Does the VA Provide “Primary” Primary Care?

The Veterans Health Administration is the largest integrated health care system in the United States. Approximately 3 million veterans use this system in any given year.¹ Many veterans also have access to health care outside this system through private or public health insurance plans such as Medicare or Medicaid,^2,3 and there is increasing awareness of the dual use by veterans of both VA and non-VA health care services.^4–9 Research in this area is of interest from an efficiency point of view, as some have proposed that the taxpayer is “paying twice” for care provided to veterans who are enrolled in Medicare HMOs and also use the VA system for care.⁵

In this issue, Borowsky and Cowper contribute to our understanding about dual use of VA and non-VA primary care services.¹⁰ Their examination is important because most people agree that having a single primary care provider leads to better continuity and coordination of health care.¹¹ Borowsky and Cowper found that 28% of the veterans in their sample who reported a relationship with a VA primary care provider were “dual users.”

The data for this study came from a telephone survey of a random sample of primarily white, male Minnesota veterans. Two thirds of respondents were users of the Minneapolis Veterans Affairs Medical Center. Strikingly, 50% of primary care visits by dual users were to non-VA providers. Not surprisingly, the odds of dual use were increased for those who had insurance, were more educated, or were less satisfied with VA care. Though type of insurance was not reported, the proportion of veterans with dual use was the same for those over or under age 65, suggesting that Medicare coverage was not the sole explanation for this non-VA utilization.

As is common in this type of research, these findings raise more questions than they answer. It would be interesting to know why veterans sought dual primary care, but this study was not designed to answer this question. It also would be interesting to know which provider veterans considered their “primary” primary care provider, especially since the VA has recently reorganized to a primary care delivery model.¹²

Are taxpayers really paying twice for primary care services?⁵ Because we do not know which primary care services were received by the patients in this study, we cannot know whether services were duplicated. We need to know because the possibility of fragmented care increases when patients get care from multiple providers without common medical records or mechanisms for the transfer of information. Fragmented care interferes with the delivery of good primary care, whose cardinal features are comprehensiveness, continuity, and coordination.¹¹ Conversely, it is possible that dual use occurs because non-VA plans are providing more convenient access to outpatient care and to services such as ophthalmology, dermatology, and urology, but the VA provides easier access to prescription drugs, mental health care, acute inpatient services, and long-term care. This situation might allow veterans to patch together the spectrum of services they need. Therefore, dual use might be beneficial. Also, dual use may enhance satisfaction by providing choice. An important next step in this type of work will be to determine which services are used by dual users and to compare the outcomes of dual users with those of single users.

Of those in this study with at least one primary care visit to a VA facility, 76% reported having either private or public insurance coverage. Yet only 28% were dual users. These data suggest that those who were most dissatisfied and had insurance were the most likely to use non-VA primary care services.

Though few VA users were dual users, Borowsky’s study may actually underestimate the percentage of veterans who are dual users for several reasons. First, veterans may have been hesitant to participate in the survey because of worries that dual use might disqualify them from VA services. Similarly, the investigators were not able to confirm the patients’ self-reported utilization of primary care, and patients may have underreported their use of primary care services or may not have understood the definition of “primary care.” Conversely, this study was done in 1993–94, before the implementation of meaningful primary care reorganization in the VA. If this reorganization has been effective in improving patient satisfaction, perhaps dual use has declined.

The VA’s capitation-style resource allocation system does not account for utilization of services outside the system. In other work, we have shown that the use of services by elderly veterans under fee-for-service Medicare financing differs significantly by VA service network.¹³ In another study, VA costs in fiscal year 1996 were $3,118 per patient for those continuously enrolled in Medicare HMOs and $5,547 for patients of the same age who had no HMO coverage.¹⁴ Importantly, the numbers of VA outpatient visits per capita were nearly identical for the two groups. What is not clear from these studies is whether veterans are receiving duplicate services or using whatever means necessary to obtain the services they need.¹⁵ In any case, these data indicate substantial incentives for managed care plans and the VA to encourage out-of-system use.

What should the policy response be to dual use of health care services? It might seem desirable to have a “primary payer” to ensure that there would be no payment for duplicate services. For example, in the private sector, dual eligibility occurs when a subscriber and spouse are both employed and each has health insurance with a different employer. Benefits are coordinated so that both plans do not pay for the same service. No such arrangement exists in the VA. Yet, without understanding the nature of services actually being used by these dual users, it is not clear what the policy should be. Veterans may be behaving in a very rational way, given the constraints of the current health care environment and the fact that many VA users are poor, disabled, and ill. We must ensure that any primary payer policy does not prevent veterans from receiving care to which they are legally entitled.

Borowsky and Cowper go so far as to suggest that dual use may be a marker for dissatisfaction with VA services. Yet, in the current health care environment, the demand for VA services can change dramatically and unexpectedly because of changes in market forces such as Medicare HMO capitation payments, managed care penetration, patient selection by HMOs,¹⁶ or patient dissatisfaction with HMO care.¹⁷ Given that the data in Borowsky and Cowper’s study are limited to white, male, Midwesterners who primarily used a single VAMC, any change in veterans’ health care benefits should await confirmation of these results in a more generalizable sample. Changes also should be delayed until we know more about which services are involved in dual use and what incentives lead to dual use.