The VA and Medicare HMOs — Complementary or Redundant?
http://www.100md.com
《新英格兰医药杂志》
To the Editor: U.S. veterans over the age of 65 years may be eligible to enroll in both the Veterans Affairs (VA) health care system and Medicare health maintenance organizations (HMOs).1,2,3 Although dual use of the systems has been described,4 use of health care services by these veterans has not been reported.
Using a cross-sectional survey design, we serially interviewed veterans over the age of 65 years who were receiving primary care from the Denver VA and who had been enrolled in a Medicare HMO for more than six months. We assessed the reasons why veterans joined Medicare HMOs and their self-reported use of health care services. Of the 113 eligible patients screened, 105 consented to participate in the survey (93 percent). On average, subjects were 74 years old; 93 percent of them were male, 76 percent were married, 83 percent were white, and 63 percent had service-connected eligibility for the health plans. The most commonly cited reasons for HMO enrollment were lower out-of-pocket expenses (e.g., deductibles for emergency transportation) (39 percent), enrollment with a spouse (e.g., "spouse needed insurance") (18 percent), and provision of services not available at the VA (e.g., dental services) (13 percent); 15 percent did not specify why they had joined the HMO.
Assessment of self-reported use of services the previous year revealed that 41 percent had received primary care from both the VA and the Medicare HMO. Although most patients received medications exclusively from the VA (78 percent), 18 percent received medications from both the VA and the HMO. One third reported complementary use of services from the VA and the HMO (e.g., primary care from the VA and subspecialty care from the HMO). Twenty-five percent had not received any care from the HMO in the previous year, and no patients stated that they had received less care from the VA after their HMO enrollment.
Redundant primary care might lead to confusion among providers and patients, and the dispensing of medications from both systems might lead to serious drug toxicity and interactions. Despite having received capitated payments from the Centers for Medicare and Medicaid Services, Medicare HMOs had not provided any services in the past year for 25 percent of the HMO-enrolled veterans in our study. Currently, the VA and Medicare health care systems remain isolated and independent sources of care for veterans. Providers and policymakers might consider whether enhancement of collaboration and elimination of redundancies might offer important cost savings and improved safety for dually eligible veterans under these two federally funded health care programs.
Eric J. Hester, M.D.
Oregon Health and Science University
Portland, OR 97239
hestere@ohsu.edu
Deborah J. Cook, M.D.
University of Colorado Health Sciences Center
Denver, CO 80262
Laurence J. Robbins, M.D.
Veterans Affairs Medical Center
Denver, CO 80262
References
Fisher ES, Welch HG. The future of the Department of Veterans Affairs health care system. JAMA 1995;273:651-655.
Passman LJ, Garcia RE, Campbell L, Winter E. Elderly veterans receiving care at a Veterans Affairs Medical Center while enrolled in Medicare-financed HMOs: is the taxpayer paying twice? J Gen Intern Med 1997;12:247-249.
DeVito CA, Morgan RO, Virnig BA. Use of Veterans Affairs medical care by enrollees in Medicare HMOs. N Engl J Med 1997;337:1013-1014.
Borowsky SJ, Cowper DC. Dual use of VA and non-VA primary care. J Gen Intern Med 1999;14:274-280.
Using a cross-sectional survey design, we serially interviewed veterans over the age of 65 years who were receiving primary care from the Denver VA and who had been enrolled in a Medicare HMO for more than six months. We assessed the reasons why veterans joined Medicare HMOs and their self-reported use of health care services. Of the 113 eligible patients screened, 105 consented to participate in the survey (93 percent). On average, subjects were 74 years old; 93 percent of them were male, 76 percent were married, 83 percent were white, and 63 percent had service-connected eligibility for the health plans. The most commonly cited reasons for HMO enrollment were lower out-of-pocket expenses (e.g., deductibles for emergency transportation) (39 percent), enrollment with a spouse (e.g., "spouse needed insurance") (18 percent), and provision of services not available at the VA (e.g., dental services) (13 percent); 15 percent did not specify why they had joined the HMO.
Assessment of self-reported use of services the previous year revealed that 41 percent had received primary care from both the VA and the Medicare HMO. Although most patients received medications exclusively from the VA (78 percent), 18 percent received medications from both the VA and the HMO. One third reported complementary use of services from the VA and the HMO (e.g., primary care from the VA and subspecialty care from the HMO). Twenty-five percent had not received any care from the HMO in the previous year, and no patients stated that they had received less care from the VA after their HMO enrollment.
Redundant primary care might lead to confusion among providers and patients, and the dispensing of medications from both systems might lead to serious drug toxicity and interactions. Despite having received capitated payments from the Centers for Medicare and Medicaid Services, Medicare HMOs had not provided any services in the past year for 25 percent of the HMO-enrolled veterans in our study. Currently, the VA and Medicare health care systems remain isolated and independent sources of care for veterans. Providers and policymakers might consider whether enhancement of collaboration and elimination of redundancies might offer important cost savings and improved safety for dually eligible veterans under these two federally funded health care programs.
Eric J. Hester, M.D.
Oregon Health and Science University
Portland, OR 97239
hestere@ohsu.edu
Deborah J. Cook, M.D.
University of Colorado Health Sciences Center
Denver, CO 80262
Laurence J. Robbins, M.D.
Veterans Affairs Medical Center
Denver, CO 80262
References
Fisher ES, Welch HG. The future of the Department of Veterans Affairs health care system. JAMA 1995;273:651-655.
Passman LJ, Garcia RE, Campbell L, Winter E. Elderly veterans receiving care at a Veterans Affairs Medical Center while enrolled in Medicare-financed HMOs: is the taxpayer paying twice? J Gen Intern Med 1997;12:247-249.
DeVito CA, Morgan RO, Virnig BA. Use of Veterans Affairs medical care by enrollees in Medicare HMOs. N Engl J Med 1997;337:1013-1014.
Borowsky SJ, Cowper DC. Dual use of VA and non-VA primary care. J Gen Intern Med 1999;14:274-280.