Use of Veterans Affairs and Medicaid Services for Dually Enrolled Veterans

Trajectories and Transitions in Service Use Among Older Veterans at High Risk of Long-Term Institutional Care

BACKGROUND

We aimed to identify combinations of long-term services and supports (LTSS) Veterans use, describe transitions between groups, and identify factors influencing transition.

METHODS

We explored LTSS across a continuum from home to institutional care. Analyses included 104,837 Veterans Health Administration (VHA) patients 66 years and older at high-risk of long-term institutional care (LTIC). We conduct latent class and latent transition analyses using VHA and Medicare data from fiscal years 2014 to 2017. We used logistic regression to identify variables associated with transition.

RESULTS

We identified 5 latent classes: (1) No Services (11% of sample in 2015); (2) Medicare Services (31%), characterized by using LTSS only in Medicare; (3) VHA-Medicare Care Continuum (19%), including LTSS use in various settings across VHA and Medicare; (4) Personal Care Services (21%), characterized by high probabilities of using VHA homemaker/home health aide or self-directed care; and (5) Home-Centered Interdisciplinary Care (18%), characterized by a high probability of using home-based primary care. Veterans frequently stayed in the same class over the three years (30% to 46% in each class). Having a hip fracture, self-care impairment, or severe ambulatory limitation increased the odds of leaving No Services, and incontinence and dementia increased the odds of entering VHA-Medicare Care Continuum. Results were similar when restricted to Veterans who survived during all 3 years of the study period.

CONCLUSIONS

Veterans at high risk of LTIC use a combination of services from across the care continuum and a mix of VHA and Medicare services. Service patterns are relatively stable for 3 years.

Contextual factors influencing the association between the Affordable Care Act's Medicaid expansion and Veteran VA-Medicaid dual enrollment

OBJECTIVE

To evaluate changes in dual enrollment after Affordable Care Act Medicaid expansion by VA priority group, (e.g., service connection), sex, and type of state expansion.

STUDY SETTING

Our cohort was all Veterans ages 18-64 enrolled in VA and eligible for benefits due to military service-connection or low income from 2011 to 2016; the unit of analysis was person-year.

STUDY DESIGN

Difference-in-difference and event-study analysis. The outcome was dual VA-Medicaid enrollment for at least 1 month annually. Medicaid expansion, VA priority status, whether a state expanded by a Section 1115 waiver, and sex were independent variables. We controlled for race, ethnicity, age, disease burden, distance to VA facilities, state, and year.

DATA EXTRACTION METHODS

We used data from the VA Corporate Data Warehouse (CDW) regarding age and VA Priority Group to select our cohort of VA-enrolled individuals. We then took the cohort and crossed checked it with Medicaid Analytic Extract (MAX) and T-MSIS Analytic Files (TAF) to determine Medicaid enrollment status.

PRINCIPAL FINDINGS

Service-connected Veterans experienced lower dual-enrollment increases across all sex and state-waiver groups (3.44 percentage points (95% CI: 1.83, 5.05 pp) for women, 3.93 pp (2.98, 4.98) for men, 4.06 pp (2.85, 5.27) for non-waiver states, and 3.00 pp (1.58 to 4.41) for waiver states) than Veterans who enrolled in the VA due to low income (8.19 pp (5.43, 10.95) for women, 9.80 pp (7.06, 12.54) for men, 10.21 pp (7.17, 13.25) for non-waiver states, and 7.39 pp (5.28, 9.50) for waiver states).

CONCLUSIONS

Medicaid expansion is associated with dual enrollment. Dual-enrollment changes are greatest in those enrolled in the VA due to low income, but do not differ by sex or expansion type. Results can help VA identify groups disproportionately likely to have potential care-coordination issues due to usage of multiple health care systems.

Medicaid Expansion and Veterans' Reliance on the VA for Depression Care

Background

In 2001, before the Affordable Care Act (ACA), some states expanded Medicaid coverage to include an array of mental health services, changing veterans' reliance on US Department of Veterans Affairs (VA) services.

Methods

Using Medicaid and VA administrative data from 1999 to 2006, we used a difference-in-difference design to calculate shifts in veterans' reliance on the VA for depression care in New York and Arizona after the 2 states expanded Medicaid coverage to adults in 2001. Demographically matched, neighbor states Pennsylvania and New Mexico/Nevada were used as paired comparisons, respectively. Fractional logit was used to capture the distribution of inpatient and outpatient depression care utilization between the VA and Medicaid, while ordered logit and negative binomial regressions were applied to model Medicaid-VA dual users and per capita utilization of total depression care services, respectively.

Results

Medicaid expansion was associated with a 9.50 percentage point (pp) decrease (95% CI, -14.61 to -4.38) in reliance on the VA for inpatient depression care among service-connected veterans and a 13.37 pp decrease (95% CI, -21.12 to -5.61) among income-eligible veterans. For outpatient depression care, VA reliance decreased by 2.19 pp (95% CI, -3.46 to -0.93) among income-eligible veterans. Changes among service-connected veterans were nonsignificant (-0.60 pp; 95% CI, -1.40 to 0.21).

Conclusions

After Medicaid expansion, veterans shifted depression care away from the VA, with effects varying by health care setting, income- vs service-related eligibility, and state of residence. Issues of overall cost, care coordination, and clinical outcomes deserve further study in the ACA era of Medicaid expansions.

Anticipating VA/non-VA care coordination demand for Veterans at high risk for hospitalization

U.S. Veterans Affairs (VA) patients' multi-system use can create challenges for VA clinicians who are responsible for coordinating Veterans' use of non-VA care, including VA-purchased care ("Community Care") and Medicare.To examine the relationship between drive distance and time-key eligibility criteria for Community Care-and VA reliance (proportion of care received in VA versus Medicare and Community Care) among Veterans at high risk for hospitalization. We used prepolicy data to anticipate the impact of the 2014 Choice Act and 2018 Maintaining Internal Systems and Strengthening Integrated Outside Networks Act (MISSION Act), which expanded access to Community Care.Cross-sectional analysis using fractional logistic regressions to examine the relationship between a Veteran's reliance on VA for outpatient primary, mental health, and other specialty care and their drive distance/time to a VA facility.Thirteen thousand seven hundred three Veterans over the age of 65 years enrolled in VA and fee-for-service Medicare in federal fiscal year 2014 who were in the top 10th percentile for hospitalization risk.Key explanatory variables were patients' drive distance to VA > 40 miles (Choice Act criteria) and drive time to VA ≥ 30 minutes for primary and mental health care and ≥60 minutes for specialty care (MISSION Act criteria).Veterans at high risk for hospitalization with drive distance eligibility had increased odds of an outpatient specialty care visit taking place in VA when compared to Veterans who did not meet Choice Act eligibility criteria (odds ratio = 1.10, 95% confidence interval 1.05-1.15). However, drive time eligibility (MISSION Act criteria) was associated with significantly lower odds of an outpatient specialty care visit taking place in VA (odds ratio = 0.69, 95% confidence interval 0.67, 0.71). Neither drive distance nor drive time were associated with reliance for outpatient primary care or mental health care.VA patients who are at high risk for hospitalization may continue to rely on VA for outpatient primary care and mental health care despite access to outside services, but may increase use of outpatient specialty care in the community in the MISSION era, increasing demand for multi-system care coordination.

A Cost-Consequence Analysis of Preemptive SLCO1B1 Testing for Statin Myopathy Risk Compared to Usual Care

There is a well-validated association between SLCO1B1 (rs4149056) and statin-associated muscle symptoms (SAMS). Preemptive SLCO1B1 pharmacogenetic (PGx) testing may diminish the incidence of SAMS by identifying individuals with increased genetic risk before statin initiation. Despite its potential clinical application, the cost implications of SLCO1B1 testing are largely unknown. We conducted a cost-consequence analysis of preemptive SLCO1B1 testing (PGx+) versus usual care (PGx-) among Veteran patients enrolled in the Integrating Pharmacogenetics in Clinical Care (I-PICC) Study. The assessment was conducted using a health system perspective and 12-month time horizon. Incremental costs of SLCO1B1 testing and downstream medical care were estimated using data from the U.S. Department of Veterans Affairs' Managerial Cost Accounting System. A decision analytic model was also developed to model 1-month cost and SAMS-related outcomes in a hypothetical cohort of 10,000 Veteran patients, where all patients were initiated on simvastatin. Over 12 months, 13.5% of PGx+ (26/193) and 11.2% of PGx- (24/215) participants in the I-PICC Study were prescribed Clinical Pharmacogenetics Implementation Consortium (CPIC) guideline-concordant statins (Δ2.9%, 95% CI -4.0% to 10.0%). Differences in mean per-patient costs for lipid therapy prescriptions, including statins, for PGx+ compared to PGx- participants were not statistically significant (Δ USD 9.53, 95% CI -0.86 to 22.80 USD). Differences in per-patient costs attributable to the intervention, including PGx testing, lipid-lowering prescriptions, SAMS, laboratory and imaging expenses, and primary care and cardiology services, were also non-significant (Δ- USD 1004, 95% CI -2684 to 1009 USD). In the hypothetical cohort, SLCO1B1-informed statin therapy averted 109 myalgias and 3 myopathies at 1-month follow up. Fewer statin discontinuations (78 vs. 109) were also observed, but the SLCO1B1 testing strategy was 96 USD more costly per patient compared to no testing (124 vs. 28 USD). The implementation of SLCO1B1 testing resulted in small, non-significant increases in the proportion of patients receiving CPIC-concordant statin prescriptions within a real-world primary care context, diminished the incidence of SAMS, and reduced statin discontinuations in a hypothetical cohort of 10,000 patients. Despite these effects, SLCO1B1 testing administered as a standalone test did not result in lower per-patient health care costs at 1 month or over 1 year of treatment. The inclusion of SLCO1B1, among other well-validated pharmacogenes, into preemptive panel-based testing strategies may provide a better balance of clinical benefit and cost.

Perceptions of Care Coordination Among Homeless Veterans Receiving Medical Care in the Veterans Health Administration and Community Care Settings: Results From a National Survey

BACKGROUND

Initiatives to expand Veterans' access to purchased health care outside Veterans Health Administration (VHA) facilities ("community care") present care coordination challenges for Veterans experiencing homelessness.

OBJECTIVE

Among Veterans with homeless experiences, to evaluate community care use and satisfaction, and compare perceptions of care coordination among Veterans using VHA services and community care to those using VHA services without community care.

RESEARCH DESIGN

Cross-sectional analysis of responses to a 2018 mailed survey.

SUBJECTS

VHA outpatients with homeless experiences.

MEASURES

Self-reported use of community care, Likert-style ratings of satisfaction with that care, and Access/Coordination experiences from the Primary Care Quality-Homeless (PCQ-H) survey.

RESULTS

Of 4777 respondents, 1325 (26.7%) reported using community care; most of this subsample affirmed satisfaction with the community care they received (83%) and its timeliness (75%). After covariate adjustment, Veteran characteristics associated with greater community care use included female sex, being of retirement age and nonmarried, and having higher education, more financial hardship, ≥3 chronic conditions, psychological distress, depression, and posttraumatic stress disorder. Satisfaction with community care was lower among patients with travel barriers, psychological distress, and less social support. Compared with those using the VHA without community care, Veterans using VHA services and community care were more likely to report unfavorable access/coordination experiences [odds ratio (OR)=1.34, confidence interval (CI)=1.15-1.57]. This included hassles following referral (OR=1.37, CI=1.14-1.65) and perceived delays in receiving health care (OR=1.38, CI=1.19-1.61).

CONCLUSIONS

Veterans with homeless experiences value community care options. Potential access benefits are balanced with risks of unfavorable coordination experiences for vulnerable Veterans with limited resources.

Possible Effects on VA Outpatient Care of Expanding Medicaid: Implications of Having Access to Overlapping Publicly Funded Health Care Services

BACKGROUND

Because veterans who use Veterans Health Administration (VA) health care retain VA eligibility while enrolling in Medicaid, increasing Medicaid eligibility may create improved health system access but also create unique challenges for the quality and coordination of health care for veterans. We analyze how pre-Affordable Care Act (ACA) state Medicaid expansions influence VA and Medicaid-funded outpatient care utilization.

MATERIALS AND METHODS

This study uses Difference-in-difference analysis to evaluate association between pre-ACA 2001 Medicaid expansions and VA utilization in a natural experiment. Veterans aged 18-64 years living in a study state during the study period were the participants. Dependent variables included participants' proportion of outpatient care received at the VA, whether a participant recorded care with both Medicaid and the VA, and total outpatient utilization. We analyzed changes between two states that expanded Medicaid in 2001 against three similar states that did not from 1999 to 2006. We adjusted for age, non-White race, gender, disease burden, and distance to VA facilities. This study was approved by the Baylor College of Medicine Institutional Review Board (IRB), protocol number H-40441.

RESULTS

In total, 346,364 VA-enrolled veterans lived in the five study states during the time of our study, 70,987 of whom were enrolled in Medicaid for at least 1 month. For low-income veterans, Medicaid expansion was associated with a 2.88 percentage-point decline in the VA proportion of outpatient services (99% CI -3.26 to -2.49), and a 2.07-point increase (1.80 to 2.35) in the percentage of patients using both VA and Medicaid services. Results also showed small increases in total (VA plus Medicaid) annual per-capita outpatient visits among low-income veterans. We estimate that this corresponds to an annual reduction of 80,338 VA visits across study states (66,155-94,521).

CONCLUSIONS

This study shows usage shifts when Medicaid expansion allows veterans to gain access to non-VA care. It highlights increased potential for care-coordination challenges among VA patients as states implement ACA Medicaid expansion and policymakers consider additional public health insurance options, as well as programs like CHOICE and the MISSION Act that increase veteran choices of traditional VA and community care providers.

Effects of State-level Medicaid Expansion on Veterans Health Administration Dual Enrollment and Utilization: Potential Implications for Future Coverage Expansions

OBJECTIVE

The objective of this study was to examine how pre-Affordable Care Act (ACA) state-level Medicaid expansions affect dual enrollment and utilization of Veterans Health Administration (VA) and Medicaid-funded care.

RESEARCH DESIGN

We employed difference-in-difference analysis to determine the association between pre-ACA Medicaid expansions in New York and Arizona in 2001 and VA utilization. Participants' dual enrollment in Medicaid and VA, the distribution of their annual hospital admissions and emergency department (ED) visits between VA and Medicaid were dependent variables. We controlled for age, race, sex, disease burden, distance to VA facilities and income-based eligibility for VA services.

MEASURES

Secondary data collected from 1999 to 2006 in 2 states expanding Medicaid and 3 demographically similar nonexpansion states. We obtained residency, enrollment and utilization data from VA's Corporate Data Warehouse and Medicaid Analytic Extract files.

RESULTS

For low-income Veterans, Medicaid expansion was associated with increased dual enrollment of 4.87 percentage points (99% confidence interval: 4.48-5.25), a 4.63-point decline in VA proportion of admissions (-5.87 to -3.38), and a 11.70-point decrease in the VA proportion of ED visits (-13.06 to -10.34). Results also showed increases in the number of total (VA plus Medicaid) annual per-capita hospitalizations and ED visits among the group of VA enrollees most likely to be eligible for expansion.

CONCLUSIONS

This study shows slight usage shifts when Veterans gain access to non-VA care. It highlights the need to overcome care-coordination challenges among VA patients as states implement ACA Medicaid expansion and policymakers consider additional expansions of public health insurance programs such as Medicare-for-All.

Veterans' Reliance on VA Care by Type of Service and Distance to VA for Nonelderly VA-Medicaid Dual Enrollees

BACKGROUND

Not much is known about nonelderly veterans and their reliance on care from the Veterans Affairs (VA) health care system when they have access to non-VA care.

OBJECTIVES

To estimate VA reliance for nonelderly veterans enrolled in VA and Medicaid.

RESEARCH DESIGN

Retrospective, longitudinal analysis of Medicaid claims data and VA administrative data to compare patients' utilization of VA and Medicaid services 12 months before and for up to 12 months after Medicaid enrollment began.

SUBJECTS

Nonelderly veterans (below 65 y) receiving VA care and newly enrolled in Medicaid, calendar years 2006-2010 (N=19,890).

MEASURES

VA reliance (proportion of care received in VA) for major categories of outpatient and inpatient care.

RESULTS

Patients used VA outpatient care at similar levels after enrolling in Medicaid with the exceptions of emergency department (ED) and obstetrics/gynecology care, which decreased. VA inpatient utilization was similar after Medicaid enrollment for most types of care. VA-adjusted outpatient reliance was highest for mental health care (0.99) and lowest for ED care (0.02). VA-adjusted inpatient reliance was highest for respiratory (0.80) and cancer stays (0.80) and lowest for musculoskeletal stays (0.20). Associations between VA reliance and distance to VA providers varied by type of care.

CONCLUSIONS

Veterans dually enrolled in Medicaid received most of their outpatient care from the VA except ED, obstetrics/gynecology, and dental care. Patients received most of their inpatient care from Medicaid except mental health, respiratory, and cancer care. Sensitivity to travel distance to VA providers explained some of these differences.

The Impact of Medicaid Enrollment on Veterans Health Administration Enrollees' Behavioral Health Services Use

OBJECTIVE

To examine Veterans Health Administration (VA) enrollees' use of VA services for treatment of behavioral health conditions (BHCs) after gaining Medicaid, and if VA reliance varies by complexity of BHCs.

DATA SOURCES/STUDY SETTING

VA and Medicaid Analytic eXtract utilization data from 31 states, 2006-2010.

STUDY DESIGN

A retrospective, longitudinal study of Veterans enrolled in VA care in the year before and year after enrollment in Medicaid among 7,249 nonelderly Veterans with serious mental illness (SMI), substance use disorder (SUD), posttraumatic stress disorder (PTSD), depression, or other BHCs.

DATA COLLECTION/EXTRACTION METHODS

Utilization and VA reliance (proportion of care received at VA) for BH outpatient and inpatient services in unadjusted and adjusted analyses.

PRINCIPAL FINDINGS

In adjusted analyses, we found that overall Veterans did not significantly change their use of VA outpatient BH services after Medicaid enrollment. In beta-binomial models predicting VA BH outpatient reliance, veterans with SMI (IRR = 1.38, p < .05), PTSD (IRR = 1.62, p < .01), and depression (IRR = 1.36, p < .05) had higher reliance than veterans with other BHCs after Medicaid enrollment.

CONCLUSIONS

While veterans did not change the amount of VA outpatient BH services they used after enrolling in Medicaid, the proportion of care they received through VA or Medicaid varied by BHC.

Dual Use and Hospital Admissions among Veterans Enrolled in the VA's Homeless Patient Aligned Care Team

OBJECTIVE

To examine the association between reliance on VA outpatient care and hospital admissions among Medicare-eligible Veterans enrolled in the Homeless Patient Aligned Care Team (H-PACT).

DATA SOURCES/STUDY SETTING

Registry of H-PACT enrollees linked to VA and Medicare utilization data for 2013.

STUDY DESIGN

After assigning Veterans to two groups according to whether they received >90 percent of outpatient care in VA (higher reliance) or <90 percent of outpatient care in VA (lower reliance), generalized linear models with inverse probability of treatment weights were used to estimate the association of reliance with Medicare and VA-financed hospital admissions.

PRINCIPAL FINDINGS

Compared with higher reliance Veterans, lower reliance Veterans had an equivalent number of annual VA hospitalizations (0.63 vs. 0.50; p = .14) but substantially greater Medicare hospitalizations (0.85 vs. 0.08; p < .001). Among Veterans in the highest tertile of outpatient visits, we observed statistically similar rates of VA hospital use but over 10-fold greater rates of Medicare-financed hospitalizations (1.31 for lower reliance vs. 0.15 for high reliance; p < .001).

CONCLUSIONS

Among Veterans receiving integrated care in VA's H-PACT, dual use of Medicare and VA outpatient care is strongly associated with acute hospitalizations financed by Medicare. Linking VA and non-VA data may identify a subset of homeless Veterans with fragmented outpatient care who are at increased risk of poor outcomes.

Access to Care for Homeless Veterans During Disasters

Introduction: Since 1970, natural disasters have led to both temporary and permanent closures of multiple medical centers and outpatient clinics at the US Department of Veterans Affairs (VA) nationwide. Access to care during such events is critical for vulnerable populations, especially homeless veterans. As such, facility closures may disproportionately affect homeless veteran patients who are both more likely to experience adverse effects from disasters and face multiple barriers to care. Methods: A cross-sectional survey was administered to a probability sample of 2000 homeless VA patients living in and receiving VA health care in the Northeast United States. The survey was completed by 383 respondents (20% adjusted response rate). This pilot study examines predictors of difficulty accessing care in the event that the VA facility that homeless VA patients routinely use is forced to close because of a natural disaster. Results: In a multivariate logistic regression, homeless VA patients who had Medicaid were less likely (OR 0.38; 95% CI: 0.18-0.78; P < .01) to report that they would have difficulty obtaining care elsewhere if their normal VA facility was closed in a future natural disaster. Conclusions: Findings suggest that Medicaid coverage has the potential to facilitate access to care for homeless veteran VA patients during disasters. Policy changes that decrease Medicaid coverage could limit access to care for homeless veterans during closures of VA medical facilities.