VA and Medicare Utilization Among Dually Enrolled Veterans with Type 2 Diabetes: A Latent Class Analysis

Abstract

Background Many Veterans treated within the VA Healthcare System (VA) are also enrolled in fee-for-service (FFS) Medicare and receive treatment outside the VA. Prior research has not accounted for the multiple ways that Veterans receive services across healthcare systems. Objective To establish a typology of VA and Medicare utilization among dually-enrolled Veterans with type 2 diabetes. Design Retrospective cohort. Participants 316,775 community-dwelling Veterans age ≥65 with type 2 diabetes who were dually-enrolled in the VA and FFS Medicare in 2008–2009. Methods Using latent class analysis, we identified classes of Veterans based upon their probability of using VA and Medicare diabetes care services, including patient visits, laboratory tests, glucose test strips, and medications. We compared amount of healthcare use between classes and identified factors associated with class membership using multinomial regression. Key Results We identified 4 distinct latent classes: class 1 (53.9%) had high probabilities of VA use and low probabilities of Medicare use; classes 2 (17.2%), 3 (21.8%), and 4 (7.0%) had high probabilities of VA and Medicare use, but differed in their Medicare services used. For example, Veterans in class 3 received test strips exclusively through Medicare, while Veterans in class 4 were reliant on Medicare for medications. Living ≥40 miles from a VA predicted membership in classes 3 (OR 1.1, CI 1.06–1.15) and 4 (OR 1.11, CI 1.04–1.18), while Medicaid eligibility predicted membership in class 4 (OR 4.30, CI 4.10–4.51). Conclusions Veterans with diabetes can be grouped into 4 distinct classes of dual health system use, representing a novel way to characterize how patients use multiple services across healthcare systems. This classification has applications for identifying patients facing differential risk from care fragmentation.

Evaluation of Low-Value Diagnostic Testing for 4 Common Conditions in the Veterans Health Administration

“…To aid in this task, our claims-based approach to identify low-value testing may help the development of future value-based metrics. 23 , 30 , 31 , 32 , 33 …”

Fee‐for‐Service Medicare‐Enrolled Elderly Veterans Are Increasingly Voting with Their Feet to Use More VA and Less Medicare, 2003–2014

“…; Radomski et al. ). No research has assessed population‐ or system‐level changes in VA reliance on outpatient care among Medicare‐enrolled veterans over an extended time period (≥5 years) and across an extensive array of outpatient service types.…”

“…In 2016, 52 percent of all VA enrollees were also covered by Medicare, including 92 percent of enrollees age 65+ (Huang et al 2017). However, prior studies in dual use of VA and Medicare are mostly cross-sectional, use data from late 1990s to early 2000s (Hynes et al 2007;Humensky et al 2012), or are focused on subpopulations (Zhu et al 2009;Fischer et al 2010;Radomski et al 2016). No research has assessed population-or system-level changes in VA reliance on outpatient care among Medicare-enrolled veterans over an extended time period (≥5 years) and across an extensive array of outpatient service types.…”

Physicians’ Perspectives Regarding Prescription Drug Monitoring Program Use Within the Department of Veterans Affairs: a Multi-State Qualitative Study

“…6 As dual use of VA and non-VA care continues to grow, an increasing number of Veterans may turn outside VA to receive opioids, thus undermining VA's internal efforts to reduce opioid-related overdose and death. [9][10][11][12][13] State-based prescription drug monitoring programs (PDMPs) track dispensed controlled substances, including opioids, and are a tool to identify Veterans' receipt of opioids from non-VA prescribers. [14][15][16] With the exception of Missouri, every state had an operational PDMP of some form as of 2016, although laws governing prescriber accessibility and use varied widely.…”