Abstract
Objective
Veterans with spinal cord injuries and disorders (SCI/D) utilizing Veterans Affairs healthcare facilities are also Medicare eligible. Use of multiple health care systems potentially duplicates or fragments care in this population; yet little is known about those using multiple systems. This study describes dual use of services paid for by VA and Medicare among Veterans with SCI/D.
Design
Retrospective, cross-sectional, observational study.
Participants
Veterans with SCI/D (n = 13,902) who received healthcare services within the VA SCI System of Care and were eligible for or enrolled in Medicare in 2011.
Interventions
N/A.
Outcome Measures
Patient characteristics, average number of visits and patient level frequencies of reasons for visits were determined for individuals within healthcare utilization (VA only, Medicare only, or dual VA/Medicare) groups. Multinomial logistic regression analyses were used to investigate associations of patient variables on dual use.
Results
65.3% of Veterans with SCI/D were VA only users for outpatient encounters, 4.4% had encounters paid for by Medicare only, and 30.3% were dual users. Veterans were less likely to be VA only users if they were older than 69 and if they had been injured for greater than ten years. African American Veterans with SCI (compared to white) were more likely to be VA only users.
Conclusion
A substantial number (∼30%) of Veterans with SCI/D are dual users. These numbers highlight the importance of improved strategies to coordinate care and increase health information sharing across systems.
Keywords: Spinal cord injuries and disorders, Veterans, Medicare, Healthcare utilization, Coordination of care
Introduction
Approximately 282,000 people in the United States are currently living with a spinal cord injury or disorder (SCI/D), with approximately 17,000 new injuries occurring each year.1 While there have been tremendous advances in care for people living with SCI/D,2–4 numerous secondary health conditions associated with SCI/D persist long after the initial injury.5,6 These conditions include cardiovascular disease, spasticity, diabetes, bowel and bladder dysfunction, osteoporosis, obesity, fatigue, and respiratory complications.7 Aside from these secondary health conditions, mental health issues such as depression, anxiety and post-traumatic stress disorder have also become increasingly recognized in individuals with SCI/D.8,9
The US Department of Veterans Affairs (VA) is the largest provider of comprehensive SCI/D care in the nation.10 Composed of 24 VA SCI Centers (hubs) and numerous community-based outpatient clinics (spokes), these hub and spoke facilities are geographically distributed throughout the U.S. Each VA SCI Center offers a variety of inpatient, outpatient, rehabilitation and specialty care services to assist with management of secondary conditions throughout the Veteran’s lifetime.11 In addition to the array of services offered within the VA system, Veterans with SCI/D are eligible for (and may elect to use) Medicare benefits in non-VA community-based settings. Although access to both VA and Medicare systems may enhance or improve access to care, it also has the potential to cause unintended duplication of services, costs and fragmentation of care.12–14 This is particularly crucial for individuals with SCI/D due to their specialized healthcare needs, and high frequency of healthcare utilization.
Minimal research quantifying dual utilization among Veterans living with SCI/D is available. One study published in 2009 investigating mental illness and substance use disorder among Veteran clinic users with SCI/D, showed that as many as 54% of registry individuals were also enrolled in Medicare fee-for-service during the 2-year study period.15 Another study investigating dual healthcare use among 2.6 million Veterans eligible for both VA and Medicare found that individuals with higher health risk scores (defined by the Hierarchical Condition Category16) were more likely to be dual system users;17 those with SCI/D have higher likelihood of higher health risk scores. These are suggestive of the potential for high dual healthcare use among Veterans with SCI/D, yet they did not explicitly examine dual use patterns or percentages across all Veterans with SCI/D.
The objective of the current study was to examine the patterns and characteristics associated with dual use of outpatient services obtained through VA and Medicare among Veterans with SCI/D throughout the U.S. We also determined the average number of visits, and patient level frequencies of the most common reasons for outpatient visits in VA only, Medicare only, and dual user groups.
Methods
Design. Retrospective, cross-sectional, observational study.
Participants. Following processes previously used by this research team,18 the cohort of patients for the current study was drawn from the VA Spinal Cord Injury and Disorders Outcomes Database (SCIDO).19 The SCIDO is a clinical database that includes ∼29,000 Veterans with SCI/D who have received outpatient healthcare from one or more VA SCI Center(s) and at the time this study was the primary VA database used for collecting clinical data among Veterans with SCI/D. Veterans were excluded if they were deceased, or diagnosed with other spinal cord disorders including Amyotrophic Lateral Sclerosis (ALS), Multiple Sclerosis (MS), Acute Myelitis, or Guillian-Barre. Veterans with missing demographic data including distance to VA, rural location, race, and sex were also excluded from analyses. Veterans with dates of injury after 2011 were also excluded. This cohort of remaining patients was then matched against 2011 Medicare enrollment files (the most recent Medicare data available). The final sample was comprised of 13,902 Veterans with SCI/D. Of note, we elected not to exclude Veterans with missing values for injury characteristics (injury level and type) due to the large percentage of individuals with missing information on these particular variables.
Data sources and measures
Patient Characteristics. Patient characteristics including age, race, sex, ethnicity, marital status and geographic location were derived from the VA Medical SAS Outpatient National Datasets, which include information from VA electronic medical records.20 Injury characteristics including level of injury (i.e. paraplegia, tetraplegia), etiology (i.e. traumatic, non-traumatic), and duration of injury were obtained from the SCIDO database.
Differential Distance. Zip codes were used to determine the differential distance between patients nearest VA SCI System of Care facility (hub or spoke) and Medicare-reimbursed facility. Distance differentials were calculated using the distance to the nearest VA hospital minus the distance to the nearest Medicare-reimbursed hospital. Rural/urban status for each individual in our sample was calculated; these calculations were based on Rural-Urban Community Area (RUCA) codes derived from patient zip codes.21
Healthcare Utilization. Veterans’ healthcare utilization data came from national VA databases and Medicare claims and event files. VA utilization was derived from the VA Medical SAS Outpatient Dataset, which use data extracted VA medical records to quantify outpatient care provided by the VA.22 Standard ICD-9 codes were used to identify all outpatient services across both the VA and Medicare (community-based) healthcare systems.23 Inpatient services were not included in this study analysis.
Patient Diagnoses. To identify and compare the most prevalent diagnoses among the Veterans in our cohort across healthcare groups, we separately queried the top 15 ICD-9 codes for Veterans within each system across groups (see description below). The percentage of patients in each group who had that diagnosis were then calculated.
Analyses
We divided our patient cohort into three mutually exclusive groups based on their healthcare system utilization: (1) those who received care only through the VA (‘VA only users’), (2) those who were eligible for VA care but received care only from community-based providers using their Medicare benefits (‘Medicare only users’), and (3) those who received care at both the VA and through community-based providers using their Medicare benefits (‘dual users’). Analyses were conducted separately for each group.
Chi-squared tests were used to compare patient demographics, injury characteristics, geographic information and differential distances between the VA only, Medicare only, and dual user groups. Associations between specific patient variables and health care utilization were assessed using multinomial logistic regression analyses. A series of unadjusted models were run first, followed by adjusted models accounting for potentially confounding variables: results display adjusted models/numbers. Relative risk ratios (RRRs) were used for regressions where RRRs equal to 1 suggest equal risk/incidence in groups being compared, RRR > 1 suggests an increased incidence in first group listed, and an RRR < 1 suggests a decreased incidence. The magnitude of RRRs and P-values of < 0.05 were used to assess the level and significance of probability of use of outpatient healthcare services among the 3 healthcare system utilization groups (i.e. VA only, Medicare only, dual users). All analyses were performed using STATA MP version 14.2 software (StataCorp, College Station, TX).
Results
Demographics and injury characteristics
Across the 3 utilization groups (i.e. VA only, Medicare only and dual users), our cohort was predominantly male (96.2%, 93.8% and 96.8%, respectively), white (i.e. 74.2%, 81.5% and 80.3%, respectively), of non-Hispanic ethnicity (95.5%, 97.7% and 96.3%, respectively), between the ages of 51–68 years (61.9%, 50.2% and 53.1%, respectively), and lived in an urban area (i.e. 85.8%, 78.7% and 80.8%, respectively). Nearly half of the individuals in each utilization group resided in the southern United States (45.4%, 44.1%, and 47.6%, respectively), with more than half of the Veterans in each utilization group living with their SCI/D for ten or more years (56.5%, 67.8%, and 60.5%, respectively). Age, race, ethnicity, marital status, region, rurality, distance to both VA and Medicare facilities, and injury characteristics were all significantly associated with utilization group. Injury characteristics (shown separately by utilization group) can be found in Table 1; of note, the chi-square association presented in this table examine the overall association between the demographic and injury-related categories and the type of utilization.
Table 1.
Patient characteristics by healthcare system utilization group.
| VA Onlya | Medicare Onlyb | Dual Usersc | ||
|---|---|---|---|---|
| (n = 9073; 65.3%) | (n = 615 4.4%) | (n = 4214; 30.3%) | ||
| Injury Characteristics | ||||
| Level of injury** | n (%) | n (%) | n (%) | |
| Paraplegia | 3652 (40.3) | 214 (34.8) | 1697 (40.2) | |
| Tetraplegia | 3741 (41.2) | 212 (34.5) | 1760 (41.8) | |
| Missing/unknown | 1680 (18.5) | 189 (30.7) | 757 (18.0) | |
| Type of injury** | ||||
| Traumatic | 2864(31.6) | 153 (24.9) | 1286 (30.6) | |
| Non-traumatic | 2954 (32.6) | 179 (29.1) | 1312 (31.1) | |
| Missing/unknown | 3255 (35.9) | 283 (46.0) | 1616 (38.4) | |
| Duration of injury** | ||||
| <2 yrs | 916 (10.1) | 11 (1.8) | 265 (6.3) | |
| 2–9 yrs | 2543 (28.0) | 134 (21.8) | 1193 (28.3) | |
| 10 + yrs | 5123 (56.5) | 417 (67.8) | 2548 (60.5) | |
| Missing/unknown | 491 (5.4) | 53 (8.60) | 208 (4.9) | |
| Demographic Characteristics | ||||
| Sex | ||||
| Male | 8727 (96.2) | 577 (93.8) | 4077 (96.8) | |
| Female | 346 (3.8) | 38 (6.2) | 137(3.3) | |
| Age** | ||||
| 18–29 | 272 (3.0) | 7 (1.1) | 95 (2.3) | |
| 30–50 | 2075 (22.9) | 131 (21.3) | 775 (18.4) | |
| 51–68 | 5617 (61.9) | 309 (50.2) | 2238 (53.1) | |
| 69–85 | 1034 (11.4) | 153 (24.9) | 1012 (24.0) | |
| 85 + | 75 (0.1) | 15 (2.4) | 94 (2.2) | |
| Race** | ||||
| African American | 1989 (21.9) | 87 (14.2) | 699 (16.6) | |
| White | 6742 (74.2) | 501 (81.5) | 3382 (80.3) | |
| Other | 501 (81.5) | 27 (4.4) | 133 (3.2) | |
| Ethnicity** | ||||
| Hispanic | 405 (4.5) | 14 (2.3) | 158 (3.8) | |
| Not Hispanic | 8668 (95.5) | 601 (97.7) | 4056(96.3) | |
| Marital Status** | ||||
| Married | 4122 (45.4) | 68 (11.1) | 2236 (53.1) | |
| Unmarried | 4951 (54.6) | 547 (88.9) | 1978 (46.9) | |
| Rurality** | ||||
| Urban | 7780 (85.8) | 484 (78.7) | 3406 (80.8) | |
| Rural | 1293 (14.3) | 131 (21.3) | 808 (19.2) | |
| Distance to Nearest Medicare Facility** | ||||
| <5 | 3504 (38.6) | 199 (32.3) | 1375 (32.6) | |
| 5–19 | 5025 (55.4) | 355 (57.7) | 2512 (59.6) | |
| 20–39 | 505 (5.6) | 54(8.8) | 292 (6.96) | |
| 40–59 | 35 (0.4) | 4 (0.7) | 28 (0.7) | |
| 60 + | 4 (0.0) | 3 (0.5) | 7 (0.2) | |
| Distance to Nearest VA Facility** | ||||
| <5 | 3168 (34.9) | 144 (23.4) | 1115 (26.5) | |
| 5–19 | 2871 (31.6) | 179 (29.1) | 1253 (29.7) | |
| 20–39 | 1539 (17.0) | 131 (21.3) | 895 (21.2) | |
| 40–59 | 759 (8.4) | 80 (13.0) | 494 (11.7) | |
| 60 + | 736 (8.1) | 81 (13.2) | 457 (10.8) | |
| Geographic Characteristics** | ||||
| Midwest | 1746 (19.2) | 130 (21.1) | 858 (20.4) | |
| Northeast | 1141 (12.6) | 81 (13.2) | 549 (13.0) | |
| South | 4119 (45.4) | 271 (44.1) | 2005 (47.6) | |
| West | 2067 (22.8) | 133 (21.6) | 802 (19.0) | |
Veterans living with SCI/D who only received care at a VA facility.
Veterans living with SCI/D who were eligible for VA services but used only community-based providers via their Medicare benefits.
Veterans living with SCI/D who received care from both VA and Medicare.
** indicates P < 0.01.
Health care system utilization
Out of the 13,902 Veterans in our patient cohort, 65.3% (n = 9,073) were VA only users, 4.4% (n = 615) were Medicare only users, and nearly one-third (30.3%; n = 4,214) were dual users (see Table 1).
Diagnoses
The 15 most common diagnoses in individuals within each utilization group (i.e. VA only, Medicare only, and dual users) are shown in Table 2. Across all groups, the most common diagnoses included: neurogenic bladder/bowel, hypertension, hyperlipidemia, and urinary tract infections. Differences included encounters for therapy (occupational and physical) and counseling (specified and unspecified) at VA facilities (in VA only and Dual group) as opposed to Medicare.
Table 2.
Most common diagnoses among veterans by healthcare system utilization group.
| VA Onlya | Medicare Onlyb | Dual Usersc | ||||||
|---|---|---|---|---|---|---|---|---|
| VA Diagnosis | MC Diagnosis | |||||||
| Rank | Diagnosis | n (%) | Diagnosis | n (%) | Diagnosis | n (%) | Diagnosis | n (%) |
| 1 | Neurogenic Bladder NOS | 4567 (50.3.%) | Unspecified Essential Hypertension | 273 (44.4%) | Neurogenic Bladder NOS | 2332 (55.3%) | Unspecified Essential Hypertension | 1701 (40.4%) |
| 2 | Unspecified Essential Hypertension | 4278(47.2%) | Urinary Tract Infection, site not specified | 240 (39.0%) | Unspecified Essential Hypertension | 2013(47.8%) | Urinary Tract Infection, Site Not Specified | 1469 (34.9%) |
| 3 | Paraplegia | 3768(41.5%) | Other and Unspecified Hyperlipidemia | 207 (33.7%) | Paraplegia | 1895(45.0%) | Paraplegia | 1351(32.1%) |
| 4 | Neurogenic Bowel | 3625(40.0%) | Need For Prophylactic Vaccination And Inoculation, Influenza | 198 (32.2%) | Neurogenic Bowel | 1884 (44.7%) | Neurogenic Bladder NOS | 1080(25.6%) |
| 5 | Other And Unspecified Hyperlipidemia | 3476(38.3%) | Long term (current) use of other medications | 198 (31.2%) | Other and Unspecified Hyperlipidemia | 1703(40.4%) | Other and Unspecified Hyperlipidemia | 1049(24.9%) |
| 6 | Need For Prophylactic Vaccination And Inoculation, Influenza | 3303(36.4%) | Paraplegia | 190 (30.9%) | Other Unspecified Counseling | 1463(34.7%) | Diabetes Mellitus without mention of complication | 945 (22.4%) |
| 7 | Other Unspecified Counseling | 3102(34.2%) | Neurogenic Bladder NOS | 170 (27.6%) | Other Specified Counseling | 1431(34.0%) | Long term (current) use of other medications | 869 (20.6%) |
| 8 | Other Specified Counseling | 2977 (32.8%) | Benign Essential Hypertension | 166 (27.0%) | Vaccination, Influenza | 1278 (30.3%) | Pain in Limb | 767(18.2%) |
| 9 | Late Effect of Spinal Cord Injury | 2706(29.8%) | Pain in Limb | 158(25.70%) | Late Effect Of SCI | 1263(30.0%) | Benign Essential Hypertension | 747 (1.47%) |
| 10 | Care Involving Other Physical Therapy | 2261(24.9%) | Diabetes Mellitus Without Mention of Complication | 148 (24.1%) | Quadriplegia, unspecified | 1068(25.3%) | Other Malaise and Fatigue | 738 (17.5%) |
| 11 | Lumbago | 2150 (23.7%) | Anemia | 147 (23.9%) | Diabetes without mention of complication, type II | 1040(24.7%) | Esophageal Reflux | 701 (16.6%) |
| 12 | Quadriplegia, Unspecified | 2138(23.6%) | Esophageal reflux | 147(23.9%) | Urinary Tract Infection, site not specified | 1034(24.5%) | Quadriplegia, Unspecified | 687(16.6%) |
| 13 | Tobacco Use Disorder, Unspecified Use | 2052 (22.6%) | Other Malaise and Fatigue | 136 (22.1%) | Care involving other physical therapy | 906 (21.5%) | Unspecified Chest Pain | 666 (15.8%) |
| 14 | Urinary Tract Infection, Site Not Specified | 2040 (22.5%) | Depressive Disorder, Not Elsewhere Classified | 126 (20.5%) | Encounter for Occupational Therapy | 870 (20.6%) | Lumbago | 517 (14.6%) |
| 15 | Encounter for Occupational Therapy | 1973(21.7%) | Quadriplegia, Unspecified | 113 (18.3%) | Depressive Disorder, Not Elsewhere Classified | 860 (20.4%) | Anemia | 613 (14.5%) |
Veterans living with SCI/D who only received care at a VA facility.
Veterans living with SCI/D who were eligible for VA services but used only community-based providers via their Medicare benefits.
Veterans living with SCI/D who received care from both VA and Medicare.
Data for this table are at the person-level. Percentages within each group may not add up to 100% because individuals may have multiple diagnoses.
Health care services use
When we looked at the average number of visits for health care services between the three utilization groups VA only users had higher average diagnostic and mental health-related visits compared to Medicare only and dual users; whereas Medicare only users had the highest average specialty visits (Table 3). If we look at trends across all the groups, Veterans with SCI use the VA over Medicare for mental health related services (greater than 4x average number of mental health visits at VA vs. Medicare in dual users and between VA only and Medicare only users; Table 3). There is also a slight preference for the VA for diagnostic-related visits (4.7 vs. 1.9 for dual users).
Table 3.
Health care service utilization by system use.
| *Values represent mean number of visits for each service | VA Onlya | Medicare Onlyb | Dual Usersc | |
|---|---|---|---|---|
| VA | Medicare | |||
| Specialty Care | 6.7 | 8.6 | 6.0 | 6.1 |
| Primary Care | 2.9 | 2.6 | 2.6 | 1.6 |
| Diagnostic | 5.4 | 2.9 | 4.7 | 1.9 |
| Mental Health | 2.4 | 0.7 | 1.8 | 0.2 |
Veterans living with SCI/D who only received care at a VA facility
Veterans living with SCI/D who were eligible for VA services but used only community-based providers via their Medicare benefits
Veterans living with SCI/D who received care from both VA and Medicare
Predictors of health care system utilization
Multiple multinomial logistic regression results that adjust for all included demographic and injury characteristics, allow comparison with a reference group and yield predictors of health care system utilization (Table 4) suggest that Veterans who had been living with their SCI/D from 2–9 and 10 + years (compared to those < 2 years) were less likely to be VA only users compared to dual users (P < 0.01 for both) and Medicare only users (P < 0.01 for both). Similarly, Veterans over 69 (69–84 and 85 + groups) were also less likely to be VA only users than dual users and Medicare only users (P < 0.01 for both). Veterans living in rural areas, (compared to urban; P < 0.01), and those living any distance greater than 5 miles away (compared to those < 5 miles; P < 0.01) from a VA facility were less likely to be VA only users
Table 4.
Adjusted multiple logistic regression results: predictors of health care system utilization.
| Characteristic | VA Only Vs. Dual (n = 9073 vs. 4215) | Medicare Only vs. Dual (n = 615 vs. 4215) | VA Only Vs. Medicare Only (n = 9073 vs. 615) |
|---|---|---|---|
| RRR (95% CI) | RRR (95% CI) | RRR (95% CI) | |
| Injury Characteristics | |||
| Level of Injury | |||
| Paraplegia | Ref | Ref | Ref |
| Tetraplegia | 1.0 (0.9 – 1.1) | 0.9 (0.8 – 1.2) | 1.1 (0.9 – 1.4) |
| Missing | 1.1 (1.0 – 1.3)* | 2.0 (1.6 – 2.6)** | 0.5 (0.4 – 0.7)** |
| Type of Injury | |||
| Non-traumatic | Ref | Ref | Ref |
| Traumatic | 0.9 (0.8 – 1.0) | 0.9 (0.7 – 1.1) | 1.1 (0.9 – 1.4) |
| Missing | 0.8 (0.8 – 0.9)** | 1.2 (0.9 – 1.5) | 0.7 (0.6 – 0.9)** |
| Duration of injury | |||
| 0-2 Years | Ref | Ref | Ref |
| 2-9 Years | 0.6 (0.5 – 0.7)** | 2.7 (1.4 – 5.2)** | 0.2 (0.1 – 0.4)** |
| 10 + Years | 0.6 (0.5 – 0.7)** | 3.9 (2.1 – 7.2)** | 0.2 (0.1 – 0.3)** |
| Missing | 0.7 (0.5 – 0.8)** | 4.1 (2.0 – 8.3)** | 0.2 (0.1 – 0.3)** |
| Demographic characteristics | |||
| Sex | |||
| Female | Ref | Ref | Ref |
| Male | 1.0 (0.9 – 1.3) | 0.7 (0.5 – 1.1) | 1.4 (0.9 – 2.0) |
| Age | |||
| 18-29 | Ref | Ref | Ref |
| 30-50 | 1.0 (0.7 – 1.3) | 1.9 (0.8 – 4.3) | 0.5 (0.2 – 1.1) |
| 51-68 | 0.94 (0.7 – 1.2) | 1.6 (0.7- 3.6) | 0.6 (0.3 – 1.3) |
| 69-84 | 0.4 (0.3 – 0.5)** | 2.2 (0.9 – 5.0) | 0.2 (0.1 – 0.4) ** |
| 85+ | 0.3 (0.2 – 0.4)** | 2.0 (0.7 – 5.4) | 0.1 (0.1 – 0.4)** |
| Race | |||
| White | Ref | Ref | Ref |
| African American | 1.3 (1.1 – 1.4)** | 0.7 (0.6 – 0.9)* | 1.8 (1.4 2.3)** |
| Other | 1.2 (0.9 – 1.4) | 1.3 (0.8 – 2.1) | 0.9 (0.6 – 1.3) |
| Ethnicity | |||
| Not Hispanic | Ref | Ref | Ref |
| Hispanic | 1.1 (0.9 – 1.3) | 0.6 (0.3 - 1.0) | 1.9 (1.1 – 3.3) |
| Marital Status | |||
| Not Married | Ref | Ref | Ref |
| Married | 0.8 (0.8 – 0.9)** | 0.1 (0.1 – 0.1)** | 8.2 (6.3 – 10.6)** |
| Rurality | |||
| Urban | Ref | Ref | Ref |
| Rural | 0.9 (0.8 – 0.9)** | 1.0 (0.8 – 1.3) | 0.9 (0.7 – 1.1) |
| Regions | |||
| Midwest | Ref | Ref | Ref |
| Northeast | 1.0 (0.9 – 1.2) | 1.0 (0.7 – 1.4) | 1.0 (0.8 – 1.4) |
| South | 1.0 (0.9 – 1.1) | 1.1 (0.9 – 1.5) | 0.9 (0.9 – 1.1) |
| West | 1.3 (1.1 – 1.5)** | 1.3 (0.9 – 1.7) | 1.0 (0.8 – 1.4) |
| Distance to Medicare Facility | |||
| <5 miles | Ref | Ref | Ref |
| 5-19 miles | 1.0 (0.9 – 1.1) | 1.0 (0.8 – 1.3) | 1.0 (0.8 – 1.2) |
| 20-39 | 1.0 (0.8 – 1.2) | 1.1 (0.7 – 1.7) | 0.9 (0.6 – 1.3) |
| 40-59 | 0.7 (0.4 –1.2) | 0.9 (0.3 – 2.9) | 0.7 (0.2 – 2.2) |
| 60+ | 0.4 (0.1 –1.3) | 1.9 (0.4 – 8.7) | 0.2 (0.0 – 0.9)* |
| Distance to VA Facility | |||
| <5 miles | Ref | Ref | Ref |
| 5-19 miles | 0.8 (0.8 – 0.9)** | 1.2 (0.9 – 1.5) | 0.7 (0.6 – 0.9)** |
| 20-39 | 0.6 (0.6 – 0.7)** | 1.2 (0.9 – 1.6) | 0.5 (0.4 – 0.7)** |
| 40-59 | 0.6 (0.5 – 0.7)** | 1.4 (0.9 – 1.9) | 0.4 (0.3 – 0.6) |
| 69+ | 0.6 (0.5 – 0.7)** | 1.4 (0.9 – 1.9) | 0.5 (0.3 – 0.6)** |
* indicates P < 0.05.
** indicates P < 0.01.
Interestingly, Veterans with SCI/D who were African American were more likely (than white) to be VA only users compared to dual or Medicare only users (P < 0.01), but less likely to be Medicare only users than dual users (P < 0.01).
Discussion
This study examined the characteristics associated with outpatient VA and Medicare use among ∼13,000 Veterans with SCI/D throughout the U.S. Within this cohort, 30% of Veterans with SCI/D who were alive during the study period were found to be dual system users. This is a substantial percentage and suggests the need for increased efforts regarding improved health information exchange and continuity of care between VA and Non-VA clinicians due to the frequent and specialized care required in this population.
Prior research has shown in the general Veteran population that more than 40% used a combination of VA and Medicare services.24 Age, distance from VA, and complexity of one's condition (higher hierarchal condition or aggregated condition categories) were all factors associated with Veterans’ use of health care outside the VA.24,25 Although slightly lower percentages were seen in this population, similar predictors (age and distance from VA facilities) were found. Importantly, despite the slightly lower percentage, the impact and unintended consequences of dual system use in this specific population is likely much greater. Individuals with SCI/D have approximately three times the number of rehospitalizations, physician contact/visits and time spent in long-term care admissions, compared to matched uninjured controls.26 This is largely due to the fact that these individuals have several, sometimes overlapping, secondary (specialized) health conditions.27,28 This was seen in our study with high percentages of dual users experiencing hypertension, hyperlipidemia, diabetes, urinary tract infections and care related to quadriplegia/paraplegia. We argue that splitting such frequent care across different systems (and across clinicians) could substantially impact health outcomes. This is based on previous studies showing that, compared to VA only users, Veterans with heart failure who were dual using VA and non-VA facilities had significantly higher rates of hospitalization, readmissions, and emergency department visits.29 Similarly, other studies have shown 38-56% increased mortality risks for male Veterans using dual healthcare, than non-Veteran, non-dual (male) users.14,30 Veterans with acute myocardial infarction who received community-based care using their Medicare benefits were more likely to undergo heart-related surgeries thereby increasing the potential for complications and risks.31 Presumed etiological rationale behind these negative outcomes for dual users are; (a) dual system use causes increased risk of uncoordinated and/or inefficient care which leads to; (b) exacerbation of existing conditions or acquisition of other, related, conditions/complications which then can leads to; (c) increased hospitalizations, admissions, mortality risks or overall health. Thus, dual use is associated with negative outcomes due to disruptions in continuity of care. Indeed, studies have shown that disruptions in any type of continuity of care (informational, management, and relational)32,33 cause negative health outcomes.34–36 Notably, a randomized trial in Veteran males over the age of 55 showed relational continuity of care (alone) was significantly associated with decreased emergency department use, shorter lengths of stay in the hospital and less time in intensive care units.37 Dual system use and discontinuity of care across systems can also result in duplication of services. Studies show that VA users concurrently enrolled in, and using, Medicare services incur federal payments made to two separate managed care program for the same individual during the same time.13
Improving continuity of care
Studies, including randomized controlled trials, investigating the association of continuity of care in individuals with SCI/D and improved outcomes have yet to be performed. Despite this, the need for multidisciplinary care teams (management continuity of care) has already been recognized in the field,38–40 and various health systems (including the VA SCI/D center) have increased efforts to implement this type of care for individuals with SCI/D. For example, Veterans with SCI/D admitted to the hospital, can receive care from a team including but not limited to a physician, nurse practitioner or physician assistant, nurse, physical therapist, occupational therapist, recreational therapist, speech & language pathologist, vocational rehabilitation counselor, psychologist, social worker, and case manager. Care is typically coordinated via weekly team meetings. After a new injury, prior to discharge an interdisciplinary hand-off meeting is completed with the VA hospital with which the Veteran will continue receiving routine outpatient care. The idea is to discuss all of the medical findings and treatment(s) provided/started while admitted at the VA hospital to the receiving community clinic so they can efficiently continue care. Additionally, on an annual basis Veterans with SCI/D are asked to return to their VA SCI/D hub, regardless of where they receive their primary care, for a Comprehensive Preventative Health Evaluation. These annual evaluations ensure that all Veterans with SCI/D continue to be evaluated by an interdisciplinary team that has the resources and training available for SCI/D specific care. Any new updates or recommendations found from the annuals are then shared throughout the VA system and/or provided to known providers outside the VA network.
In addition, the Virtual Lifetime Electronic Record (VLER) system41 and the addition of the Blue Button feature in My HealtheVet,42,43 which allows Veterans to view and print information from their VA electronic medical record, were recently created by the VA to improve information exchange (example of informational continuity of care). These features ensure that all Veterans have their VA care and current health status at their fingertips to share with other non-VA providers. However, one of the current limitations of these VA electronic systems, and the multidisciplinary care coordination practices noted above, is that the transfer of information is mostly from the VA to outside entities. Incorporation of information from non-VA systems/ clinicians back to the VA is dependent on patient self-report. Previous research has shown, unfortunately, that majority of Veterans are not discussing non-VA interactions with their VA providers.44,45 This is a substantial gap that continues to need work.
By exploring healthcare service use and characteristics associated with dual healthcare systems use among Veterans with SCI/D, our results also suggest which groups of individuals or types of services have the highest cross over. First stage approaches for improving information exchange can be targeted at Non-African American Veterans, who have had their injury for over ten years, and/or 69 years old; especially those that are greater distances from the VA (not necessarily those in rural areas). These development and implementation strategy groups need to also focus on including more specialty and primary care clinicians at non-VA sites to help identify the greatest informational gaps.
Limitations
Data included in our analyses was limited to VA and Medicare claims data; it is possible that some of these patients may have accessed healthcare through private insurance. Moreover, visits to private providers in the community through the Veterans Choice Act (which has subsequently been superseded by the MISSION Act)46 could not be identified. The database that was used to identify Veterans with SCI/D (the SCIDO) was designed for clinical use and as such (1) might not include all Veterans with SCI/D throughout the US and (2) was missing data for some Veterans. Additionally, Veterans with SCI/D that utilized only VA inpatient services (and not outpatient services) during the study time period were not included in this cohort; future research examining dual systems users may benefit from including, or focusing on, Veterans with solely inpatient visits. Notably, these results suggest generic/general effects by estimating associations and types of service use based on classifications of service type (VA and/or Medicare). We also cannot definitively link dual system use due to access vs. preference, or both.
Conclusion
Thirty percent of Veterans with SCI/D were found to be dual system users. This is a substantial percentage, especially when considering the potential costs and outcomes associated with fragmented care. If options for multi-system health care use are to remain available for this unique population, better programs and tools to improved health information exchange and continuity of care between VA and Non-VA clinicians are needed.
Acknowledgements
The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs or the United States government.
Disclaimer statements
Contributors None
Funding This work was supported by VA Health Sciences Research and Development: [grant number IIR 07-165-2].
Conflict of interest Authors have no conflict of interests to declare
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