Aug 23, 2004 - OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT ... achieve the dream of returning to graduate school to obtain my doctorate. ...... existing insurance policies, including pharmacy, prosthetics, and psychological ...... The National Survey of Veterans 2001 final report (VA Assistant Secretary for.
ACCESS, UTILIZATION, AND PROVIDER SELECTION PATTERNS OF UNITED STATES VETERANS
By DIANE CONSTANCE COWPER
A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2004
Copyright 2004 by Diane Constance Cowper
This document is dedicated to Bruce Alan Ripley.
ACKNOWLEDGMENTS There are many people who have supported me along this journey. My committee, employer, mentors, colleagues, friends, family and significant other all helped me to achieve the dream of returning to graduate school to obtain my doctorate. I will be eternally grateful. I wish to thank my doctoral advisor and dissertation chair, R. Paul Duncan, Ph.D., for his support and guidance throughout the doctoral process. Committee members Gerben DeJong, Ph.D., W. Bruce Vogel, Ph.D., and Murray Côté, Ph.D., were tremendous resources in providing relevant policy and methodological perspectives. I greatly appreciate the time and effort these busy individuals took to help me complete this work. Samuel Wu, Ph.D., my “unofficial” committee member is acknowledged for the statistical consults he provided to me (sometimes on a moment’s notice). This work could not have been possible without the encouragement of my former mentor and employer, Dr. John Demakis, and my current employer, Dr. Pamela Duncan. These two individuals gave me the confidence to pursue my goals and provided unwavering assistance in helping me to achieve them. I thank my community of colleagues and friends, not only in Gainesville, but also in Chicago, Houston, Kansas City, Minneapolis, Palo Alto, and Washington, DC, who had faith that I would be successful in this endeavor. I have been blessed by having a number of mentors during my career that encouraged me at every turn. I thank Drs. Jeanne Biggar, Chuck Longino, Larry Manheim, Caroline Ross, John Demakis, and Pamela Duncan. I am sorry that Jeanne and iv
Caroline are no longer with us, but I think they would be pleased to see me finally receive this degree. I am thankful for my VA colleagues/friends who have endured this process with me, especially Ellen Esparolini, Elizabeth Cope, Amber Larsen, Kristen Wing, Jared Deane, Kathy Byers, Sooyeon Kwon, Maude Rittman, Charlie Jia, Jim Stansbury, Kimberly Reid and the entire RORC staff. My fellow graduate students Nes Gurol, Kezia Awadzi, William Mkanta, and Babak Mohit are thanked for their support and camaraderie through all the classes, papers, and preliminary examinations. My mother and father, Connie and Larry Cowper, are acknowledged for all the support they lent to me over the past three years. I do not know what I would have done without their weekly phone calls to check on my progress and their cheerful optimism when I was discouraged. My sisters Sandi, Sara, and Kathlein, and brother-in-law John, likewise provided me with encouragement and confidence. I would not have been able to complete this work without my significant other, Bruce A. Ripley. It was his shoulder that I leaned on the heaviest during the past three years and I will always be indebted to him for his generosity, compassion, patience and culinary skills.
v
TABLE OF CONTENTS page ACKNOWLEDGMENTS ................................................................................................. iv LIST OF TABLES...............................................................................................................x LIST OF FIGURES ........................................................................................................... xi ABSTRACT...................................................................................................................... xii CHAPTERS 1
INTRODUCTION ........................................................................................................1 Overview of the Research Topic ..................................................................................1 Access to Health Care ...........................................................................................2 Health Care Utilization..........................................................................................3 Provider Selection .................................................................................................5 Relevance of the Research............................................................................................7
2
THE DEPARTMENT OF VETERANS AFFAIRS ...................................................12 Introduction.................................................................................................................12 Current Organizational Structure of the Department of Veterans Affairs..................12 A Brief History of the VHA .......................................................................................15 The New Department of Veterans Affairs...........................................................16 Desert Shield and Desert Storm ..........................................................................19 U.S. Health Care Reform.....................................................................................20 The Changing Face of U.S. Medicine .................................................................22 VHA’s New Leadership ......................................................................................23 The Winds of Change ..........................................................................................24 The VA’s Safety Net Role..........................................................................................27 Summary.....................................................................................................................29
3
LITERATURE REVIEW ...........................................................................................32 The Behavioral Model of Health Services Use ..........................................................32 Theoretical Framework...............................................................................................39 vi
Veterans Health Care Utilization Behavior ................................................................40 VA Utilization ............................................................................................................41 Multiple System Use...................................................................................................43 Summary.....................................................................................................................45 4
RESEARCH OBJECTIVES AND METHODS.........................................................47 Introduction.................................................................................................................47 Objectives ...................................................................................................................47 Key Research Questions/Hypotheses .........................................................................48 Objective 1...........................................................................................................48 Objective 2...........................................................................................................49 Objective 3...........................................................................................................49 Data Source.................................................................................................................50 Study Design...............................................................................................................51 Characteristics of the Study Population......................................................................51 Dependent and Independent Variables .......................................................................52 Defining the User Groups....................................................................................52 Independent Variables .........................................................................................54 Data Collection Strategy and Timeline.......................................................................57 Strategy for Data Analysis..........................................................................................58 Summary.....................................................................................................................61
5
DESCRIPTIVE FINDINGS .......................................................................................66 Introduction.................................................................................................................66 Objective 1: Characteristics of Study Groups ...........................................................66 Hypothesis 1 ........................................................................................................66 Hypothesis 2 ........................................................................................................66 Hypothesis 3 ........................................................................................................67 Predisposing Characteristics................................................................................67 Summary of Results ............................................................................................72 Profile: VA-only users ................................................................................72 Profile: Non-VA only users.........................................................................74 Profile: Multiple system users.....................................................................75 Profile: Non-user group...............................................................................76 Objective 2: Utilization Patterns of Study User Groups............................................78 Research Question and Hypothesis .....................................................................78 Emergency Room ................................................................................................79 Outpatient Visits..................................................................................................79 Inpatient Admissions ...........................................................................................79 Prescription Use...................................................................................................80 Treatment for Specific Conditions/Services........................................................80 Multiple System Users................................................................................................81 Emergency Room ................................................................................................81 Outpatient Care....................................................................................................82 Inpatient Care ......................................................................................................82 vii
Prescription Use...................................................................................................82 Treatment for Specific Conditions/Services........................................................83 Summary.....................................................................................................................83 6
MODELING PROVIDER SELECTION ...................................................................90 Introduction.................................................................................................................90 Total Sample...............................................................................................................92 Use v. No Use......................................................................................................93 VA-Only v. Non-VA Only Users........................................................................94 VA-Only v. Multiple System Users ....................................................................96 Non-VA Only v. Some VA Use ..........................................................................97 Veterans 65 Years of Age and Older..........................................................................98 Use v. No Use......................................................................................................98 VA-Only v. Non-VA Only Users.......................................................................99 VA-Only v. Multiple System Users ..................................................................100 Non-VA Only v. Some VA Use ........................................................................100 Veterans Aged Under 65 ..........................................................................................101 Use v. No Use....................................................................................................102 VA-Only v. Non-VA Only Users......................................................................102 VA-Only v. Multiple System Users ..................................................................103 Non-VA Only v. Some VA Use ........................................................................103 Veterans in Priority Category 1-6.............................................................................104 Use v. No Use....................................................................................................105 VA-Only v. Non-VA Only Users......................................................................105 VA-Only v. Multiple System Users ..................................................................106 Non-VA Only v. Some VA Use ........................................................................106 Veterans in Priority Category 7 ................................................................................107 Use v. No Use....................................................................................................108 VA-Only v. Non-VA Only Users......................................................................108 VA-Only v. Multiple System Users ..................................................................109 Non-VA Only v. Some VA Use ........................................................................109 Highlights .................................................................................................................111 Hypotheses Revisited ........................................................................................111 Scenarios............................................................................................................112 Case Examples...................................................................................................113 Summary...................................................................................................................114
7
SUMMARY AND CONCLUSIONS .......................................................................122 Summary...................................................................................................................122 Conclusions and Contributions.................................................................................122 Future Research ........................................................................................................126 Study Limitations......................................................................................................127
viii
APPENDIX A
RELEVENT MODULES FROM THE NATIONAL SURVEY OF VETERANS 2001 ..........................................................................................................................130
B
DATABASE CONTENTS .......................................................................................156
REFERENCES ................................................................................................................161 BIOGRAPHICAL SKETCH ...........................................................................................169
ix
LIST OF TABLES Table
page
2.1: Priority Level Descriptions........................................................................................31 4.1: Assignment of Veterans to User Types .....................................................................62 4.2: Dependent and Independent Variables ......................................................................63 5.1: Predisposing Characteristics of User Groups ............................................................85 5.2: Enabling Characteristics of User Groups...................................................................86 5.3: Need Characteristics of User Groups.........................................................................87 5.4: Utilization Data for User Groups...............................................................................88 5.5: Utilization Data for Multiple System Users ..............................................................89 6.1: Logistic Regression Models for Total .....................................................................116 6.2: Logistic Regression Models for Age GE 65............................................................117 6.3: Logistic Regression Models for Age LT 65 ............................................................118 6.4: Logistic Regression Models for Priority 1-6 ...........................................................119 6.5: Logistic Regression Models for Priority 7...............................................................120 6.6: Summary of Significant Variables by Total Sample and Subgroups ......................121
x
LIST OF FIGURES page
Figure
3.1: Theoretical Framework..............................................................................................46 4.1: Decision to Utilize Any Outpatient Services and Sources of Care............................64 4.2: Logistic Regression Models Used in Analyses..........................................................65
xi
Abstract of Dissertation Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy ACCESS, UTILIZATION, AND PROVIDER SELECTION PATTERNS OF UNITED STATES VETERANS By Diane Constance Cowper December 2004 Chair: R. Paul Duncan Major Department: Health Services Research, Management and Policy This study employed the Andersen Behavioral Model of Health Service Use to investigate veterans’ use of any health care during a one year period and explored whether provider selection could be predicted based on veterans’ predisposing, enabling, and need characteristics. The data source was the National Survey of Veterans 2001. The sample of respondents was 12,905 individuals. The objectives were (1) to describe veterans who were non-users, VA-only users, non-VA-only users, and Multiple System users; (2) to compare the types and amounts of health care services VA-only, non-VA-only and Multiple System users receive from their providers; and (3) to model veteran selection of medical care provider in sufficient detail and precision to enhance understanding of veteran utilization of VA services as well as the likely impact of changes in VA policy and shifts in the veteran demographic profile.
xii
The dependent variable was user type. Independent variables included age, race, marital status, education, and military experience (predisposing); income, presence of health insurance, type of health insurance, presence of service-connected disability, and meets VA “means test” threshold (enabling); and perceived health status, number of health problems, and activities of daily living limitations (need). Descriptive statistics on all variables were obtained. Sequential conditional logistic regression models were used to distinguish between user types. Results showed veterans are active consumers of health services. Almost ninety percent of veterans surveyed reported receiving some type of medical care in the previous year. Their selection of health care provider was primarily outside of the VA; onequarter indicated at least some VA use and, of those, one-quarter were VA-only users. The results showed low socioeconomic status and the absence of alternate private or public insurance appeared to be factors in VA use. Veterans with lower self-reported health status and higher numbers of chronic health conditions had higher odds of VA use. Multiple system users appeared to access the VA for services not well-covered by existing insurance policies, including pharmacy, prosthetics, and psychological disorders. There was considerable interplay between different public programs, indicating these programs should begin to coordinate their benefit packages.
xiii
CHAPTER 1 INTRODUCTION Overview of the Research Topic A recurring issue in U.S. health policy is how best to synchronize systems of medical care, especially for individuals who are likely to participate in more than one system due to their eligibility for multiple public and/or private health plans. Among private health plans, for example, there is debate about how best to coordinate benefits across multiple plans when insured individuals participate in more than one plan because of spousal coverage, workers compensation, public assistance status, and retiree plans. In the public sector, this issue takes on additional urgency because the nation’s pluralistic (some would say dysfunctional) health care system depends on the strength of public programs such as Medicaid and the VA health care system that serve as a backstop for the shortcomings in other private and public health plans. This dissertation is a study of the Veterans Health Administration’s role as an effective health care program as compared to other programs in which veterans are eligible to participate. This issue is especially compelling considering the nation’s social contract with its veterans—“to care for him who shall have borne the battle and for his widow and his orphan” (Lincoln, 1865). Recent political discourse in the United States clearly indicates that this social contract remains very much intact. But the social contract is only as good as the ability of the various public and private health plans to
1
2 adequately take into account the diverse needs and circumstances of the nation’s 25 million veterans. And, as eligibility and coverage policies of non-veteran programs change, it becomes equally important to adjust accordingly veteran eligibility and coverage policies. In coming to grips with the interface between veteran and non-veteran health services, this dissertation draws on two well-known, but not always well understood, multidimensional concepts that occur repeatedly in health services research, access to health care, and health care utilization. Access to Health Care Access to health care has been a core topic of concern to health services researchers for decades. The Institute of Medicine’s Committee on Monitoring Access to Personal Health Care Services defines access to health care as “the timely use of personal health services to achieve the best possible outcomes” (Millman, 1993, p. 33). Poor access to health care can result from several factors, including low socioeconomic status, lack of insurance, supply of health care providers, transportation barriers, attitude toward and perception of medical care providers, consumer knowledge, and ethnic and cultural differences. Inadequate access to health care services contributes to increased mortality, increases in morbidity from chronic disease, higher treatment costs, and inappropriate use of emergency services. The concept of access is not one dimensional. In attempting to define and operationalize the term “access,” Penchansky and Thomas (1981) note that there are a number of dimensions that comprise this multifaceted concept: availability, accessibility, accommodation, affordability, and acceptability. Availability refers to the actual supply of resources obtainable in the community (e.g., the number of physicians, hospitals,
3 clinics, specialists, etc.). Accessibility refers to “the relationship between the location of supply and the location of clients, taking account of client transportation resources and travel time, distance and cost” (p. 128). The third dimension, accommodation, centers on how the supply of health care is delivered to the patient and how amenable the pattern of delivery is to the individual seeking care. An example of accommodation is hours of operation (e.g., care available after-hours or weekends or 24 hour walk-in service). Affordability focuses on the patient’s financial ability to pay (either out-of-pocket or via insurance or both) for medical care. The final dimension, acceptability, is “the relationship of clients’ attitudes about personal and practice characteristics of providers to the actual characteristics of existing providers” (p. 129). Additionally, this aspect of access refers to providers’ attitudes toward patient characteristics. Health Care Utilization Health care utilization in this research study refers to the consumption of health care services or contact with a health care provider. This is often referred to as “realized access” of health services (Aday, Andersen and Fleming, 1980a; Aday, Andersen and Fleming, 1980b; Aday, Andersen and Fleming, 1984; Aday, Fleming and Andersen, 1984; Andersen, 1995; Andersen, Rice and Kominski, 2001). An important element in the ability to obtain health care is the presence of insurance. In the United States, citizens can have private, public, or a combination of both types of insurance coverage to defray the cost of their out-of-pocket expenditures for medical care. Americans primarily obtain private insurance from a health plan offered through their employer. Insurance companies charge premiums in order for employees to be covered against the risk of catastrophic illness. The premiums are often shared by the employer and the employee. Further, the insurance company may charge a co-payment
4 or deductible to the subscriber. Blue Cross/Blue Shield is perhaps the best known private insurance company. Private insurance may also extend into retirement as part of an employee’s retirement benefit package. Individuals can purchase insurance directly from insurance companies to cover themselves and their families, but these policies are generally expensive in terms of premiums, co-payment, and high deductibles. Public insurance is based on the characteristics of the target population. For example, the public insurance entitlement program that covers low-income families is Medicaid. In 1999, Congress expanded Medicaid to cover more children in low-income families through the State Children’s Health Insurance Program (SCHIP), another example of a public insurance program. For older Americans, Medicare is the major public health insurance program. Medicare covers almost all of those individuals aged 65 and over and also those individuals under 65 who are unable to work because of a disability and/or end-stage renal disease. Honorably discharged veterans can obtain health care from the Department of Veterans Affairs (VA) and, depending on their priority ranking, this care is often free-of-charge. There are instances where individuals are eligible for more than one public program. For example, a person may be dually eligible for Medicare (65 years of age or older/disabled) and Medicaid (meets the state’s poverty definition). An individual could potentially be “tri-eligible,” qualifying for the VA (honorably discharged veteran), Medicare (older/disabled), and Medicaid (poor) programs. While the Medicare program has certainly improved the affordability of health care to the elderly population, there are two major limitations to the program that may become increasingly important to older veterans: (1) Medicare and private supplementary
5 policies are weak in long-term care coverage (if it is provided at all) and, (2) even under the expanded Medicare drug coverage, pharmaceuticals may not be sufficiently covered. Rising Part B premium costs, deductibles, and co-payments make it difficult for some individuals to continue with private physicians as their primary source of care. For elders who happen to be veterans, the Department of Veterans Affairs (VA) health system services may become a much less costly and more attractive alternative. Older veterans who currently use both VA and non-VA health care may constitute a population that will rely more heavily on VA health care services in the future if the cost of utilizing non-VA physicians continues to rise. Access to and utilization of health care services encompass more than the presence of insurance or having the necessary medical or socio-demographic characteristics to qualify for a special program. Healthcare-seeking behavior is complex and involves many different aspects. The Behavioral Model of Health Care Use (Andersen, 1968) posits that the decision to use medical services is influenced by an array of the individual’s predisposing, enabling (of which insurance is only one of many variables), and need characteristics. This framework aptly taps the multiple dimensions of access to predict realized access (utilization) of health care services. Provider Selection This is a study of veterans’ selection of health care providers. A provider in this dissertation refers to the system and/or sector of care where a veteran receives care, rather than to an individual physician or allied health care professional. It is an attempt to understand what factors may contribute to the decision to use health care in general and VA health care in particular. Studies of patients’ patterns of health care services use have been conducted in the private health care system where individuals choose freely among
6 available private health care providers. Considerable effort is expended to understand the context, including market forces that influence the decisions made by individual consumers to obtain care. This body of work is in contrast to a publicly funded system of care that makes no explicit effort to attract patients and is not generally viewed by health market analysts as actively competing with other publicly funded or private health systems. In this limited view, users of services are defined as those eligible for services and estimates of service use are synonymous with estimates of eligibility for services. In general, publicly funded health care systems are regarded as health care sources of last resort in which the only choice is to use them or not use care at all. In this context, patients do not choose between alternative health care providers and there is little research interest in the question of patients’ selection of provider. In reality, veterans who use VA services do have multiple systems of care from which to select. Eligibility and priority ranking for VA care determine the number of veterans who can consider VA as a health care provider. Many eligible veterans have other types of health insurance, predominantly Medicare, but also private insurance and Medicaid, which together or in combination may allow them financial access to other health care sectors. The generosity of these programs influences veterans’ financial ability to obtain care from alternative sources. When care from alternative providers is more expensive, veterans’ provider selection reflects a willingness to pay for valued attributes of health care services outside of the VA health care system. In other words, veterans choose between VA and other sources of care considering both direct and indirect costs of care, as well as issues of other dimensions of access. In addition to financial considerations, veterans may choose not to utilize a VA hospital because of, for
7 example, geographic distance, long waiting times to appointments, perceived quality of care provided, and/or the supply of alternative choices of non-VA care. The decentralized Veterans Integrated Service Networks (VISNs) were formed in 1995 for the purpose of pooling VA facility resources, decreasing service duplication, providing continuity of care, ensuring quality of care, and reducing cost of VA medical centers within specific geographic areas. These goals cannot be achieved without an understanding of what health care services veterans are receiving both inside and outside the VA system. Although the overall veteran population has been declining, VA health care enrollees have been increasing and the portion of the veteran patients aged 65 and older is projected to increase by 41% in the next 10 years (VHA Office of Policy and Planning, 2002). Thus, we can expect the number of veterans enrolled in the VA who will potentially use additional health services under Medicare to increase. Relevance of the Research There are several reasons why veterans’ use or non-use of VA health care is an important area of study. First, the VA must have a sound basis for estimating demand for care to plan for the extent and types of services that may be needed. Current practice in estimating demand for care assumes that eligibility is the primary determinant of services use. Estimates of VA service use based solely upon eligibility may be misleading, however, if the veteran population proves to be heterogeneous with regard to utilization of services. Studies that more precisely delineate the individuals who will use VA services, the reasons for their using (or not using) VA care, and the scope and intensity of the services they will use can help to refine current practice in the estimation of VA health care utilization.
8 A second reason to study veterans’ use of VA services is to evaluate accurately the effects of different policies regarding eligibility for VA and other types of publicly funded health care upon VA service utilization. Clearly, modifications in VA eligibility for care will expand or reduce the populations of veterans who can consider the VA as a potential health provider. Increases or decreases in eligibility or coverage for Medicare will have a significant impact upon many veterans’ ability to seek private health care and their need to rely fully or partially upon VA care. Enactment of any new laws mandating expanded private or public health care coverage will increase the range of options available to veterans to obtain health care services. In order to understand the combined effects of a myriad of private and public mechanisms to provide health care upon veteran utilization of VA services, it is necessary to understand who uses VA care and how and why they use it. There are numerous additional benefits to studying why veterans use VA or nonVA health care services. Eligibility for VA has changed from an initial focus upon veterans who incurred an injury while on active duty in the Armed Forces (serviceconnected injured), to providing a safety net to low income veterans, to becoming an enrollment system. Veterans without a service-connected disability may be unaware of the VA as an option for care. In an analysis of an earlier survey, it was found the primary reason given for non-VA use by veterans was the presence of a personal physician and adequate insurance coverage. Interestingly, 18 percent of the surveyed veterans responded that they did not know if they were eligible to use VA health care (Cowper et al., 1993). This finding suggests a potentially important VA access barrier. Further, criticism of the quality of VA care may discourage eligible veterans from enrolling in the
9 VA health care system. The study of why veterans use or do not use VA care provides information about veterans’ knowledge of VA services, perceptions about the quality of the VA, and the influence of these factors upon veterans’ selection of provider. The objective that eligible veterans know about VA care and are able to make an informed appraisal about the quality of that service option is a reasonable goal. This study examines the extent to which lack of information about services and poor evaluations of VA health care quality represent barriers to service utilization. Another important contribution of this research is to broaden the literature on barriers to health care services to gain a more complete picture of why, for example, individuals who have high eligibility to use a publicly funded health care system, e.g., disabled or low-income persons, use these health care systems. Using the VA as an example, one might question whether service-connected injured veterans are not using the VA because they have good access to other non-VA health care providers and services, because they have poor access to VA services (e.g., the VA is difficult to get to or needed services are not readily available) or because they view the VA in a negative context (for example, too much red tape, not convenient, and so on). In a wider context, this work can inform health policy analysts and, ultimately, health policy makers about determinants of out-of-network health care utilization in general. Use of both VA and non-VA care is not necessarily a negative, as it may enhance access, flexibility, and choice in health provider for veterans. Alternatively, using multiple systems of care may result in fragmented care and may lead to disruptions in care continuity. The pros and cons of using both VA and non-VA health resources
10 have been raised by several researchers in recent years (Wright et al., 1997; VIREC, 2003; Jia et al., 2003). Moreover, multiple system utilization may present opportunities for cost-shifting and lead to increases in public health care costs as other programs try to slow their spending growth (Cowper et al., 1993; Wright, et al., 1997). These concerns have made out-of-system utilization an important topic of study within the VA system and for other organizations that serve dually-eligible clients. The ability to predict who is at “risk” for health services in and outside the VA will inform other health care systems, such as Medicare (the major alternative provider of health care services to veterans), about the types of veterans that they will likely encounter in the future as well as the extent and types of services that may be required. A better understanding of who is more likely to use VA care, non-VA care or both may also provide, in the long-term, information on a health care system’s prospective costs. Further, if enabling and need factors are found to be more significant in predicting source of care than predisposing factors, interventions could be designed to promote better access to health care utilization across systems. This work contributes to the health services literature in defining and shaping important policy issues in the area of access to and utilization of health care services. As Aday and colleagues (1993) note, “health services research produces knowledge about the performance of the medical care system, and policy analysis applies this knowledge in defining problems and evaluating policy alternatives” (p. 1). A key contribution this work makes to the general health services literature is that the analyses provide an insight into the extent that predisposing, enabling, and need characteristics predict both health care use and the provider source that veterans use for their health care needs. A past gap
11 in the current literature is that the characteristics distinguishing veterans who receive care in both systems from those veterans who rely solely on VA care are not well described nor understood. Further, the effect of veterans’ past experience both in the military and with the VA on multiple system use has not been previously explored. In summary, the concepts of access, utilization, and provider selection are discussed in this chapter, along with a number of reasons why the research conducted in this dissertation is important. The results of this work are relevant not only to the Department of Veterans Affairs, but to other payers who have clientele with multiple program eligibility for health care, and the wider health services research community. The next chapter provides an overview of the organizational structure of the Veterans Health Administration (VHA), the health care delivery arm of the Department of Veterans Affairs (VA). In addition, the chapter describes a number of social and political factors that contributed to a massive organizational transformation in the late 1990s. The chapter’s concluding section elaborates on the role the Department of Veterans Affairs plays as a safety net institution in the United States.
CHAPTER 2 THE DEPARTMENT OF VETERANS AFFAIRS Introduction This chapter contains a brief history of the organizational changes that have occurred in the VA during the past 75 years and the social and political factors that led up to the latest reorganization in 1995. An understanding of the changes that transpired over the past ten years is important to this research because the majority of research investigating veterans’ access to and utilization of health care services took place prior to 1995. This study builds upon previous literature by investigating the predisposing, enabling, and need characteristics associated with provider selection in 2001, six years after the VA reorganization and three years after becoming an enrollment system. Current Organizational Structure of the Department of Veterans Affairs The Veterans Benefits Administration (VBA), the National Cemetery Administration (NCA), and the Veterans Health Administration (VHA) are the three prongs that collectively make up the Department of Veterans Affairs. The VBA is responsible for administering and delivering a wide variety of programs for eligible veterans including disability and death compensation, education, life insurance, home loan guaranties, and vocational rehabilitation and employment. The NCA is responsible for the upkeep on 120 national cemeteries in 39 states and Puerto Rico. The VHA oversees the largest health care system in the United States under a single management
12
13 structure, and it is this branch of the Department of Veterans Affairs that is of primary interest in this study. In July 2001, the VHA managed 163 hospitals, 846 outpatient clinics, 137 nursing homes, and 43 domiciliaries. During Fiscal Year 2003 (October 1, 2002 – September 30, 2003) alone, VA Medical Centers had 46,543,786 outpatient visits and 560,881 acute inpatient hospital discharges. In 1998, the VA became an enrollment system, whereby any honorably discharged veteran could sign up for VA health care services. Currently, there are approximately 6.8 million veterans enrolled in the VA health care system out of the roughly 25 million living veterans nationally (Klein, 2001). In addition to its medical care mission, the veterans’ health care system is the largest provider of graduate medical education and one of the largest research organizations in the United States. Veterans have been provided a source of health care, through the Department of Veterans Affairs medical facilities, by virtue of their military service to their country. Where veterans obtain their care and the predisposing socio-demographic, enabling factors, and medical need associated with their choice are important in understanding the utilization of health care by an area’s veterans. Not only are veteran characteristics important in health resource planning, so too are the effects of restrictions on utilization of medical care facilities imposed on veterans by Congress (e.g., the “priority” system). Access to VA facilities in terms of system capacity is limited by the available supply of VA services, constrained by VA budgetary allocations. As the quantity of services consumed grows relative to available resources, access to the VA medical system will increasingly become limited to veterans designated as “high priority.”
14 While all veterans who enroll in the VA health care system are eligible to use services, veterans are given differing priorities for care. The eligibility system in 2001 had seven priorities, depending generally on whether or not they have disabling conditions that are “service connected” in origin, the severity of those disabling conditions, and whether they have the financial ability to obtain care outside of the VA health system. Top priority for care is for veterans who have been determined to be 50%-100% Service-Connected disabled (Priority 1). Priority Group 2 veterans are individuals who have been rated 30%-40% disabled. Priority Group 3 are veterans who are former POWs, veterans whose discharge was for a disability that was incurred or aggravated in the line of duty, veterans with service-connected disabilities rated 10% or 20% disabling, and veterans awarded special eligibility classification under Title 38, U.S.C., Section 1151, Benefits for Individuals Disabled by Treatment or Vocational Rehabilitation. Priority Group 4 is comprised of veterans who are receiving aid and attendance or housebound benefits and veterans who have been determined by theVA to be catastrophically disabled. Veterans in Priority Group 5 are non-service-connected injured veterans and service-connected veterans rated 0% disabled whose annual income and net worth are below the established dollar “means test” threshold. Priority Group 6 includes all other eligible veterans who are not required to make co-payments for their care, including World War I and Mexican Border War veterans; veterans receiving care solely for disabilities resulting from exposure to toxic substances, radiation or for disorders associated with service in the Gulf War; or for any illness associated with service in combat in a war after the Gulf War or during a period of hostility after November 11,
15 1998; and compensable 0% service-connected veterans. Last, Priority Group 7 is comprised of non-service-connected veterans and non-compensable 0% serviceconnected veterans whose needed care cannot be provided by enrolling in any of the groups above and who agree to pay a specified co-payment. Table 2.1 provides greater detail on each of the priority groups as outlined in Title 38, U.S.C., Section 1705. A Brief History of the VHA The Department of Veterans Affairs has experienced a number of organizational changes and many internal reforms throughout its 75-year history. In 1930, President Hoover signed an Executive Order to place the U.S. Veterans’ Bureau, the National Homes for Disabled Soldiers and the Bureau of Pensions, Interior Department, under the Veterans Administration. At the end of 1930, the VA operated 48 hospitals and 54 regional offices. By 1937, the VA operated 81 hospitals in 43 states plus the District of Columbia. After World War II, the VA reorganized its structure into 13 branch areas under a Deputy Administrator responsible for overseeing VA operations. The growth of the VA health system in the years directly following World War II was rapid; in 1948 the VA was operating 125 hospitals; in 1950, there were 136; in 1951, the number was 151; in 1958 the number stood at 172. More recently, in the 1980s, the VA system was comprised of 27 medical districts under seven regions and an administrator in Washington, DC. These seven Regions were reduced to four in 1990 and all 27 medical district offices were closed. Past reorganizations in the VA were generally done with the change of political administration or change in the top VA leadership. One administration favored a centralized focus of power over a decentralized system to promote uniform and standardized processes; another administration felt a decentralized system better understood the needs and environment of the local
16 community. “As one hospital director cynically noted [in the 1991 Survey of the VA’s Health Delivery System] ‘Centralization, decentralization, it’s all been tried before’” (Shortell, 1991a, p. 35). These internal changes primarily focused on the VA as a separate system of health care, operating without significant connection to the remainder of the U.S. health care system. What distinguishes the 1995, and latest, reorganization from other restructuring efforts is that it was accompanied by a paradigm shift in how the VA viewed itself within the context of the larger health care industry. It is this new outlook that differentiates the latest reorganization as a “transformation” from another internal political reorganization. The New Department of Veterans Affairs In 1988, Ronald Reagan signed legislation that elevated the Veterans Administration to a cabinet level agency and in 1989 Edward J. Derwinski became the first Secretary of the Department of Veterans Affairs. In rising to cabinet level, the VA was politically in a more favorable position in terms of access to the President. However, the rise was also accompanied by greater scrutiny of the new Department from the media and outside interest groups. As the 1980s ended, the Department was under fire by Congress, Veterans Service Organizations, and veterans themselves to change the structure and processes of what they considered an antiquated system. “The system was convoluted, fragmented, and self-defeating. It emphasized medical specialization, high technology, biomedical research, and acute inpatient services at a time when all trends in health care were heading in the opposite direction, toward primary care, or basic services” (Kizer, 1998, p. 3). There were even proposals to close the VA system down entirely and provide vouchers to veterans to “purchase” health care from the private sector. Politicians,
17 however, are extremely reticent to enact legislation that would dismantle the VA health care system. The term “veteran-o-mania,” coined by Senator Alan Simpson, describes the “hands off” attitude of politicians when it comes to any proposals that would integrate the VA into the wider health care industry. “Time and time again, politicians of every stripe have reaffirmed their belief–reinforced by the veterans’ lobby–that veterans are served better medically through a separate system” (Inglehart, 1996, p. 1408). However, even veteran lobby groups were beginning to complain about substandard and fragmented health care. “For years, these groups [Veterans Service Organizations] had been voicing their dissatisfaction over the long waits to see a doctor, being treated with a lack of respect, and long hospital stays for conditions better treated in an outpatient setting...” (Kizer, 1998, p. 2). The tensions between the VA, Office of Management and Budget (OMB) and Congress continued to escalate in the late 1980s, often resulting in the OMB cutting the VA’s budget request below needed operational expenses. Veterans Service Organizations and Secretary Derwinski were often successful in lobbying for supplemental funds from Congress during this period, but the VA’s budget often did not even keep pace with inflation (Commission on the Future Structure of Veterans Health Care, 1991). The budget shortfalls, together with the escalating costs of medical care, seriously hampered the operation of the health care system. In response to the ongoing debate surrounding the operation of the VA health care system, Secretary Derwinski appointed an independent group of experts, chaired by Oliver E. Meadows, the former staff director of the House Committee on Veterans’ Affairs, to provide recommendations to him, the President, and Congress on how best to
18 serve the nation’s veterans. The Commission on the Future Structure of Veterans Health Care was comprised of noted experts from private industry, university medical schools, and medical associations. The “Mission Commission,” as it became known, sub-contracted an analysis of the structure and management function of the VA to the J. L. Kellogg Graduate School of Management at Northwestern University. Dr. Stephen Shortell, a noted expert in health care organizational behavior, was the Principal Investigator of the study. Shortell, with a team of analysts from Northwestern University and the Midwest Health Services Research & Development (HSR&D) Field Program at the Edward A. Hines Jr. VA Hospital, conducted interviews with VA management, surveyed the “rank-and-file,” and reviewed countless documents supplied by the Mission Commission to come up with recommendations for substantive changes within the organization. Two major reports were submitted to the Mission Commission based on their results: (1) Analysis of the Organizational Structure and Management Functioning of the VA’s Health Delivery System (Shortell, 1991a) and (2) Supplemental Report: Analysis of the Organizational Survey of the VA’s Health Delivery System (Shortell, 1991b). Shortell identified four major management challenges facing the VA: “(1) the high regard for (VHA) personnel is not shared by the highest level of the Department; (2) the elevation of the VA to cabinet status has increased the ‘politicization’ of the Department; (3) a resulting preoccupation with image and public relations associated with this politicization is resulting in micromanagement from the top, “a reaching down” into the organization, with a resulting decline in morale and perception of declining authority and responsibility of (VHA) management; and (4) a ‘military model’ is implicit in managing
19 the department” (Shortell, 1991a, p. ii). Recommendations from the report included decentralizing the VA health care system into 20 to 30 Geographic Service Areas that would provide regionally integrated health delivery systems, the elimination of the Regional Offices, the need for a public education campaign on the merits of the VA system, and the “active dismantling of the extreme level of regulation… and the climate of fear that permeates its management” (Shortell, 1991a, p. iv). As one might imagine, Shortell’s views were not particularly well received by VA members of the Commission. In fact, the official report released by the Commission in November 1991 included a Minority View on the Final Report submitted by John A. D. Cooper, a Commissioner and Distinguished VA Physician. The majority of the Commission, however, accepted the recommendations from the consultants and the final report that outlined the strategy for restructuring the system was submitted to Secretary Derwinski. The notion of a decentralized system with regionally based integrated service networks was now on record and under consideration by top VA management. Desert Shield and Desert Storm In times of national crises, as evidenced by the tragic events of September 11, 2001, the American public is overwhelmingly supportive of military personnel and veterans’ benefits. When the United States entered the Persian Gulf War in August 1990, first as part of Operation Desert Shield and subsequently as Operation Desert Storm, focus again centered on the VA health care system. In March 1991, Congress passed the Persian Gulf Conflict Supplemental Authorization and Personnel Benefits Act which gave Gulf War veterans eligibility for war-time pensions, medical treatment, educational benefits, housing loans, and unemployment payments, and offered psychological counseling at Vet Centers for readjustment counseling (U.S. Senate, 1991).
20 One of the missions of the VA is to provide back up to the Department of Defense as a provider of care to injured service personnel. Fears of biochemical weapons and germ warfare were especially high during the Gulf War. The effects of toxins used on military troops could have devastating health implications on returning reservists many years after they were discharged from military service. When returning Gulf War veterans began complaining of various symptoms that included fatigue, skin rash, headache, muscle and joint pain, memory loss, difficulty concentrating, shortness of breath, sleep problems, gastrointestinal problems, and chest pain (now collectively referred to as the Gulf War Syndrome), these fears increased. Congress responded to the growing concern of veterans and Veterans Service Organizations by authorizing medical care for Gulf War veterans for conditions that might be related to toxic substance exposure in 1993 (U.S. House of Representatives, 1993). In 1994, primarily on the urging of the VA, Congress authorized compensation to veterans with chronic disabilities resulting from undiagnosed illnesses, if the illnesses appeared while in the Persian Gulf or within a set period following service in the Gulf (U.S. Senate, 1994). The question of optimal health service delivery to a new service era of veterans again pointed attention to the VA’s organizational structure. U.S. Health Care Reform The Clinton Administration raised health care reform to a high priority in the early 1990s. At the center of the Clinton Health Care Reform proposal were three features: universal coverage, community rating, and employer mandates. Providing universal health care coverage to all citizens in the United States created renewed questions about the role of the VA. At the time, about half of the patients treated in VA facilities had high priority for treatment because their incomes fell below the “Means
21 Test” threshold. In many instances, these veterans used the VA because they had no other health insurance, did not qualify for Medicaid, and could not afford to pay out-ofpocket expenses for health care. If veterans used VA hospitals because they had no other health care alternative, would they continue to use VA hospitals if they had a choice of providers? The U.S. General Accounting Office published a report on the potential effects of health financing reforms on demand for VA services. According to the report and subsequent congressional testimony, “demand for VA inpatient services, as measured by days-of-care provided to veterans, could drop by about 18 percent if employers nationwide were mandated to either provide health insurance for their workers or pay a tax that would be used to obtain the coverage. Under a nationwide universal health plan, the impact could be greater–demand for VA inpatient care could drop by 47 percent” (United States Government Accounting Office, 1993, p. 1). The VA, for the first time, needed to address how it would “compete” with the non-VA sector for patients. The Department responded to the impending legislation by holding a VA Health Care Reform conference in early 1994. For two weeks in January and another two weeks in February, VA personnel from all over the country convened in Washington, DC, to strategize on the VA’s future survival as a health care system. The participants in the conference were a cross-section of the VA’s workforce divided into “clusters” that addressed numerous aspects of the VA: managed care, primary care, research, education and training, organizational structure, financial systems, infrastructure, human resources, data and information systems, and administrative support. Additionally, culture and external market clusters were added to get input from outside interests including Congress, Veterans Service Organizations, and medical community leaders.
22 The Changing Face of U.S. Medicine The decade of the 1980s represented an era of radical change for the health care industry. Managed Care Organizations (MCOs) such as Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), and Points of Service Plans (POS) rose from virtual obscurity (less than one percent market share in 1982) to market dominance, with more than 54 percent of employer-based health premiums in 1991 (Sullivan et al., 1992). The growth of these alternative health care delivery systems and their emphasis on cost-effective care changed the size and scope of physician practices, shifted some traditional physician responsibilities to physician extenders, and fundamentally altered the way in which the practice of care was organized. The main objectives in managed care are to improve the coordination of health services while, at the same time, to rein in the cost of health care costs. In order to accomplish this goal, the financing and delivery of health care under managed care changed dramatically from traditional fee-for-service and affected hospitals, physicians, employers, insurance companies, and consumers alike. The federal government, concerned about the rising costs in both the Medicare and Medicaid, also looked favorably toward managed care and other cost-cutting mechanisms to control expenditures in public programs. In 1983, Medicare instituted a Prospective Payment System (PPS). Instead of retrospectively reimbursing hospitals for care provided under Medicare Part A, Congress ordered the Center for Medicare and Medicaid Services, formerly known as the Health Care Financing Administration, to devise a plan to control spending. “The result was a dramatic reform of hospital reimbursement under Medicare Part A. Previously, the government had reimbursed hospitals for the costs of treatment after Medicare services had been rendered. Under the new system, based on a schedule of ‘diagnosis-related
23 groups’ (DRGs), the government began paying hospitals prospectively for specific diagnoses” (Patashnik and Zelizer, 2001:24). Managed care and Medicare reimbursement changes since the early 1980s have put added financial pressure on hospitals, increasing fears that community hospitals will decrease support for indigent care and those hospitals serving the indigent may be forced to close. In fact, the number of hospital closures in the U.S. increased substantially after the implementation of Medicare’s Prospective Payment System in 1983. According to the American Hospital Association (AHA), there were only 53 hospital closures between 1981 and 1983 (AHA Data Center, 1992, 1994). Almost three times as many hospital closures occurred between 1984 and 1986. Hospital closures increased more than oneand-a-half times in the following two years and peaked in 1988. Overall, 500 hospitals closed in the U.S. between 1980 and 1990, and private hospitals were more than twice as likely to close as public hospitals (Gifford, Manheim and Cowper, 2002). This is the context in which the VHA faced its own need for reform. The political pressure for a more decentralized hospital system into regional service areas, new military combat operations, health care reform, and the growth of managed care in the private health care sector all contributed to the VA making unprecedented organizational changes. One of the early changes was in the leadership of the Veterans Health Administration. VHA’s New Leadership Dr. Kenneth W. Kizer was confirmed by the U.S. Senate as the VA Under Secretary for Health on September 28, 1994. Dr. Kizer was a political appointee, not a career civil servant. Prior to stepping into the role as the chief medical officer in the VA, he held positions in the private sector, philanthropy, academia, and state government. Dr.
24 Kizer also served on the corporate board of Health Systems International, Inc., one of the nation’s largest managed care companies. As an academic, he held positions at the University of California at Davis and the University of Southern California. In state government, he was the Director of California’s Department of Health for six years. Interviews with VHA employees and other agencies that interacted with the VHA between 1995 and 1999 point to three factors that made Dr. Kizer an effective leader during this period in VHA. “First, he was an outsider and, therefore, had no loyalties within the agency. Second, Dr. Kizer had substantial leadership experience in the public sector that prepared him to work effectively with both policy-makers and career civil servants. He also had experience as a medical department chair, a position that prepared him to manage VHA’s important but complicated relationships with its affiliated medical schools. Third, Dr. Kizer was an astute student of innovations in the financing and delivery of health care services, and he brought this spirit of innovation and experimentation to VHA” (Young, 2000, p. 2). In the section below, Kizer’s vision, prescription and journey of change are briefly discussed. The Winds of Change This reorganization is not a simple realignment … into 22 VISNs. Nor is it a reshuffling of bureaucratic boxes on a central office organizational chart. Rather, it is a fundamental change in the way responsibility is spread across many decision points in order to imbue the organization with a common sense of purpose. VHA will become less like a mega-corporation and more like a system of federated networks that are bound together by a determination to provide quality patient care. If roles are properly defined and executed, and if power, authority and accountability are balanced and dispersed throughout the organization, then the result will be an interdependent and interlocking system whose whole is greater than the sum of its parts. – KW Kizer, 1995 In March 1995, Kizer submitted his plan, Vision for Change, for the reorganization of the VA health care system, to Congress, followed by testimony in May.
25 Alan Simpson, on hearing Kizer’s ideas, remarked, “This is the first new blood I’ve seen in 16 years. I’m looking for really tremendous things from this person. I think the President made an excellent choice” (VA Office of Congressional Affairs, 1995). The plan entailed the dismantling of four regional offices and decentralizing the system into 22 Veterans Integrated Service Networks (VISNs), based on existing patient referral patterns. Countering claims that the VISN structure would merely be another bureaucratic layer, the plan also called for a reduction in central office staff in Washington, DC by more than 25 percent. The new VISNs were comprised of a small administrative staff (7–10 individuals) that would focus on local needs by pooling and aligning resources in the network and improve patient access and satisfaction. Each VISN would have a network director who would be responsible for strategic planning, budgeting, and coordinating patient care in the VISN. In shifting accountability to the network directors, the plan called for performance contracts with each of the directors, addressing access of care, delivery of services, and support of education and research. Network directors were named in September 1995 and all were on board by January 1996. Kizer also recognized the need for a cultural reorientation of employees. In the Vision for Change, education and training, along with communication about the reorganization, were stressed as necessary elements in achieving a smooth transition to the network structure. The next document released on reorganization of the VHA was the Prescription for Change (Kizer, 1996). In this document, five specific mission goals were identified: (1) provide excellence in health care value; (2) provide excellence in service as defined by customers; (3) provide excellence in education and research; (4) be an organization
26 that is characterized by exceptional accountability; and (5) be an employer of choice. Both the Vision for Change and the Prescription for Change created a blueprint for the strategic plan that VHA would follow in transforming its health care system. A strategic management framework was created that included linking five specific concepts: mission goals, domains/themes, strategic targets, annual performance measures, and operational strategies and actions. In subsequent documents, including the Journey of Change I (VHA, 1997), II (VHA, 1998), and III (VHA, 2000), and the Discovering 6 for 2006 (VHA, 2001), the plans outlined in the Vision for Change and the Prescription for Change (“goals and objectives”) evolved into detailed strategic plans (“strategies and actions”) and annual progress was reported for the domains of value: technical quality, access to care, patientreported outcomes, patient functional status, and cost. In these reports, the organization’s strategic direction is overviewed and highlights of the past year are presented. The reports are widely distributed throughout the VHA and both successes in terms of achieving strategic goals and shortcomings where these goals have not been realized are included. Accountability for the achievements rests with the leadership of the networks and performance measures are compared across the organization. On June 15, 1999, Dr. Kizer announced that he would not be seeking re-nomination as the VA’s Under Secretary for Health (U.S. Senate, 1999). Dr. Thomas Garthwaite, however, continued the principles and momentum of the “Journey of Change.” Garthwaite, who served as the Deputy Under Secretary for Health from 1995 to 2001, became the acting Under Secretary in May 2000. The Republicans won the White House in the 2000 elections and President Bush selected new members of his cabinet. Anthony
27 J. Principi became the new Secretary of Veterans Affairs in 2001. In May 2001, Dr. Garthwaite announced his resignation, citing that Secretary Anthony Principi “should have the chance to select [his] own Under Secretary” (VA, 2001). President Bush approved the nomination of Robert Roswell, M.D., the Network Director for VISN 8, as Garthwaite’s successor; the turnover of top VA administrators was complete, but the legacy of Dr. Kizer’s vision continues. In summary, most scholars of health care organizational behavior point to 1995 as the year that demarcates when the Department of Veterans Affairs (VA) Health Care system underwent remarkable transformation (Vestal, Fralicx and Spreier, 1997; Bezold, Mayer and Dighe, 1997; Booss, 1997; Kizer, 1999; Kizer, Demakis and Feussner, 2000). Historically, the VA was a health care system that largely focused on acute inpatient care. The “new” VA attempted to mirror the private sector trend to shift to more efficient delivery patterns, primarily moving health care into the ambulatory care setting. Additionally, many of the recommendations of the Mission Commission, including decentralizing into 21 Veteran Integrated Service Networks, were implemented in a relatively short period of time. Throughout this transition, however, the VA continued its role as one of the nation’s largest safety net institutions for physically and financially disadvantaged veterans. The VA’s Safety Net Role The VA health care system serves as a national safety net for veterans who are disadvantaged either financially, physically, or mentally, but who do not qualify for state nor Federal assistance. The barriers to these public programs, coupled with the absence of private medical insurance, can make utilization of private medical services difficult or impossible. In particular, even if medical need is perceived by the patient to be great and
28 even if one is predisposed to seek care, the lack of insurance may cause individuals to forego any use of medical care services or to use a less than optimal amount of health care. If health care is not obtained in a timely manner and optimal health care outcomes are not achieved and, further, if these conditions are evident in a specific segment of the population, then, by definition, these groups suffer from a lack of health care access. Wilson and Kizer (1997) use the term, “safety net,” to convey the notion that publicly funded health facilities, such as the VA, municipal hospitals, community health centers, and local public health departments, are providing uncompensated care for an increasing number of the uninsured due to increasing cost pressures on private health facilities. The VA was not immune to the changes occurring in the wider health care environment. There is indirect evidence that the VA health system has been used as a “safety net” for the private health sector. First, younger veterans showed a rapid increase in discharge rates in the 1980s. For example, there were 15 discharges per thousand veterans in the 35–44 veterans age group in 1980, but by 1990, the discharges per thousand for this group nearly doubled to 29.3 (2.9%) per thousand (Cowper, Durczak and Steigman, 1991). Second, total VA discharges increased by seven percent in the 1980s despite a six percent drop in the number of veterans (Ashton et al., 1994). These researchers argue that increasing utilization of VA health services by younger veterans is primarily a result of increasing barriers to private health care for uninsured veterans. Other research efforts measure a more direct link between private health delivery and VA utilization. One study of emergency patient transfers from community hospitals to a metropolitan area VA medical center found that 58% of transferred patients had no
29 health insurance, and that the lack of health insurance was the most frequent reason for a transfer (Kerr and Byrd, 1989). Further, the transferred patients had significantly higher lengths of stay and mortality rates than non-transferred VA patients, which indicates that “many decisions to transfer were made as a result of patient dumping or clinical projections of poor outcomes” (Kerr and Byrd, 1989, p. 73). These findings are consistent with recent research which shows that veterans who use the VA health care system have a higher level of illness than the general population, and 60 percent have no private or Medigap insurance (Wilson and Kizer, 1997). Another study found that Medicare eligible veterans, from 1988 to 1991, were often “dumped” by community hospitals to VA medical centers (Hisnanick, 1995). In a study of hospital closures in Chicago during the introduction of Medicare’s Prospective Payment System and legislative efforts aimed at changing Medicaid eligibility, the investigators found that non-VA hospital closures increase the utilization rates of VA hospitals, especially for low-income veterans under the age of 65 (Cowper, Manheim, and Gifford, 1996; Gifford, Manheim, and Cowper, 2002). Overall, these research findings indicate that private hospital management decisions had an effect on the VA. Summary Prior empirical evidence appears to support that fundamental changes have indeed taken place in the organization and delivery of health care services by the VA: (1) the growth of ambulatory care facilities indicate increased access points of entry into the health care system, (2) health delivery patterns have shifted dramatically from the inpatient to the outpatient setting, (3) focus on patient satisfaction has increased, (4) performance measures based on quality and cost efficiency by networks are followed
30 closely and reviewed annually, and (5) the VA has taken the lead in translating the best medical practices from evidence-based research into improved patient care. The decentralization into 22 (now 21) geographic regions based on patient referral patterns, the shifting of accountability to the network directors, the emphasis on patientcentered care, and an emphasis on continuous quality improvement all combined to create a new cultural consciousness throughout the Veterans Health Administration. The National Survey of Veterans 2001 provided a timely data source to investigate whether, and how, the changes within the VHA have affected veterans’ perception of the quality and timeliness of health care services provided. It also allowed for an investigation into whether the factors that predicted veterans’ use of VA health care services prior to the 1995 reorganization are still valid measures. The next chapter provides an overview of the Behavioral Model of Health Services Use, originally developed by Andersen (Andersen, 1968). It is this framework that guides the analyses in the dissertation. In addition, overviews of the literature on VA utilization and multiple system users are summarized.
31 Table 2.1: Priority Level Descriptions Level
Description
1
Veterans with service-connected disabilities rated 50 percent or more disabling.
2
Veterans with service-connected conditions rated 30 to 49 percent disabling.
3
Veterans who are former POWs. Veterans awarded the Purple Heart. Veterans with service-connected disabilities rated 10 to 29 percent disabling. Veterans discharged from active duty for a disability incurred or aggravated in the line of duty. Veterans awarded special eligibility classification under 38 U.S.C., Section 1151, ‘benefits for individuals disabled by treatment or vocational rehabilitation’.
4
Veterans who are receiving aid and attendance or housebound benefits. Veterans who have been determined by the VA to be catastrophically disabled.
5
Non-service-connected veterans and noncompensable service-connected veterans rated 0 percent disabled whose annual income and net worth are below the established VA Means Test thresholds. Veterans receiving VA pension benefits. Veterans eligible for Medicaid benefits.
6
All other eligible veterans who are not required to make co-payments for their care, including: World War I veterans; Mexican Border War veterans; and veterans solely seeking care for disorders associated with exposure to herbicides while serving in Vietnam or to ionizing radiation during atmospheric testing or during the occupation of Hiroshima and Naasaki; for disorders associated with service in the Gulf War; or for any illness associated with service in combat in a war after the Gulf War or during a period of hostility after Noverber 11, 1998; or Compensable zero percent service-connected veterans.
7
Veterans who agree to pay specified copayments with income and/or net worth above the VA Means Test threshold and income below the HUD geographic index. Subpriority a: Noncompensable 0 percent service-connected veterans who were enrolled in the VA Health Care System on a specified date and who remained enrolled since that date. (Also known as 7-1 or 7a). Subpriority c: Non-service-connected veterans who were enrolled in the VA Health Care System on a specified date and who have remained enrolled since that date. (Also known as 72 or 7c). Subpriority e: Noncompensable 0 percent service-connected veterans not included in Subpriority a above. Subpriority g: Non-service-connected veterans not included in Subpriority c above.
CHAPTER 3 LITERATURE REVIEW The Behavioral Model of Health Services Use The framework of the Behavioral Model of Health Services Use developed and refined by Ronald M. Andersen and Lu Ann Aday is used in this research to classify individual patient characteristics. The behavioral model of health services utilization posits that use of medical care services is influenced by predisposing, enabling, and need characteristics. The model is typically best at explaining an individual’s choice in seeking contact with the medical care system. The model is not as good at explaining the volume of care a person receives in the health care system, as the volume is influenced largely by how much the provider(s) prescribe. Ronald M. Andersen originally developed the Behavioral Model of Health Services Use over 35 years ago (Andersen, 1968). Dr. Andersen was initially interested in families’ use of formal health services. Because of the differences among family members, however, his model was revised to focus on the individual as the unit of analysis. The model had three basic constructs to both explain and predict health care utilization: predisposing, enabling, and need. Predisposing characteristics of the individual are those attributes that influence the individual to use the health care system and include three broad categories: demographic characteristics, social structure, and health beliefs. Demographic characteristics are variables such as age, sex, and race, and are frequently found to be significant predictors of health services utilization. Social structure variables include socioeconomic status 32
33 measures of the individual, for example, their educational attainment level and occupation. Health beliefs are values and attitudes an individual has regarding how or even if they can benefit from medical treatment and their perception that medical care is needed. Enabling characteristics measure an individual’s ability to access the health care system, which can, in turn, be measured by the actual utilization of a health care system by a sub-population. Enabling characteristics encompass such variables as income, health insurance, welfare, the availability of health care resources such as physicians and hospital beds in the community, and distance to health care facilities. The third component of the behavioral model, need, can be thought of as an individual’s perceived need for medical care, based on the individual’s self-reported health status and an individual’s ability to function in day-to-day activities. The Andersen Behavioral Model of Health Utilization is one of the most widely used models in the access and utilization health services research literature. The dependent variables used in past research include various measures of health services utilization, such as: number of physician visits in the past year; contact with a physician (Yes/No); days of care used; annual expenditures; emergency care visits (Yes/No; and number of visits); any hospitalizations; primary care service use; specialty care use; utilization of long-term care facilities in nursing facilities; assisted living facilities, and home and community-based services; use of outpatient surgery; use of home care; number of health screens; and dental service use, to name a few. Over the past 35 years, the Andersen model has evolved and expanded beyond the original framework, primarily through the continued intellectual contributions of
34 Andersen and his colleague Lu Ann Aday. In an article published in the Journal of Health and Social Behavior, Andersen revisits the Behavioral Model of Health Care Utilization (Andersen, 1995). He traces the evolution of the model from its initial conceptual formulation through a series of “phases,” each of which expands, refines, and shows the interrelationship between predictive variables and health services utilization. In later articles and chapters, Andersen incorporates external environment, providerrelated variables and characteristics of the health care system, along with including outcomes as a dimension in the behavioral model of health services use (Andersen and Davidson, 1996; Phillips et al., 1998). An important extension of the behavioral model is the work of Gelberg, Andersen, and Leake (2000) on vulnerable populations. “The Behavioral Model for Vulnerable Populations was designed to include domains especially relevant to the health and health-seeking behavior of vulnerable populations” (p. 1274). The rationale behind added domains is that vulnerable populations have additional personal attributes that may influence their access to the health care system. Under each of the original predisposing, enabling, and need components are “vulnerable” domains. For example, under the predisposing vulnerable domain for the homeless population, the researchers added: acculturation, immigration status, literacy, childhood characteristics, residential history, living conditions, mobility, criminal behavior, victimization, mental illness, psychological resources, and substance abuse. The enabling vulnerable domain includes “personal/family resources, such as receipt of public benefits, competing needs, and availability and use of information sources” (Gelberg, Andersen, and Leake, 2000, p. 1277). The additional characteristics under the vulnerable need domain includes
35 “perceptions and evaluated need regarding conditions of special relevance to vulnerable populations, such as tuberculosis, sexually transmitted diseases, premature and low-birth infants, and immunodeficiency syndrome (AIDS)” (Gelberg, Andersen, and Leake, 2000, p. 1277). These additional variables were added to the model and the results show that many of them were useful in adding to the explanatory power for vulnerable populations. The Behavioral Health Model of Health Care Use, as well as the Behavioral Model for Vulnerable Populations, have been used in studies of ethnicity (LaVeist, Keith, and Gutierrez, 1995; Ryu, Youn, and Park, 2001; Andersen et al., 1995; Burnett and Mui, 1999), gender (Keenan, Marshal, and Eve, 2002; Albizu-Garcia et al., 2001), non-elderly (Kubrin, 1995), and vulnerable populations such as the elderly (Mitchell and Krout, 1998; Andersen and Davidson, 1997; Wolinsky et al., 1989; Wolinsky and Johnson, 1991; Wolinsky and Johnson, 1992; Wolinsky, 1994; Tennstedt et al., 1994), the homeless (Gallagher et al., 1997; Stein et al., 2000; Broyles, McAuley, and BairdHjolmes, 1999), HIV/AIDS patients (Kilbourne et al., 2002; Andersen et al., 2000; Malow and Ireland, 1996; Dobalian, Tsao, and Duncan, 2004), people with mental health disorders (Toseland et al., 2002), or a combination of subgroups (e.g., African-American Females). A few of these studies are summarized below. The purpose of reviewing these select studies is to show how the Andersen model has been used for different subpopulations, and also to show some examples of the way predisposing, enabling, and need characteristics are operationalized in the literature. LaVeist, Keith, and Gutierrez (1995) used the Andersen model as a framework to examine the differences between black and white women and their prenatal care use. The study sample was comprised of respondents to a survey conducted by the Michigan
36 Department of Public Health on women that gave birth between December 1988 and January 1989 at any Michigan hospital that had an obstetrics unit. A total of 1,772 responses were analyzed (white=1386, black=275). In their analyses, predisposing characteristics were defined as: marital status, age, education, and per capita income. Enabling characteristics were defined as health insurance status, distance traveled to receive prenatal care, and the relative availability of prenatal care in the county. Since the study focused on prenatal care utilization and all the respondents were pregnant, the “need” component of the model was controlled by sample selection. Bivariate analyses (Chi-Square and F-tests) were conducted to provide evidence of racial differences in the independent and dependent variables. A step-wise multivariate analysis was then conducted that used the predisposing, enabling, and dichotomous race variable to predict three outcome measures: total number of prenatal visits, month of first contact, and adequacy of prenatal care received. Finally, the model was run separately for each racial group. Respondents were not asked about their health beliefs or attitudes on the questionnaire, so it was not possible to include these variables in the model. In this study, several variations on the Andersen model were incorporated. The first is the use of “per capita” income, defined as “total income divided by the number of people in the household” (p. 48) as a predisposing and not an enabling characteristic. Second, an important element in realized utilization is the client’s attitude toward the health care system and whether she (in this case) expects prenatal care to be of benefit. Because they used a secondary data set, the absence of these elements was unavoidable. The third is the absence of any “need” characteristics. The authors explain that since all the
37 individuals in the study were pregnant that “need” was controlled by the sample selection; however, Andersen’s model incorporates both actual need and perceived need for care into this category. Ryu and colleagues (2001) used the Andersen model to investigate the predictors of health care utilization of a special ethnic group, Korean Americans. In particular, they were interested in whether insurance coverage of Korean Americans differed significantly from other Asian-American subpopulations and whether this in turn affected their health utilization patterns. The data for the study came from the 1992 National Health Insurance Study, administered by the U.S. Department of Health and Human Services. Responses from a total of 345 Korean Americans and 3,059 Asian Americans were used in their analysis. Predisposing factors used in the model included age, sex, education, living with a spouse (Yes/No), and family size. Enabling characteristics were comprised of family income, type of employment, years lived in the United States, and health insurance (Y/N). Needs factors were operationalized as respondent-assessed health status, the number of conditions, and bed days in the past year. The utilization of interest in the study was the number of physician visits in the past year. In addition to conducting the analyses on health service use, the researchers also used the conceptual framework to guide a within-group chi-square analysis of those individuals who had insurance and those individuals who did not. In this study, bed days of care was used as a need characteristic not as a health utilization measure. Additionally, the length of time living in the United States was added to the predisposing characteristics for this special ethnic group.
38 The Andersen model has been used extensively in studies of the health care utilization of elderly persons. An article by Henton, Hays, Walker and Atwood (2002) examined the determinants of Medicare home health services using this approach. Of particular note in their study is the refinement of the variables included in the “needs” domain. The researchers included not only perceived need but mental health status, cognitive impairment, functional impairment, vision impairment, and hearing impairment. Hurwicz and Berkanovic (2002) investigated Medicare recipients contact with physicians. An interesting operational variable in their list of predisposing characteristics was the presence of a chronic condition. Rather than defining this as a need characteristic, the rationale for incorporating it into the predisposing domain was that “the presence of a chronic condition at baseline is… a proxy for probable past experience with illness and medical care, and resulting knowledge about disease” (p. S190). Dunlop and colleagues at Northwestern University (2002) examined the ethnic/racial differences in a number of utilization measures (any contact [Yes/No], number of physician visits, any hospitalizations [Yes/No], outpatient surgery [Yes/No], home health care visits, and nursing home stays [Yes/No]) using the Andersen model. Of note here is the reclassification of “enabling” characteristics (i.e., income, assets, health insurance) as “economic access” measures. Also, education is not considered a predisposing characteristic but, rather, an “economic access” measure. This study is an example of how a sociological framework can be adopted by other disciplines, in this case, economics.
39 In vulnerable populations, the Andersen model is enhanced by the addition of domains that are specific to the population under study. In the HIV population, for example, Dobalian, Tsao and Duncan (2004) incorporate a number of HIV-specific need characteristics including “pain, change in pain…, energy/fatigue (vitality), changes in energy, whether the person had been diagnosed with AIDS…, and lowest CD4 count” (p. 131). The adapted behavioral health model of health care use for vulnerable populations (Gelberg, Andersen and Leake, 2000) has also been applied to health use issues in the VA. For example, Desai, Rosenheck, and Kasprow (2003) investigated the determinants of receiving outpatient care in a sample of mentally ill homeless veterans using this conceptual framework. Two predisposing variables specific to a homeless population were added to the traditional variables: where the patient slept the night before and how long the veteran had been homeless. Non-traditional enabling characteristics used in this study were whether the veteran received service connected disability benefits (Yes/No) and/or whether the veterans received a VA non-service-connected pension (Yes/No). Because this study was a multi-site study, the investigators also incorporated a number of system-level characteristics in addition to the individual level variables; specifically: annual patient volume of facility, percent of funds spent on teaching/research at the facilities, and percent of funds spent on mental health programs at the facilities. Theoretical Framework Figure 3.1 provides a schematic of the original Andersen model of health care utilization with enabling, predisposing, and need characteristics predicting the use of health care services. The modified theoretical framework in Figure 3.1 illustrates the extension beyond predicting health care use to predicting the locus of where that care is
40 provided. The National Survey of Veterans 2001 final report (VA Assistant Secretary for Policy and Planning, 2003) estimates that, of the approximately 25 million living US veterans, there are veterans who do not use any health care (11.8%), veterans who use only the VA for their health care needs (6.5%), veterans who only access non-VA providers (67.6%) and veterans who use multiple systems of health care (14.1%). Veterans Health Care Utilization Behavior Numerous national studies on the demand for VA care have focused on the characteristics of veterans who use VA health care (Page, 1982; Schlesinger, Moran, and Zangwill, 1984; Randall et al., 1987; Kosloski, Austin and Borgatta, 1987; Cowper et al., 1993). VA users have been found to differ significantly from non-VA users in terms of demographics, economics, insurance coverage, health status, eligibility priority ranking, and access to VA facilities. Comparable work has explored whether veterans differ from non-veterans in their health services utilization behavior. Earlier work by Wolinsky and colleagues (1985) analyzed data from the 1978 Health Interview Survey to investigate veteran and non-veteran use of medical care within the wider context of Andersen’s behavioral model of health services utilization. They concluded that the predisposing, enabling, and need characteristics of veterans were consistent with those reported in the literature on health care utilization behavior of non-veterans. The researchers also found that limited activity and perceived health status were the most important determinants of health service use for veterans and non-veterans alike. Although not nearly as important as the effects of the need characteristics, several other factors were found to have significant effects on the use of health services: age, having a regular physician, and having health insurance coverage.
41 VA Utilization Past studies of VA utilization have concentrated in three main areas: (1) veterans’ choice of using VA facilities over alternate providers, (2) the extent of current and future use of the VA system, and (3) the veteran characteristics associated with VA usage. The major studies have used national survey samples of veterans and have focused on personal characteristics associated with the use of VA facilities. Page (1982) found a strong independent effect of health insurance reducing the odds of choosing a VA facility. Horgan, Taylor, and Wilensky (1983) showed that veterans who used the VA health care system differed in a variety of ways from veterans who chose alternative providers. They found veterans who use the VA were more likely to be poor, elderly, and have had less education. Nonwhites were also found to use VA care more than whites. Kosloski, Austin and Borgatta (1987) found that race and income had strong relationships with VA use; low income and African-American veterans were found to be higher users of VA facilities. Other variables associated with explaining the variation in use of VA services include proximity to a VA facility, lack of private insurance coverage, eligibility, and service-connected injury status, with all variables having an impact in the expected direction. Researchers have found that historically only a small proportion of veterans utilize VA health care facilities. For example, Romeis, Gillespie and Coe (1988) found that only about five percent of veterans were estimated to use a VA facility in a given year. The relatively low utilization rate may be due to a variety of reasons, including VA eligibility restrictions and the availability of alternative private sector care. In general, the characteristics of veterans who use VA rather than non-VA services include older
42 age, lower income and educational attainment, lack of private health insurance, and greater burden of illness. Planning for future utilization of VA health services requires knowledge of what factors will affect a veteran’s selection of provider, taking into account the restrictions imposed by VA eligibility rules, the availability of non-VA health care alternatives, demographic shifts in the veteran population, and veteran preferences in health care. While VA eligibility rules may change over time, it is unlikely that service-connected injured veterans will ever be deemed less than the highest priority group to the VHA health care system. It is important, therefore, to focus on this group of veterans as one facet of the sub-analyses in this project. One previous study in 1997 surveyed veterans who received VA compensation and pension (C&P) but who did not use the VA for health care within the last three years (Cowper and Harrison, 1997; Cowper and Harrison, 1998). The overall objective of this survey was to gain a better understanding of why C&P veterans, individuals who have high priority for care in the VA, choose to use alternative health care providers instead of VA medical facilities for their health needs. Results indicated that C&P veterans in this network were not as aware of VHA and VBA programs as they could be and information dissemination about all VA programs was warranted, particularly in the area of the VA’s health care programs for eligible veterans. Neither the types of services that the VA offers to veterans nor the priority ranking of low-income veterans to receive services appeared to be well understood by the respondents. Findings indicated that the primary reason veterans chose non-VA health care providers centered predominately on the doctor-patient relationship with their current physician and their ability to afford the cost
43 of care through their other insurance coverage programs. Most C&P veterans considered their health insurance coverage to be adequate when considering their health needs and those of their families. Multiple System Use The phenomenon of multiple system use (often referred to as “dual use”) of VA and non-VA health care has received considerable attention from health services researchers in the past several years. Fleming et al. (1992) offered the first analysis of a merged individual-level database for Medicare and VA patients. They investigated inpatient health care use by Medicare recipients in New England and New York, combining four major data sources: (1) the CMS-maintained Medicare Provider Analysis and Review, (2) the Health Information Skeletonized Eligibility Write-off Files (3) the Patient Treatment File and the Beneficiary Identification, and (4) the Record Locator Subsystem (the latter two are VA databases). They found that dual use between the VA and Medicare is substantial. In analyzing a previous Survey of Veterans, Cowper and colleagues (1993) discovered that older veterans’ utilization of the VA health care system was higher than the figures reported in the literature. Changes in the veteran demographic profile, along with revised eligibility priorities, altered the VA’s potential patient pool substantially from the late 1970s to the late 1980s. They also discovered substantial dual utilization among the VA’s older patient population. In particular, veterans were asked how many hospitalizations they had in the previous 12 months and, of that number, how many were in VA facilities. Results showed that 10% of veterans used VA health care facilities and 44% of that group used non-VA medical facilities as well.
44 Wright et al. (1997) examined Medicare and VA hospitalizations of elderly veterans with acute myocardial infraction in both the VA and non-VA health care sectors. The authors concluded that the relatively high rate of out-of-system services poses a challenge to those charged with measuring or managing the costs of health care. Policy changes that affect access to and use of one system may lead to unpredictable results in the other. A high proportion of dual eligibility and utilization of VA and non-VA services by veterans has also been reported by recent studies at the national and local level. In a recent study on veterans’ use of Medicare and VA health care services, for example, Hynes (2003) found that half of VA patients were dually eligible for VA and Medicare in 1999. In a local study in the Midwest, Barnett et al. (2003) found that two-thirds of the VA patients aged 65 years and over were found to have received care under the Medicare program during 1998. Although these studies contribute to our understanding of multiple system use among Medicare-eligible veterans, relatively little is known about multiple system use by veterans under age 65 years. These data are not collected systematically; rather they come from periodic surveys such as special surveys conducted by the state, the Veterans Integrated Service Network, or the National Survey of Veterans conducted by the VA Central Office. Borowsky and Cowper (1999) examined data from a Network Survey conducted with Minnesota veterans in early 1995. Of the veterans in the sample, 28% reported contact with a non-VA provider. The investigators concluded that because a substantial minority of VA health care users makes primary care visits to other providers, coordination between the health care systems could potentially be improved.
45 Summary This chapter provided information on the Behavioral Model of Health Care Use as originally developed by Andersen in the late 1960s and introduces the theoretical framework used in this dissertation. Several examples are given regarding the use of the model by health services researchers, as well as the variations that investigators have employed to use the model in vulnerable populations. The chapter reviewed the literature on veterans’ health utilization and introduced the findings on multiple system utilization. In the next chapter, an overview of the objectives of the study is provided, along with the methods used to address the research aims. The chapter contains a description of the data source and operationally defines the dependent and independent variables. Further, the plan to investigate veterans’ provider selection using sequential conditional logistic regression is discussed.
46
PREDISPOSING
ENABLING
NEED
Figure 3.1a: Traditional Health Behavioral Model
PREDISPOSING
ENABLING
NEED
Figure 3.1b: Modified Theoretical Framework
Figure 3.1: Theoretical Framework
CHAPTER 4 RESEARCH OBJECTIVES AND METHODS Introduction A number of national studies of the use of VA care have examined the characteristics associated with the veterans who access the system. Generally, absence of health insurance, poverty, poor health, low education, minority group status, and presence of a service-connected disability all increase the likelihood VA medical facilities will be used by a veteran. A summary of these research findings and sources is available in Cowper et al. (1993). These characteristics are generally considered indicators of medical need and access to private health care services and past research clearly suggests use of VA medical services by those veterans with higher medical needs and lower access to private medical care services. This work examines veterans’ use or non-use of VA health care services from a 2001 national survey. Further, it considers the patterns of health services utilization for subgroups of veterans. Of particular interest are veterans who have high priority for care but choose not to access the VA for their health care needs and the variations in the utilization patterns among different age groups of veterans. Objectives The objectives of this study are: 1. To identify and describe veterans who were non-users, VA-only users, non-VAonly users, and multiple system users in 2001 using the recently released National Survey of Veterans;
47
48 2. To examine and compare the types and amounts of health care services VAonly, non-VA-only, and multiple system users receive from their providers; and 3. To model veteran selection of medical care provider in sufficient detail and precision to enhance understanding of veteran utilization of VA services as well as the likely impact of changes in VA policy and shifts in the veteran demographic profile. Key Research Questions/Hypotheses This study modeled differences in the health care source utilized by veterans (VA, non-VA, or multiple providers) and operationalized the concept of access to medical care services. Veteran selection of provider was based on the same variables used in nonveteran populations to examine utilization of any medical services and, if medical care was used, determined whether that utilization was from the VA, private providers of medical care, or from both. Objective 1 To identify and describe veterans who were non-users, VA-only users, non-VAonly users, and multiple system users in 2001 using the recently released National Survey of Veterans. Research Question: How do the predisposing, enabling, and need characteristics differ between the different groups of veterans (non-users, VA-only, non-VA-only, multiple system users)? Hypothesis 1: There are significant differences between the groups in terms of predisposing characteristics (age, race, marital status, education, prior use of VA benefits, and military experience);
49 Hypothesis 2: There are significant differences between the groups in terms of enabling characteristics (income level, the presence of health insurance, type of health insurance, presence of service-connected disability); Hypothesis 3: There are significant differences in need characteristics between the groups, including perceived health status, ADL and IADL limitations, and number of health problems. Objective 2 To examine and compare the types and amounts of health care services VA-only, non-VA-only and multiple system users receive from their providers. Research Question: What are the differences in the types and amount of services used by each group? Hypothesis 1: There are significant differences in the amounts and types of health services used by the three user groups. Hypothesis 2: Multiple system users access the VA for services not well covered by existing insurance policies, including pharmacy, prosthetics, and mental health services. Objective 3 To model veteran choice of medical care provider in sufficient detail and precision to enhance understanding of veteran utilization of VA services as well as the likely impact of changes in VA policy and shifts in the veteran demographic profile. Research Question: What predisposing, enabling, and need characteristics are significant predictors of utilization of a particular provider source? Hypothesis 1: Medical need is a significant positive predictor of medical service use.
50 Hypothesis 2: Factors that indicate a lack of access to private medical care (“enabling” variables) are significant predictors of use of VA medical services, controlling for medical need. Data Source The Department of Veterans Affairs periodically conducts surveys of the veteran population. These surveys are conducted under U.S. Code Title 38, Section 527, which authorizes the Secretary of Veterans Affairs to gather data for the purposes of planning for the future needs of veterans, evaluating the services currently offered to veterans, and updating information to help with policy development. For researchers, these surveys provide an opportunity to following changing trends in the veteran socio-demographic profile and benefit utilization. The latest of these surveys, the National Survey of Veterans 2001 (NSV 2001) became available in July 2003 as a SAS database at the VA’s Austin Automation Center. This comprehensive national survey contains detailed information on veterans’ socio-demographics, military experience, health status, health insurance and utilization patterns, and disability compensation, pension, and other VA benefit use (see Appendix for relevant questions posed on the questionnaire). This survey is the data source for the project. Of particular interest is that these national surveys offer an opportunity to examine both users and non-users of the VA health care system. The NSV 2001 is the first survey of veterans that has been conducted after the VA became an enrollment system whereby any honorably discharged veteran can use VA facilities. However, access to care still favors veterans with serviceconnected (SC) injuries and low incomes, placing them in higher priority groups than those veterans without a SC injury or with incomes above the “means test” threshold. The survey provides an opportunity to investigate whether characteristics that in the past
51 predicted the use of VA health services still hold true or whether the VA needs to revise its planning forecasts. Results from these inquiries are compared with earlier work by the author on a previous national survey of veterans. Study Design The design is a retrospective, observational, cross-sectional study of a cohort of veterans who responded to the 2001 National Survey of Veterans (VA, 2003). The NSV 2001 is a cross-sectional national survey of veterans. The survey collectors used a dual frame methodology: random digit dialing (RDD) and “list” samples. The majority of cases (12,905) was obtained through the random digit dialing strategy in the contiguous United States. The remainder of cases (7,092) was obtained from a comprehensive list of all VA enrollees and recipients of VA compensation and/or pension. In essence, then, there are two samples in one. Since this research is not looking at specific health conditions or patient cohort types (e.g., diabetics, veterans with cancer, etc.), there is no need to supplement the RDD sample. It is the 12,905 veterans from the RDD sample that are analyzed in this work. Characteristics of the Study Population The target of the survey was a nationally representative sample of noninstitutionalized veterans residing in the United States and Puerto Rico. Institutionalized veterans, homeless veterans, and veterans living outside the U.S. and Puerto Rico were not targeted populations and are not covered in this survey. Because is it a nationally representative sample, minorities and women are included in the same proportion in the survey as they are in the veteran population. Women and minority veterans are not excluded from investigation in this study, although limited subgroup analyses can be performed due to their small numbers.
52 Dependent and Independent Variables Based on their utilization behavior, veterans are classified as (1) VA-only users, (2) non-VA users, (3) both VA and non-VA users or “multiple system users” and (4) nonusers. User type is the Dependent Variable. There are detailed questions in the Health Care Benefits Module of the survey that elicit the health care utilization of veterans (see Appendix). Specifically, veterans were asked about the type of service utilization (i.e., emergency room, outpatient care, inpatient care, prescriptions, psychological counseling, therapy, alcohol or drug treatment, in-home health care, prosthetic devices, and treatment for exposure to environmental hazards), how much care was provided (for ER visits, outpatient visits, number of new prescriptions filled only; the other types of treatment are dichotomous forced choice responses (Y/N), who provided the care (VA, non-VA), and who paid for the care they received in non-VA settings (VA, CHAMPUS, TRICARE, or the military, Medicare, Medigap insurance, Medicaid, some other government program, private insurance from an employer, self-pay, or other source). From these questions, it is possible to determine whether the respondent was a non-user, a VA user only, a nonVA user only, or a user of multiple systems of care and what services (if any) they obtained from each source. Defining the User Groups There are eight specific types of utilization used to define the user groups. If a respondent indicated that the number of emergency room visits to a VA medical facility was greater than 0, they were coded as a “1” indicating they are a VA “ER” user. Likewise, if the number of emergency room visits was greater than 0 for non-VA facilities, they received a code of “1” indicating that they are a non-VA “ER” user. Thus, a respondent could have a “1” as a VA “ER” user, and a “0” as a non-VA “ER” user, a
53 “1” for both VA and non-VA ER use or a code of “0” in both the VA ER or non-VA ER fields. A similar coding strategy was used for inpatient use, outpatient use, and prescription use. If a respondent answered “yes” to being treated at a VA facility for exposure to environmental hazards care, they received a “1” as a VA environmental hazards user. If the same veteran also responded “yes” to being treated at a non-VA facility for exposure to environmental hazards care, they received a “1” as a non-VA user of medical services for exposure to environmental hazards. Thus, similar to the coding for emergency room use, outpatient use, inpatient use, and pharmaceutical use, a respondent could receive a “1” in the VA use column only, a “1” in the non-VA use column only, a “1” in both the VA and non-VA columns, or a “0” in both fields. The same classification schema was used for the dichotomous responses to the use (Yes/No) of psychological counseling, home health services, and prosthetics. Identifying VA and/or non-VA utilization for all eight types of services was calculated by summing the services: VAsum=VAER+VAINPT+VAOUT+VARX+VACHEM+VAPSYCH+VAHCARE+ VALIMB NVAsum=NVAER+NVAINPT+NVAOUT+NVARX+NVACHEM+NVAPSYCH VAHCARE+VALIMB Where: VAER =VA Emergency Room Use
VALIMB= VA Prosthetic Use
VAINPT= VA Inpatient Care Use
VAHCARE= VA In Home Health Care
VAOUT= VA Outpatient Care Use
NVAER=Non-VA Emergency Room Use
VACHEM= VA Treatment for Exposure to
NVAINPT= Non-VA Inpatient Care Use
Environmental Hazards
NVAOUT=Non-VA Outpatient Care Use
VAPSYCH= VA Psychological Counseling or
NVACHEM =Non-VA Treatment for
Therapy
Exposure to Environmental Hazards
54 NVAPSYCH =Non-VA Psychological
NVALIMB =Non-VA Prosethics
Counseling or Therapy
NVAHCARE =Non-VA VA In-Home Care
The VA-only users are defined as having a VASum score of greater than 0 and a NVASum score equal to 0 (VASum > 0 and NVASum =0). The non-VA-only users are defined as having a NVASum score of greater than 0 and a VASum score equal to 0 (NVASum > 0 and VASum =0). Multiple system users are defined as respondents who have a VASum greater than 0 and a NVASum score greater than 0 (VASum > 0 and NVASum > 0). Non-users of health care are defined as respondents who have VASum and NVASum scores both equal to zero (VASum =0 and NVASum =0). Table 4.1 illustrates the coding results for the first 20 cases in the data set. For the full dataset, the numbers of respondents in each of the user categories are: VA-only users=700 (5.42%), Non-VAonly users=8,927 (69.2%), Multiple System Users=1,815 (14.1%) and Non-Users=1,463 (11.3%). Independent Variables The explanatory variables include predisposing (P), enabling (E), and need (N) characteristics that have been found to influence utilization of health care services. In addition, we identify variables that we believe increases the accessibility to VA services (E*). The independent variables that will be used in the models are as follows: Age (P): age can be calculated from the month and year of birth that is asked on the survey (question MB0a). Education (P): the survey asks the question, “What is the highest grade or year of school you have ever completed?” (question SD11 in the Socio-demographic Information Module). The level of education ranges from no formal schooling to a doctoral degree.
55 Five categories are used in the analyses: 1) Less than high school diploma, 2) High school diploma or GED certificate, 3) Some college, 4) Bachelor’s degree, and 5) Advanced degree. Race/Ethnicity (P): Question SD10 asks the respondent to identify his/her race. Our analyses use three categories: White, Black and Other Race. A separate question (SD9) also asks whether the respondent is Spanish, Hispanic, or Latino. Marital Status (P): Question SD12 obtains information on the current marital status of respondents; that is, whether they are married, widowed, divorced/separated, or never married. Gender (P): Gender is asked of respondents if not obvious to the interviewer in the Military Background section as question MB0. Military Experience (P): There are a number of military-specific questions that are important in a veteran’s decision to access the VA for health care services. First is the period of service in the military (Question MB18). Pre-World War I, World War I, and Between World War I and World War II are collapsed into one category, Pre-World War II, because there are so few veterans in these three categories. The remaining categories remain the same as in survey: In World War II, Between World War II and Korea, During Korean Conflict, Between Korea and Vietnam, Vietnam, Post Vietnam 19751980, Post-Vietnam, 1980-1990, and During the Persian Gulf Era 1990-present. Further, service in a combat or war zone (MB24), exposure to dead, dying, or wounded people (MB25), whether they were ever a prisoner of war (MB26), and whether they were ever exposed to environmental hazards (MB216) are hypothesized to be important in the decision to use or not use VA health care.
56 Prior Use of VA Health Care Services (P): The questionnaire asks respondents (HC25) whether they have ever used any VA health care benefits that they are entitled to because of their military services (Yes/No). Health Insurance (E): A series of questions about the veterans’ health insurance coverage are asked within the Health Background module. Veterans are asked whether they are currently covered by Medicare (HB21), whether they have Medigap insurance (HN25), Medicaid (HB26), TriCare/CHAMPUS, or private insurance. Income/Assets (E), (E*): The primary variable for income used in this study is obtained from question SD15 that asks, “In studies like these, household are sometimes grouped according to income. Including any VA payments you receive, and from all of these sources [from question SD14] combined, what was your total family income for 2000, before taxes and deductions?” Service Connected Disability (N, E*): Questions were asked of veterans on both whether they had a VA service-connected disability and, if so, the percentage of disability they had. Functional Status (N): The survey asks a number of questions that focus on both veterans’ activities of daily living and on instrumental activities of daily living. The questionnaire asked respondents whether they had difficulty with a number of activities of daily living (Yes/No) and instrumental activities of daily living (Y/N) including bathing, dressing, getting in or out of chairs or bed, walking, eating, using the toilet, controlling their bladder, preparing meals, doing light housework, managing money, using the telephone, going places within walking distance, shopping for groceries, shopping for personal items, and getting to places out of walking distance. Three
57 variables were compiled from these variables: 1) the total number of ADL limitations, 2) the total number of IADL limitations, and 3) the total number of limitations (ADL + IADL). Health Problems (N): The survey has a complete module on the health background of the veteran, including disability and also whether they received any medical treatment in the past 12 months for high blood pressure; lung trouble; a hearing condition; any other ear, nose or throat condition; any eye or vision problem, including glasses; cancer; heart trouble; a stroke; kidney or bladder trouble; arthritis or rheumatism; Hepatitis C or other liver disease; an immune deficiency disease like HIV/AIDS; diabetes; stomach or digestive disorder; severe chronic pain; drug abuse or alcoholism; post-traumatic stress syndrome; other mental or emotional problems; an accident-related injury; or any other serious condition. The number of chronic health problems is summed to give an overall score of morbidity. In addition, drug abuse or alcoholism, post-traumatic stress syndrome, and other mental or emotional problems are included because these conditions are traditionally not well covered by private insurance. Perceived health status (N): The first question in the Health Background (HB1) asks respondents to answer the question: “In general, would your say your health is…. Excellent, Very good, Good, Fair, or Poor?” Table 4.2 summarizes the variables that are used for both the descriptive analyses and the predictive modeling. Data Collection Strategy and Timeline The survey was administered via telephone using a computer-assisted telephone interviewing (CATI) system. Prior to fielding the survey, a pretest was conducted to test the face validity of the survey questions, as well as the CATI program. The average
58 interview took 33 minutes from the RDD sample. Westat, Inc., a consulting firm, conducted the survey via telephone from February 2001 through November 2001. The NSV 2001 final report was completed and released in hard copy in March 2003. After generating the final report for the VA Office of Policy and Planning, the data were transferred into a SAS dataset and housed at the Austin Automation Center (AAC), the VA’s main data repository, and made available to VA researchers with appropriate access to the data. The data set became available in July 2003. Since these data are extant, the project does not require a data collection strategy or timeline in which to obtain the data. Strategy for Data Analysis Objective 1: To identify and describe veterans who were non-users, VA-only users, non-VA-only users, and multiple system users in 2001 using the recently released National Survey of Veterans. The following three steps are followed for all descriptive data analyses (Objectives 1 and 2): 1. Obtain descriptive statistics on all variables (means, medians, maximums, minimums, and standard deviations) for all continuous variables and proportions/percentages for all categorical variables. 2. Provide summary statistics for non-users, each user group, as well as by the entire sample. 3. Use Chi-Square tests for categorical or ordinal variables to test the differences between groups (3 user groups and the non-user group) or perform analysis of variance (ANOVA) tests to examine the differences for continuous variables. The key variables to be used for examining predisposing, enabling, and need characteristics are as follows:
59 Predisposing Variables: Gender, Age, Race, Marital Status, Education, Prior Use of VA health benefits, and Military Experience. Enabling Variables: Income, Presence of Health Insurance, Type of Health Insurance, Presence of Service-Connected Disability, and Meets VA “Means Test” Threshold. Need Variables: Percent Service-Connected Disability, Number of Health Problems, Activities of Daily Living limitations, and Instrumental Activities of Daily Living Limitations. Objective 2: To examine and compare the types and amounts of health care services VA-only, non-VA-only and multiple system users receive from their providers. The following variables are used for the data analysis of this objective: Service Use: Emergency Room visits in past 12 months; Number of times at the emergency room; Use of outpatient care; Number of outpatient visits; Hospitalized in the past 12 months; Number of times hospitalized; Use of prescription medication in past 12 months; Number of prescriptions; Receipt of psychological counseling, therapy; Alcohol or drug treatment in the past year; Receipt of in-home health care; Receipt of any prosthetics, including hearing aids, eye glasses or home oxygen; and source of care for all services. This objective is achieved by using the same three-step data analysis plan as described above for Objective 1 for the categorical variables. The utilization variables, however, are count variables. Unlike the continuous variables that use ANOVA to assess differences, the technique to examine the group differences for the count variables use is a nonparametric analysis of variance.
60 Objective 3: To model veteran choice of medical care provider in sufficient detail and precision to enhance understanding of veteran utilization of VA facilities as well as the likely impact of changes in VA policy and shifts in the veteran demographic profile. The analytic steps for data analyses can be broken down into the following: (1) specify and estimate the role of a set of predictors of medical care utilization decisions and (2) specify and estimate access and utilization for veterans with given measured characteristics. 1. Specify and estimate the role of a set of predictors of medical care utilization decisions. The need for medical care triggers two decisions: whether to seek care and where to seek care. Whether care is sought and where that care is delivered is determined by enabling variables and individual patient preferences. Thus, predisposing, enabling, and need variables are expected to jointly determine if care is received and then, given that care is received, whether that care will take place in a VA medical facility or outside of the VA. Figure 4.1 illustrates the decision tree for veterans in accessing health care. The third research question poses, “What predisposing, enabling, and need characteristics are significant predictors of utilization a particular provider source?” In this case, the four outcomes are the probability that, in the preceding 12 month period, the veteran utilized: 0) no health care at all, 1) only VA services, 2) only non-VA services, or 3) both VA and non-VA services. The dependent variable (source of provider) is unordered and categorical. After a number of statistical consultations with Dr. Samuel Wu from the Department of Statistics at the College of Medicine, it was recommended that the approach to the analysis be a series of sequential conditional logistic regression models. The first model compares the non-user group to the three user
61 groups, the second model compares non-VA-only users to VA-only users, the third model compares multiple system users to VA-only users and the final model compares non-VAonly users to some VA use (collapses the VA-only and multiple system users). The approach allows for more flexibility in the group comparisons and permits more meaningful interpretations of the independent variables across user groups. The next step in the analyses entails applying the results from the general veteran population models outlined above to subgroups of the veteran population, specifically, (1) high priority (service-connected injured and low-income) veterans, (2) low priority, category 7 veterans, (3) veterans 65 years of age and older, and (4) veterans under the age of 65. Summary This chapter overviewed the research questions, objectives, and hypotheses that are explored in greater detail in the next three chapters. The data source for this work was the 2001 National Survey of Veterans, a cross-sectional survey of veterans across the United States. The Random Digit Dialing sample from the survey was the study population. The final number of respondents analyzed in the survey was 11,676. The dependent variable, user type, was operationally defined and the list of predisposing, enabling, and need characteristics that are used as independent variables in both the descriptive analyses and the predictive models are presented. Finally, the strategy for data analysis was presented. In the next chapter, the descriptive characteristics of the non-user and three user groups of veterans are presented. Predisposing, enabling, and need characteristics are discussed along with, where applicable, the type and volume of health care used during the previous 12 month period.
62 Table 4.1: Assignment of Veterans to User Types O B S
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
VA Use
Non-VA Use
User Types
VA ER
VA Out
VA Inpt
VA RX
VA VA Drug Psy
VA HC
VA Pros
VA NVA SUM ER
NVA Out
NVA Inpt
NVA RX
NVA NVA Drug Psy
NVA HC
NVA Pros
NVA VA SUM Only
NVA Only
MSU Non User
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0 0 1 0
0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 4 0 0 0 1 0 0 0 0 0 0 2 0
1 1 1 1 0 1 1 0 0 1 1 0 1 1 1 1 1 1 1 1
1 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0
1 0 1 1 0 1 1 0 1 1 1 1 0 1 1 1 1 1 1 1
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0
0 1 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0
4 2 2 2 0 2 3 0 1 2 3 1 1 3 3 2 4 2 3 3
1 1 1 1 0 1 1 0 1 1 1 0 1 1 1 1 1 1 0 1
0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0
ER=Emergency Room Use RX=Pharmacy Use HC=In-Home Health Care Use Drug=Substance Abuse
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 1
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0
Out=Outpatient Use Inpt=Inpatient Use EH=Environmental Hazards Treatment Psy=Treatment for Psychological Pros=Prosthetics Use Disorder MSU=Multiple System User
0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
63 Table 4.2: Dependent and Independent Variables VARIABLE TYPE
CATEGORIES
DEPENDENT VARIABLE
Type of User
VA-only, Non-VA-only, Multiple System, Non-User
INDEPENDENT VARIABLES
Predisposing Gender Age Race Ethnicity Marital Status Education Prior use of VA health benefits Military Experience Service in a war/combat zone Former Prisoner of War Exposure to environmental hazards Exposure to death/dying/wounded Enabling Income Health Insurance Type of Insurance Medicare Medicaid Medigap Tricare Private Insurance Presence of SC disability Meets VA “Means Test” threshold Specific Medical Conditions Alcohol/Drug PTSD Mental/Emotional Problem Need Perceived Health Status Number of Chronic Health Problems Functional Status * Increases VA Priority Level
Male/Female in years Caucasian, African-American, Other % Hispanic Married, Widowed, Divorced/Separated, Never Married LT HS, HS, Some College, Completed College, Advanced Degree Yes/No Yes/No Yes/No Yes/No Yes/No Assets $50,000 Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No* Yes/No* Yes/No Yes/No Yes/No Excellent, Very Good, Good, Fair, Poor Sum of Health Problems #ADLs, #IADLs
64
Use VA Health Care Only N=700
N=12,905 Any Health Care?
YES N=11,442 N=11,676
Use NonNon-VA Health Care Only N=8,927
Use Both VA & NonNon-VA Health Care N=1,815 NO N=1,463
Use Use of of any anyservices services and and source source (s) (s) of of care care
Figure 4.1: Decision to Utilize Any Services and Sources of Care
65
N=12,905 N=12,905 Any AnyVisits? Visits?
NO NO N=1,463 N=1,463
Use VA Health Use VA Health Care Only Care Only N=700 N=700
Use Non- VA Use Non- VA Health Care Health Care Only N=8,927 Only N=8,927
MODEL 2
Use Both VA Use Both VA & NonNon- VA & Non- VA Health Care Health Care N=1,815 N=1,815
YES YES N=11,442 N=11,676 N=11,676
Use VA Health Use VA Health Care Only Care Only N=700 N=700
MODEL 3
MODEL 1
Use Some VA Use Some VA Health Care Health Care N=2,515 N=2,515
Use Non- VA Use Non- VA Health Care Health Care Only N=8,927 Only N=8,927
MODEL 4
Figure 4.2: Logistic Regression Models Used in Analyses
CHAPTER 5 DESCRIPTIVE FINDINGS Introduction The first two objectives of the research study are addressed in this chapter. To review, the first objective is to describe veterans who were non-users, VA-only users, non-VA-only users, and multiple system users and the second objective is to examine and compare the types and amounts of health care services VA-only, non-VA-only and multiple system users receive from their providers. Non-users, by definition, did not receive health care in the prior 12-month period and, therefore, are not analyzed in the section comparing utilization patterns. Objective 1: Characteristics of Study Groups The specific research question posed in the following section is: “How do predisposing, enabling, and need characteristics differ between the four different groups of veterans (non-users, VA-only, non-VA-only, and multiple system users)?” Hypothesis 1 The first hypothesis under Objective 1 is that there are significant differences between the four groups in terms of predisposing characteristics (age, race, marital status, education, prior use of VA benefits, and military experience). The null hypothesis is that there are no significant differences between groups. Hypothesis 2 The second hypothesis under Objective 1 is that there are significant differences between the groups in terms of enabling characteristics (income level, the presence of
66
67 health insurance, type of health insurance, presence of SC disability). The null hypothesis is that there are no significant differences between groups. Hypothesis 3 The third hypothesis is that there are significant differences in need characteristics between the groups including perceived health status, ADL and IADL limitations, and number of health problems. The null hypothesis is that there are no significant differences between groups. Predisposing Characteristics Table 5.1 presents the predisposing characteristics of the user groups under investigation. Demographic characteristics show that the Multiple System users are significantly older than individuals in the other two user groups and the non-user group. The average age is 63.4 years, with a median age of 67.0 years. By contrast, the VA-only group’s mean age was just under 60 years (59.7), the average age for Non-VA-only users was 58.9 years and the average age of non-users was 51.2 years. The older age of the Multiple System group may be the inclusion of veterans who are eligible for Medicare and using both VA and non-VA health services through their dual eligibility. Not surprisingly, the vast majority of all groups are male, ranging from a low of 94% male in the Non-VA-only group to 96.9% male in the Non-User group. This finding reflects the veteran population as a whole, as most veterans are male. This trend may change in the future cohorts of veterans, as women represent about 16% of the current active duty Armed Forces. It is projected that by 2010 women will make up approximately 10% of the veteran population. Racially, the group with the largest percentage of minority representation is the VA-only users. About one-fifth (20.7%) of this group is from a racial group other than Caucasian. In addition, the VA-only and non-user groups have a
68 larger proportion of veterans who are from self-identified Hispanic backgrounds than either the non-VA-only or multiple system users. While the majority of all groups have a marital status of married, the percentage varies widely by the study groups. Almost eighty percent (79.6%) of non-VA-only users are in this category, but only 58.4% of veterans who seek care exclusively from the VA are married. Further, over one-quarter (25.2%) of VA-only users are either divorced or separated. In comparison, only 9.7% of non-VA-only users are in this marital status. The percentages of veterans who have never been married is nearly double for the VA-only and non-user group than the nonVA-only and multiple system user groups. These findings are, in general, consistent with the general access and utilization literature that has documented barriers to private health care for minorities and unmarried individuals. The level of education also shows a number of interesting differences between groups. The non-VA-only group appears to be the most educated, with only 8.9% not completing high school and 12.9% with degrees higher than a baccalaureate degree. The VA-only group has relatively low educational attainment. The percentage of veterans who have less than a high school education is 19.4% for the VA-only group and they have the lowest percentage of individuals who achieved a college degree or higher than the other groups. By definition, both the VA-only and the multiple system users have used VA health benefits in the past. For those veterans who did not use any health care in the past 12 months, approximately 15% (14.9%) had used VA health care services at some point in the past. Less than eighteen percent (17.9%) of non-VA-only users had ever used the VA as a health provider.
69 The final set of predisposing characteristics center on veteran’s military experience. First, the service era by group is examined. The data show that the multiple system users have greater representation in earlier service periods than other groups. Over one-quarter (25.1%) of this group served in World War II. By contrast, about 17% of the VA-only and non-VA-only groups, and only about 7% of the non-users are World War II veterans. Since period of service and age are highly correlated, this finding is not surprising. In addition to service era, the percentages of veterans in each group who (1) had service in a War or Combat Zone, (2) were former Prisoners of War, (3) were exposed to dead, dying, or wounded soldiers, or (4) were exposed to environmental hazards (for example, Agent Orange or the radiation from nuclear weapons) were obtained. The rationale for including these variables as predisposing characteristics is that those veterans who answer “yes” to one or more of these questions on the survey are hypothesized to be more predisposed to use the VA as a health care source. This supposition appears to be borne out in the data. Over half of the VA-only users and veterans who used both VA and Non-VA health care providers served in a combat zone. This finding is in contrast to 36.6% of the non-VA-only users and 36.4% of the non-user groups who experienced combat. Further, a small but higher proportion of veterans who had some contact with the VA health care system in the previous year were former prisoners of war than those veterans who did not receive care from the VA. Both the VA-only and multiple system users had relatively large percentages of their groups who had exposure to soldiers who died or who were seriously injured while serving in the Armed Forces. The VA-only group also had the highest percentage of individuals who
70 claim exposure to environmentally hazardous material than any of the other groups (26.3%). Non-users and non-VA-only users had the lowest, and similar, percentages (16.8% and 16.2% respectively) of environmental hazards exposure. These findings show the importance of past military experience on both accessing the VA and using the VA health care system for specific, military-related conditions. Enabling Characteristics Two traditional enabling characteristics, income and insurance, two VA-specific enabling characteristics, service-connected (SC) disability and meeting the VA “means test” threshold, and three disease/condition-specific conditions are presented by study group in Table 5.2. It appears that the non-VA-only user group is the most financially advantaged of the groups, with more than a third of the respondents in this category (36%) reporting incomes greater than $50,000 per annum. Less than eight percent (7.7%) of veterans who use the VA as their sole provider of health care have incomes at this level. The data show that 31% of veterans who did not use health care in the previous 12 months (non-users) report income levels of greater than $50,000, a higher percentage than either the VA-only (7.7%) or multiple system users (15%). The group with the highest percentage of Medicare coverage is the multiple system users (59.7%). This finding is not surprising, given that this group is older than any of the other group, as seen in the predisposing characteristics section. Less than half of the VA-only users (46.6%) have Medicare coverage, followed by 40.6% of the nonVA-only group and 20% of the non-user group. A relatively small percentage of all groups have Medicaid coverage. Roughly five percent of VA-only (5.3%) and multiple system (5.5%) users have Medicaid coverage. The non-users have the smallest
71 percentage of Medicaid enrollees (2.2%), a finding that is not surprising, given their relative financial advantage. The non-VA-only and non-user groups are primarily covered by private insurance (71.6% and 63.8% respectively). By contrast, only 40.6% of multiple system users and 21.4% of VA-only users have this form of coverage. As expected, VA-only and multiple system users have the highest percentage of Tri-Care coverage of the study groups (9.9% and 9.8% respectively). The groups also show significant differences for Medicare enrollees who have additional Medigap insurance. Only about one-quarter of the VA-only user group who are Medicare beneficiaries also have a Medigap policy (25.5%). The other three groups have larger percentages of individuals who have both Medigap in addition to Medicare coverage: non-VA-only users (47.4%), multiple system users (49.5%), and non-users (46.6%). The VA-specific enabling variables show that both groups that had contact with the VA health care system in the past year have the highest percentages of SC disability. This is not a surprising finding, given that service-connected injured veterans have high priority in terms of treatment in the VA health system. VA-only users also have the highest percentage of individuals who meet the VA “means test” threshold (39.7%). The final set of enabling variables focuses on specific medical conditions: substance abuse, Post-Traumatic Stress Disorder (PTSD), and mental/emotional conditions. These services are not well-covered by private insurance and it is thought that individuals with these conditions would use the VA in the absence of alternative coverage. The data appear to validate this hypothesis. Similar to the military experience variables, the findings show that veterans who have one or more of these medical
72 problems have substantially greater representation in the VA utilization groups than those veterans who did not have contact with the VA. Need characteristics Responses to perceived health, the number of activities of daily living limitations, the number of instrumental activities of daily living limitations, and the number of chronic health problems by study group are presented in Table 5.3. Veterans who had used the VA either exclusively or in combination with another health system rate their health “poor” to a greater degree than either the non-VA-only or the non-user groups. On the other end of the spectrum, the non-user group has the largest percentage of response to “excellent” health than the other groups (30.3%). Multiple system users had the highest average number of both activities of daily living (1.3) and instrumental activities of daily living limitations (1.2). Further, this group, on average, had more chronic health care problems than the other groups (4.2). Again, since this group is the oldest, this finding is not unexpected. Non-users report low levels of impairment and lower numbers of chronic health problems than any of the user groups. Summary of Results Clearly, the study groups show significant differences in their predisposing, enabling, and need characteristics. All research hypotheses that state there will be significant differences between the groups are supported by the data presented here. The descriptive statistics on the four groups provide an insight into the characteristics that appear to be associated with veterans who belong in each group. Profile: VA-only users VA-only users are, on average, 59.7 years old and have a higher representation of minorities (20.7%). The percentage of veterans who use only VA health care that is
73 married is quite low in contrast with the two other user groups, as well as the non-user group. VA-only users also appear to have relatively low educational attainment. Service in the military during the Vietnam War is the largest period of service era for the nonuser group (28.3%), World War II (17.2%), and Between Korea and Vietnam (15.9%). The military experience variables show that the VA-only user group has a larger proportion of individuals who have served in combat in comparison with the groups that had no contact with the VA in the prior 12 months. They also have had greater exposure to dead and dying soldiers while in the Armed Forces and treatment for exposure to environmental hazards during the past year. While the percentage is low, this group also has the largest percent of its constituents who were former Prisoners of War as compared to other groups. The enabling characteristics associated with this group seem to support past research findings; that is, VA users are financially disadvantaged and lack the resources (e.g., private insurance) to access alternative health providers (Page, 1982; Horgan, Taylor and Wilensky, 1983; Kosloski, Austin and Borgatta, 1987; Cowper et al., 1993). Further, this group has the highest percentage of individuals who have a serviceconnected disability rating (37.0%) and the highest percentage of individuals who meet the VA’s “means test” threshold (39.7%), both variables that have been shown in the past to be strong predictors of VA health care use. In terms of the specific medical conditions under investigation, this group had relatively high percentages of individuals who were treated for substance abuse problems, Post-Traumatic Stress Disorder, and mental or emotional conditions. A substantial percentage of the VA-only user group report their health as fair (26.4%) or poor (17.7%)
74 and have, on average, 3.6 chronic health care problems. Further, the group averages one ADL and one IADL impairment. Profile: Non-VA-only users The majority of veterans access only non-VA providers for all their health care service utilization (69.2%). The profile that emerges after examining the descriptive data is that veterans falling into this category are younger than those who use the VA for all or some health services, they are predominantly white, married, and have relatively high educational attainment. Their period of service is similar to the VA-only user group, with Vietnam constituting the largest service era (26.7%), followed by service between Korea and Vietnam (17.1%), and World War II (16.7%). Only about a third served in a War or Combat Zone during their tour of duty in the Armed Forces (36.6%). This group also contains the highest proportion of females of all groups, indicating perhaps that there may be some perceived access barriers to VA health care by women veterans. Compared to the two other user groups, non-VA users had less exposure to dead or dying comrades and a lesser proportion were treated for exposure to environmental hazards or sought treatment for substance abuse, PTSD, or mental/emotional conditions. Non-VA-only users appear to be the most financial advantaged of the four groups with more than a third reporting incomes of over $50,000 per annum (36.0%). Over seventy percent of this group (71.6%) is covered by private insurance. Because of the relative financial advantage, it is not surprising that only a small percent of this group meets or is below the VA’s “means test” threshold level (16.7%). Further, this group has a low percentage of its members with a service-connected disability rating when compared to the other user groups.
75 The non-VA-only group appears to enjoy better health status and has fewer ADL/IADL impairments, on average, than other users. Close to eighty percent (79.6%) reported their health as good, very good, or excellent, with only 5.7% responding that they perceived their health to be poor. This group has a median of 2 health problems which is lower than either other user group. Profile: Multiple system users As one might suspect, the multiple system users are an interesting blend of the VAonly and non-VA-only group profiles. Older age is the main characteristic that separates this group from the other groups, along with the attributes associated with an older population, especially in terms of perceived health status, number of ADLs/IADLs, and number of health problems (need characteristics). Moreover, this group has the largest percentage with Medicare coverage of any group (59.7%). Of those who have Medicare coverage, about half also have some sort of additional MediGap coverage (49.5%). Another indicator closely correlated with age is their period of Service. One-forth (25.1%) of the multiple system users served in the Armed Forces during World War II, a percentage that is substantially higher than for either of the other two user groups and the non-Users. The multiple system users resemble the VA-only users with regard to their military experience in serving in a Combat or War Zone, exposure to death and/or dying people, POW status, exposure to environmental hazards, the presence of a serviceconnected disability rating, and health insurance coverage by Tri-Care. Further, the multiple system users and VA-users have similar, and higher, proportions of individuals who have substance abuse, PTSD, and mental and/or emotional disorders than the NonVA-only or non-user group.
76 Profile: Non-user group This group is comprised of veterans who did not receive health care in the past 12 months from any source. The non-user group is, on average, younger than the three user groups (51.2 years of age) and almost exclusively male (96.9%). The percentage of individuals in this group who are married (69.1%) is below the percentage for non-VAonly (79.6%) and multiple system users (73%), but higher than the VA-only group (58.4%). Their younger age is reflected in the era when they served in the Armed Forces. While service is Vietnam has the largest representation, non-users have a much higher percentage of their group who served post-Vietnam, especially in the Gulf Era, than any of the other groups. Similar to the non-VA-only group, they report lower incidence of substance abuse, PTSD and mental/emotional disorders. Relatively few of the non-user group has used the VA health care system in the past (14.9%). This group appears to be financially advantaged with 31% reporting incomes in excess of $50,000. The insurance coverage variables indicate that the majority of these veterans have the resources to access health care from the private sector with 63.8% having private insurance. Not surprisingly, because of their relatively young age, they have the lowest percentage of the four groups covered by Medicare. A small percentage of the group is covered by Medicaid (2.2%) and by Tri-Care (6.2%). The VA-specific enabling variables, low income and service-connected injury status, show this group to have a relatively low percentage at or below the VA’s “means test” threshold (21.5%), and a low percentage with a service-connected disability rating (5.7%). This group reports very few ADL/IADL or chronic health problems and, by and large, the reason for not using health care services in the past year appears to be because they did not require it.
77 It is important to keep in mind that the non-user group includes primarily veterans who did not perceive a need for health care services (i.e., they are in good health) but also veterans who may potentially need health care but did not have access to medical services (i.e., potential unmet need). An interesting finding is that almost one-fifth of the nonusers meet the means test threshold (21.5%). Low income, along with service connected disability status, is a factor for high priority treatment in the VA. Therefore, the reasons why individuals choose not to avail themselves of VA services are explored in greater detail below. Non-Users’ Reasons for Not Using VA Services Question HC24 on the NSV 2001 asks respondents, “You told me you have not used any health care services from the VA in the last 12 months. What were the main reasons you didn’t use the VA health care services?” Respondents could pick up to 6 reasons for not using the VA. The reason that received the most response was that care was not needed (N=881 or 60.2%). Other responses that ten percent or more of the nonuser group report as main reasons for not using VA health care include use other sources for health care (N=270 or 18.5%), did not believe self entitled or eligible for VA health care (N=173 or 11.8%), not being aware of the VA health care benefits (N=173 or 11.8%), and did not need or want assistance from the VA (N=151 or 10.3%). While infrequent in response, a small percentage of veterans who used no health care in the past year report they did not use the VA because they did not think VA health care would be as good as that available elsewhere (N=27 or 1.9%). Additional variables that cause concern are that some veterans report being treated rudely by VA staff in the past (N=17 or 1.2%), VA health care is inconvenient to use (N=94 or 6.4%), veterans did not know
78 how to apply for benefits (N=25 or 1.7%), and applying for health care benefits is considered too much trouble or there is too much red tape (N=21 or 1.4%). If non-users who report that they did not need care in the past year or who report that they receive care elsewhere (just not in the past year) are excluded, the remaining 411 veterans may represent a group of veterans who have potential unmet need. Roughly one-quarter of these veterans are not aware of VA health benefits (N=101, 24.6%) and/or do not know that they are eligible/entitled to VA health care services (N=99, 24.1%). Another reason reported for not accessing the VA health system concerns accessibility and accommodation aspects in that they feel the VA is inconvenient to use (N=53, 12.9%). Objective 2: Utilization Patterns of Study User Groups Research Question and Hypothesis Research Question: What are the differences in the types and amount of services used by each group? Hypothesis 1: There will be significant differences in the types and amount of health care services used by the three user groups. The null hypothesis is that there are no significant differences in the types and amount of health care services between groups. Table 5.4 presents the results from the respondents’ use of health care over the past year. By definition, the non-user group did not utilize any medical care so the comparisons are made between the three user groups. The survey queries respondents on a variety of health services used in the past 12 months, including emergency room visits, inpatient episodes of care, outpatient visits, prescription use and treatment for specific conditions (i.e., exposure to environmental hazards; psychological disorders; prosthetics, including hearing aids and glasses; and in-home health care services).
79 Emergency Room The percentage of individuals who used the emergency room to obtain treatment in the past year was lowest for the VA-only user group (23.5) and highest for the multiple system users (41.9%). For those veterans who receive treatment only from non-VA providers the percentage that used emergency room treatment was only slightly higher than the VA-only users (24.2%). The relatively high percentage of emergency room use for the multiple system group may be due to a variety of factors, including advanced age and/or poor health status. Because the multiple system users may be more likely to have an acute episode that requires emergency services, it is likely that they would utilize the closest hospital that has an emergency department. In most cases, the nearest facility is a non-VA hospital. Outpatient Visits The vast majority of all user groups report having at least one outpatient care visit in the past 12 months; specifically, 78.6% of VA-only users, 86.2% of non-VA-only users, and 92.5% of multiple system users report contact with an outpatient provider. For those veterans with outpatient care use, the average number of visits to providers was highest for the multiple system users (10.7 visits), followed by VA-only users (8.3 visits) and non-VA-only users (5.2 visits). Inpatient Admissions VA-only users and non-VA-only users are very similar in the percentage of their group who had been hospitalized during the previous 12 months, at about 14%. The multiple system user group, however, had nearly double the percentage of its group who had been hospitalized (28.3%). Of those veterans who were hospitalized in the past year,
80 the average number of nights spent in the hospital was highest for the VA-only group (15.3 nights) and lowest for the Non-VA-only user group (7.3 nights). Prescription Use Similar to outpatient use, the vast majority of individuals in each of the study groups had at least one prescription over the course of the previous 12 months. Over ninety percent of both the VA-only (91.3%) and the multiple system users (96.1%) and 84.8% of non-VA-only users had at least one prescription filled in the past 12 months. The non-VA-only group averaged 5.4 prescriptions from a non-VA source, while the multiple system users averaged 5.7. However, the number of VA prescriptions was not asked in the survey, only the percentage of respondents who used any VA pharmaceuticals. Treatment for Specific Conditions/Services Treatment for environmental hazards was very infrequent for the non-VA-only group, with less than 1% of individuals seeking care for exposure. By contrast, 6.3% of individuals who used the VA exclusively and 5.7% of individuals who had contact with both VA and non-VA providers report treatment for environmental hazards. Treatment for psychological disorders, as expected, was higher for the VA-only (15.4%) and multiple system (17.0%) users than for veterans who used non-VA health care providers. Receipt of prosthetics devices (including glasses and hearing aids) was highest among the multiple system users (39.6%) and lowest for the non-VA-only users (25.6%). In-home care was received by a greater proportion of the multiple system users (8.2%) than by either the VA-only or non-VA-only users. In summary, the hypothesis that the types and amounts of services obtained differed by the study user groups is upheld in these analyses. The next hypothesis
81 focuses on the types and amounts of services that multiple system users receive from VA and non-VA providers. Multiple System Users Hypothesis 2: Multiple system users will access the VA for services not well covered by existing insurance policies, including pharmacy, prosthetics, and mental health services. The null hypothesis is that there are no significant differences between the types of services used by the study groups. Table 5.5 profiles the number and type of services received by source for the multiple system user group. On average, this group used two services (mean=2.2) from the VA (for example, outpatient and pharmacy) and two services (mean=2.4) from nonVA providers (for example, inpatient and in-home services). In cross tabulating the number of services received from VA and non-VA sources, the most common pattern exhibited was, in fact, two types of services from the VA and two types of services from the non-VA sector (N=248 or 13.7%). Emergency Room As shown in the previous section, multiple system users have a relatively high percentage of individuals who use emergency room care. They obtain emergency care predominantly in the non-VA setting. The percentage of multiple system users who used non-VA emergency room services was over twice the percentage than those seeking care from a VA emergency department (34.7% versus 15.7% respectively). However, of those persons who use emergency care, the average number of visits was higher in the VA (mean=2.3) than in the non-VA (mean=1.9).
82 Outpatient Care The data show that multiple system users access VA and non-VA outpatient care in about the same proportions. Approximately eighty percent report an outpatient visit to a VA facility or under VA auspices (79.2%) and 76.9% report an outpatient visit to a nonVA provider. Interestingly, outpatient care appears to be fairly substitutable, with 64.3% of this group reporting visits to both VA and non-VA providers. The volume of use to VA and non-VA providers was quite comparable, as was the average number of visits. Inpatient Care It appears that multiple system users favor non-VA over VA inpatient care. The percentage of this group that was hospitalized in a non-VA setting in the past year was 22.6%. By contrast, only 8.3% of the group was hospitalized at a VA hospital or under VA auspices. The number of nights spent in the hospital for those who did have an inpatient episode of care was greater, on average, for the VA (12 nights) than for the nonVA (8.7 nights). Those veterans hospitalized in a VA also had a wider range of nights during their care (1-180 nights) than those veterans hospitalized in non-VA settings (1120 nights). A small percentage, 2.5%, of multiple system users were hospitalized in both VA and non-VA hospitals in the past year. Prescription Use A greater percentage of multiple system users receive their prescriptions from the VA (75.9%) than from non-VA sources (65.5%). Further, and of potential concern, is the finding that 44.9% of multiple system users receive prescriptions from both sources. The quantity of VA prescriptions is not available from the survey, so the comparison in terms of volume between the VA and non-VA sector is not possible.
83 Treatment for Specific Conditions/Services The multiple system group utilized the VA to a greater degree than the non-VA health care sector for treatment of environmental hazards (4.3% v. 2.3%), treatment for psychological disorders (13.3% v. 6.8%), and for prosthetics (21.5% v. 20.8%). In-home health care was provided to just over 8.2% of all multiple system users. While small, these services appear to be delivered to a greater degree from the non-VA sector (6.6%) than the VA (2.1%). In general, the data support the hypothesis that multiple system users access the VA for services not well covered by existing insurance policies, including pharmacy, prosthetics, and psychological disorders. One frequent question that arises in the debate over the impact of the new Medicare Drug benefit is the impact this entitlement will have on the VA patient population. To begin to address this question, a sub-analysis was conducted to determine the magnitude of “pharmacy only” users in the multiple system group. Of the 552 individuals who used non-VA sources and only one type of service from the VA, representing 30.4% of multiple system users, almost half (46.7%) used the VA for outpatient care and nearly a third (31.3%) used the VA for pharmaceutical services. Summary This chapter provided a description of the predisposing, enabling, and need characteristics associated with the four study groups under investigation. The analyses offered an initial look at the similarities and differences in their characteristics and allowed profiles of the types of veterans who fit within each group to be developed. The hypotheses that the groups differed in their predisposing, enabling, and need characteristics are supported, as well as the hypothesis that the types and amounts of services obtained in the past year differed among the group. A separate analysis was
84 conducted on those veterans who utilize both VA and non-VA services. The hypothesis that veterans access the two systems for different services is also supported. The next chapter presents the results from the sequential logistic regressions performed to determine what predisposing, enabling, and need characteristics appear to be most influential in veterans’ (1) using any health care provider and (2) selecting a provider system (VA-only, non-VA-only, or multiple systems).
85 Table 5.1: Predisposing Characteristics of User Groups
VARIABLE Age F-Value=189.35 p
