better outcomes on measures relating to diabetes control.
  • In analyses adjusting for enrollee characteristics, health status, and number of VA outpatient visits, differences in the quality of care between VA-only and dual users were small and not statistically significant.
  • Dually-enrolled Veterans with fewer VA outpatient visits had comparable outcomes to Veterans with many VA outpatient visits, suggesting the absence of a threshold number of VA visits for achieving better intermediate outcomes in diabetes, hypertension, and heart disease.


  • Findings are restricted to users of Medicare Advantage and may not apply to dual users enrolled in fee-for-service Medicare.
  • Investigators were limited to using plan-reported HEDIS data for information about Medicare Advantage (MA) use and quality. MA claims and encounter data were not available to researchers, precluding an understanding of conditions treated and care delivered to dual users. Incomplete capture of MA utilization in the HEDIS data may partly explain the lower number of outpatient visits in dual users.

The study was funded by HSR&D. Dr. Trivedi was supported by an HSR&D Career Development and Merit Award and is part of HSR&D's Center for Innovation in Long-Term Services and Supports for Vulnerable Veterans, Providence, RI.

Cooper A, Jiang L, Yoon J, Charlton M, Wilson I, Mor V, Kizer K, and Trivedi A. Dual System Use and Intermediate Health Outcomes among Veterans Enrolled in Medicare Advantage Plans. Health Services Research. April 6, 2015;e-pub ahead of print.

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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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