The impact of private insurance coverage on veterans' use of VA care: insurance and selection effects

Association Between Self-Reported Health and Reliance on Veterans Affairs for Health Care Among Veterans Affairs Enrollees

This cross-sectional study using survey data investigates the association between level of reliance on the Department of Veterans Affairs for health care and self-reported health by type of insurance coverage among VA enrollees.

Regional market factors and patient experience in primary care

OBJECTIVES

To evaluate the association between regional market factors and experience with patient-provider communication in primary care services of safety net hospitals.

STUDY DESIGN

A retrospective cohort study with 933,407 patient experience survey respondents from 128 Veterans Health Administration (VHA) hospitals between fiscal years 2013 and 2016.

METHODS

Patient responses on 5 patient-provider communication questions were used to evaluate quality of care. Six regional market factors were used to characterize veterans' health care insurance coverage and affluence. A logistic regression was used to examine changes in individual-level patient-provider communication experience when regional market factors increase or decrease the demand for VHA primary care services.

RESULTS

Our findings supported our hypothesis that changes in regional market factors shift patient demand for VHA care and affect patient-provider communication measured by patient experience surveys. The adjusted odds ratio (AOR) of positive patient-provider communication was associated with a regional increase (first to third quartile) of employer-sponsored insurance (AOR, 1.028; 95% CI, 1.001-1.055) and a decrease (third to first quartile) in the veterans' unemployment rate (AOR, 0.966; 95% CI, 0.944-0.990). Higher primary care capacity (first to third quartile) was also associated with positive patient-provider communication (AOR, 1.050; 95% CI, 1.018-1.082).

CONCLUSIONS

Findings from this study raise concerns that safety net hospitals could be unfairly penalized by value-based payment programs and Medicare Hospital Compare. Such policies and programs could improve resource allocation by accounting for regional market factors before acting on quality of care measures.

Effect of Obesogenic Medications on Weight-Loss Outcomes in a Behavioral Weight-Management Program

OBJECTIVE

This study aimed to evaluate a possible association between the use of obesogenic medications and inadequate weight loss in a behavioral weight-management program.

METHODS

This is a case-control, single-center study of 666 adult patients within a Veterans Health Administration health system who participated in the MOVE! behavioral weight-loss program. The cohort was divided into responders (n = 150), patients who achieved ≥ 5% total weight loss by the end of the MOVE! program, and nonresponders (n = 516), those who achieved < 5% total weight loss. We reviewed each patient's medical records for exposure to obesogenic medication during the time of treatment.

RESULTS

Approximately 62% (n = 411) of patients entering MOVE! had a prescription for obesogenic medications. Obesogenic medication use was associated with worse weight-loss outcomes, and participants were 37% less likely to achieve a clinically meaningful (≥ 5% total weight loss) outcome at the end of the MOVE! program (odds ratio, 0.633; 95% CI: 0.427-0.937; adjusted P = 0.022). Patients who received three or more medications (n = 72) had the greatest difficulty achieving 5% weight loss compared with the control group (odds ratio, 0.265; 95% CI: 0.108-0.646; adjusted P = 0.003).

CONCLUSIONS

The use of provider-prescribed obesogenic medications was associated with worse weight-loss outcomes in a behavioral weight-loss program. Closer scrutiny of patient medications is necessary to help improve outcomes of weight-loss treatments.

External Determinants of Veterans' Utilization of VA Health Care

OBJECTIVE

Veterans' utilization of Veterans Affairs (VA) health care is likely influenced by community factors external to the VA, including Medicaid eligibility and unemployment, although such factors are rarely considered in models predicting such utilization. We measured the sensitivity of VA utilization to changes in such community factors (hereafter, "external determinants"), including the 2014 Medicaid expansion following the Affordable Care Act.

DATA SOURCES/STUDY SETTING

We merged VA health care enrollment and utilization data with area-level data on Medicaid policy, unemployment, employer-sponsored insurance, housing prices, and non-VA physician availability (2008-2014).

STUDY DESIGN

For veterans aged 18-64 and ≥65, we estimated the sensitivity of annual individual VA health care utilization, measured by the cost ($) of care received, to changes in external determinants using longitudinal regression models controlling for individual fixed effects.

PRINCIPAL FINDINGS

All external determinants were associated with small but significant changes in VA health care utilization. In states that expanded Medicaid in 2014, this expansion was associated with 9.1 percent ($826 million) reduction in VA utilization among those aged 18-64; sizable changes occurred in all services used (inpatient, outpatient, and prescription drugs).

CONCLUSIONS

Changes in alternative insurance coverage and other external determinants may affect VA health care spending. Policy makers should consider these factors in allocating VA resources to meet local demand.

Food Insecurity and Health Care Expenditures in the United States, 2011-2013

OBJECTIVE

To determine whether food insecurity, limited or uncertain food access owing to cost, is associated with greater health care expenditures.

DATA SOURCE/STUDY SETTING

Nationally representative sample of the civilian noninstitutionalized population of the United States (2011 National Health Interview Survey [NHIS] linked to 2012-2013 Medication Expenditure Panel Survey [MEPS]).

STUDY DESIGN

Longitudinal retrospective cohort.

DATA COLLECTION/EXTRACTION METHODS

A total of 16,663 individuals underwent assessment of food insecurity, using the 10-item adult 30-day food security module, in the 2011 NHIS. Their total health care expenditures in 2012 and 2013 were recorded in MEPS. Expenditure data were analyzed using zero-inflated negative binomial regression and adjusted for age, gender, race/ethnicity, education, income, insurance, and residence area.

PRINCIPAL FINDINGS

Fourteen percent of individuals reported food insecurity, representing 41,616,255 Americans. Mean annualized total expenditures were $4,113 (standard error $115); 9.2 percent of all individuals had no health care expenditures. In multivariable analyses, those with food insecurity had significantly greater estimated mean annualized health care expenditures ($6,072 vs. $4,208, p < .0001), an extra $1,863 in health care expenditure per year, or $77.5 billion in additional health care expenditure annually.

CONCLUSIONS

Food insecurity was associated with greater subsequent health care expenditures. Future studies should determine whether food insecurity interventions can improve health and reduce health care costs.

State-Level Variability in Veteran Reliance on Veterans Health Administration and Potentially Preventable Hospitalizations: A Geospatial Analysis

Most Veterans who use the Veterans Health Administration (VHA) also utilize private-sector health care providers. To better inform local and regional health care planning, we assessed the association between reliance on VHA ambulatory care and total and system-specific preventable hospitalization rates (PHRs) at the state level. We conducted a retrospective dynamic cohort study using Veterans with diabetes mellitus, aged 66 years or older, and dually enrolled in VHA and Medicare parts A and B from 2004 to 2010. While controlling for median age and proportion of males, we measured the association between reliance on VHA ambulatory care and PHRs at the state level using multivariable ordinary least square regression, geographically weighted regression, and generalized additive models. We measured geospatial patterns in PHRs using global Moran’s I and univariate local indicator spatial analysis. Approximately 30% of hospitalized Veterans experienced a preventable hospitalization. Reliance on VHA ambulatory care at the state level ranged from 13.92% to 67.78% and was generally not associated with PHRs. Geospatial analysis consistently identified a cluster of western states with low PHRs from 2006 to 2010. Given the generally low reliance on VHA ambulatory care and lack of association between this reliance and PHRs, policy changes to improve Veterans’ health care outcomes should address private-sector care in addition to VHA care.

An Evidence Map of the Women Veterans' Health Research Literature (2008-2015)

BACKGROUND

Women comprise a growing proportion of Veterans seeking care at Veterans Affairs (VA) healthcare facilities. VA initiatives have accelerated changes in services for female Veterans, yet the corresponding literature has not been systematically reviewed since 2008. In 2015, VA Women's Health Services and the VA Women's Health Research Network requested an updated literature review to facilitate policy and research planning.

METHODS

The Minneapolis VA Evidence-based Synthesis Program performed a systematic search of research related to female Veterans' health published from 2008 through 2015. We extracted study characteristics including healthcare topic, design, sample size and proportion female, research setting, and funding source. We created an evidence map by organizing and presenting results within and across healthcare topics, and describing patterns, strengths, and gaps.

RESULTS

We identified 2276 abstracts and assessed each for relevance. We excluded 1092 abstracts and reviewed 1184 full-text articles; 750 were excluded. Of 440 included articles, 208 (47%) were related to mental health, particularly post-traumatic stress disorder (71 articles), military sexual trauma (37 articles), and substance abuse (20 articles). The number of articles addressing VA priority topic areas increased over time, including reproductive health, healthcare organization and delivery, access and utilization, and post-deployment health. Three or fewer articles addressed each of the common chronic diseases: diabetes, hypertension, depression, or anxiety. Nearly 400 articles (90%) used an observational design. Eight articles (2%) described randomized trials.

CONCLUSIONS

Our evidence map summarizes patterns, progress, and growth in the female Veterans' health and healthcare literature. Observational studies in mental health make up the majority of research. A focus on primary care delivery over clinical topics in primary care and a lack of sex-specific results for studies that include men and women have contributed to research gaps in addressing common chronic diseases. Interventional research using randomized trials is needed.

Veterans' Preferences for Receiving Information About VA Services: Is Getting the Information You Want Related to Increased Health Care Utilization?

Although the current cohort of returning veterans has engaged more fully with care from the Department of Veterans Affairs (VA) than have veterans from previous eras, concern remains regarding low engagement with VA services, particularly for specialty services for diagnoses that can most negatively impact quality of life. This study used the framework of the Andersen Model to examine factors related to VA health care use in Operation Enduring Freedom/Operation Iraqi Freedom veterans. Match between veterans' preferences for source of information about VA programs and veterans' actual sources of information about VA services was examined as an additional predictor of help seeking. The study included 1,161 veterans recruited from the southeast United States. Results suggested that veterans prefer to receive information from VA publications and the web, whereas they actually receive information from VA publications and other veterans. Logistic regression suggested that the number of deployments, income, distance to VA, VA disability rating, self-rated health, and match between preferred source of information and actual source of information were significantly related to the use of VA services since deployment. These results suggest that future outreach efforts should focus on targeting veterans' health needs and preferences for care and source of information.

Depression and anxiety symptoms in male veterans and non-veterans: the Health and Retirement Study

OBJECTIVES

We examined whether veteran status was associated with elevated depression and anxiety symptoms in men aged 50 and older after adjusting for sociodemographic factors.

METHODS

Participants were 6577 men aged 50 years and older who completed the 2006 wave of the Health and Retirement Study (HRS). Forty-nine percent of participants were veterans. A randomly selected subset of participants completed the HRS Psychosocial Questionnaire (N = 2957), which contained the anxiety items. Elevated depression and anxiety symptoms were determined based on brief versions of Center for Epidemiologic Studies--Depression Scale (CES-D total score ≥ 4) and Beck Anxiety Inventory (BAI total score ≥ 12).

RESULTS

Elevated depression and anxiety symptoms were found in 11.0 and 9.9% of veterans, respectively, compared with 12.8 and 12.3% of non-veterans. Veteran status was not associated with increased odds of anxiety or depression symptoms in the multivariable-adjusted logistic regression analyses. Additional analyses indicated that Vietnam War veterans were more than twice as likely as World War II or Korean War veterans to have elevated depression symptoms (OR = 2.15, 95% CI: 1.54-3.00) or anxiety symptoms (OR = 2.12, 95% CI: 1.28-3.51).

CONCLUSIONS

In a community-based sample of men aged 50 and older, veteran status was not associated with the presence of elevated depression and anxiety symptoms. Rather, these symptoms were associated with age, ethnicity, education, and medical conditions. Among veterans, cohort effects accounted for differences in psychiatric symptoms. Including younger cohorts from the Global War on Terror may yield different results in future studies.

The impact of the urban resident basic medical insurance on health services utilisation in China

BACKGROUND

The Urban Resident Basic Medical Insurance (URBMI), launched in 2007 by the State Council, aims to cover around 420 million urban residents in China.

OBJECTIVE

This study aimed to assess the impact of URBMI on health services access (especially inpatient utilisation) in urban China.

METHODS

Data was drawn from the recent four-wave URBMI Survey (2008-2011). Probit and recursive bivariate probit models have been adopted to handle the possible endogeneity of medical insurance in the utilisation equations.

RESULTS

Based on the preferred results from the unbalanced four-wave panel data, we found that the URBMI had significantly increased the likelihood of receiving inpatient treatment in the past year. However, the insurance effect on reducing the refused hospitalisation was insignificant. Finally, the URBMI had also increased the probability of using outpatient services in the past 2 weeks, although the insurance reimburses mainly against critical outpatient care.

CONCLUSIONS

Given that it is still early days for the URBMI scheme, the positive effect on health services utilisation is appreciable.