Utilization and expenditures of veterans obtaining primary care in community clinics and VA medical centers: an observational cohort study

Matthew L Maciejewski,Matthew L Maciejewski,Chuan-Fen Liu,Chuan-Fen Liu,Chuan-Fen Liu,Chuan-Fen Liu,Michael Chapko,Michael Chapko,Michael Chapko,Michael Chapko,John C Fortney,John C Fortney,John C Fortney,Yu-Fang Li,Mark Perkins,Mark Perkins

doi:10.1186/1472-6963-7-56

Abstract

BackgroundTo compare VA inpatient and outpatient utilization and expenditures of veterans seeking primary care in community-based outpatient clinics (CBOCs) and VA medical centers (VAMCs) in fiscal years 2000 (FY00) and 2001.MethodsThe sample included 25,092 patients who obtained primary care exclusively from 108 CBOCs in FY00, 26,936 patients who obtained primary care exclusively from 72 affiliated VAMCs in FY00, and 11,450 "crossover" patients who obtained primary care in CBOCs and VAMCs in FY00. VA utilization and expenditure data were drawn from the VA's system-wide cost accounting system. Veteran demographic characteristics and a 1999 Diagnostic Cost Group risk score were obtained from VA administrative files. Outpatient utilization (primary care, specialty care, mental health, pharmacy, radiology and laboratory) and inpatient utilization were estimated using count data models and expenditures were estimated using one-part or two-part models. The second part of two-part models was estimated using generalized linear regressions.ResultsCBOC patients had a slightly more primary care visits per year than VAMC patients (p < 0.0001), but lower primary care costs (-$71, p < 0.0001). CBOC patients had lower odds of one or more specialty, mental health, ancillary visits and hospital stays per year, and fewer numbers of visits and stays if they had any and lower specialty, mental health, ancillary and inpatient expenditures (all, p < 0.0001). As a result, CBOC patients had lower total outpatient and overall expenditures than VAMC patients (p < 0.0001).ConclusionCBOCs provided veterans improved access to primary care and other services, but expenditures were contained because CBOC patients who sought health care had fewer visits and hospital stays than comparable VAMC patients. These results suggest a more complex pattern of health care utilization and expenditures by CBOC patients than has been found in prior studies. This study also illustrates that CBOCs continue to be a critical primary care and mental health access point for veterans.

Highlights

To compare VA inpatient and outpatient utilization and expenditures of veterans seeking primary care in community-based outpatient clinics (CBOCs) and VA medical centers (VAMCs) in fiscal years 2000 (FY00) and 2001
The VA made a major commitment to establishing CBOCs, which led to an evaluation of whether CBOC patients and veterans obtaining primary care at VA medical centers (VAMC) had comparable satisfaction, quality of care, utilization and expenditures
Patient characteristics CBOC patients are younger and more likely to be married than VAMC and crossover patients (Table 1)

Summary

Introduction

To compare VA inpatient and outpatient utilization and expenditures of veterans seeking primary care in community-based outpatient clinics (CBOCs) and VA medical centers (VAMCs) in fiscal years 2000 (FY00) and 2001. The VA made a major commitment to establishing CBOCs, which led to an evaluation of whether CBOC patients and veterans obtaining primary care at VA medical centers (VAMC) had comparable satisfaction, quality of care, utilization and expenditures. Utilization comparisons of veterans at 38 CBOCs and 32 VAMC primary care clinics showed that CBOC patients had more primary care encounters, fewer specialty care encounters, and similar hospital admission rates and length of stay as VAMC patients [4]. Comparisons of direct outpatient and inpatient expenditures of veterans at 18 VA-staffed CBOCs and 14 VAMCs showed that CBOC patients had lower specialty and total expenditures than VAMC patients, but similar primary care and inpatient expenditures [5]

Methods

Results

Discussion

Conclusion