use of primary care in va and medicare among vamc and cboc patients chuan-fen liu, mph phd herc...

Use of Primary Care in VA and Medicare among VAMC and CBOC Patients

Chuan-Fen Liu, MPH PhDHERC Cyber Seminar

September 17, 2008

This presentation includes preliminary data please DO NOT QUOTE without permission.

Dual Use, Continuity of Care, and Duplication of Services in VA and Medicare Funded by VA HSR&D, IIR 04-292

Project team Seattle: Chuan-Fen Liu, PhD; Michael Chapko, PhD;

Chris Bryson, MD; Nancy Sharp, PhD; Mark Perkins, PharmD

Durham: Matt Maciejewski, PhD Little Rock: John Fortney, PhD Boston: Jim Burgess, PhD University of Chicago: Will Manning, PhD


Outline

Background Classification of primary care across VA and

Medicare records Goal: consistent classification of primary care

Preliminary results of comparisons of VAMC and CBOC patients in 2001 - 2004


Background

VA organizational reform Veterans Eligibility Reform Act of 1996 Moving from inpatient to primary care-oriented

outpatient care Establishment of Community Based

Outpatient Clinics (CBOCs) in 1995 Improve access to primary care Contain cost of VA care


CBOCs

Congressional approval process Services: primary care and mental health

care (2001) Two types: VA-staffed and contract

VA-staffed: VA providers or mixed; VA space Contract: non-VA providers; non-VA space;

capitated or fee basis 718 CBOCs as of March 2008

162 contract and 556 VA-staffed CBOCs


Previous CBOC Evaluations CBOC and VAMC comparisons

Comparable satisfaction and quality of care CBOC patients –

More likely to be older, healthier, and new VA users More primary care visits, but similar primary care costs Lower odds of using specialty, mental health, ancillary and

hospital services Among users, fewer visits and lower costs in specialty, mental

health, ancillary, and inpatient care Lower total outpatient and total costs

Chapko et al., Borowsky et al., Hedeen et al., Maciejewski et al., and Fortney et al., Medical Care 2002; Maciejewski et al., BMC HSR 2007


Issues with Previous Evaluations Only examined VA experience

Were lower use and expenditure offset by higher non-VA use and expenditure?


Objective

Assess whether Medicare eligible veterans who get primary care at CBOCs have different primary care use than those who get primary care at VAMCs Primary care use = VA or Medicare


Study Design

Retrospective cohort study Study period: FY2000 – 2004

Patient identification in FY2000 Follow-up period: FY 2001 – FY 2004

Study sample: Medicare eligible VA primary care patients from the

previous CBOC cost evaluation study Random sample of primary care patients from 108 CBOCs

and 72 VAMCs Data sources:

Medicare claims VA administrative datasets


Cohort Selection

Exclusions Count

Initial Sample 66,366

Death prior or during FY 2000-2001 2,337

Not Medicare eligible or Part A or B only 36,050

Enrolled in an HMO 5,825

Developed ESRD 390

No VA primary care in FY00 8,290

Distance to VA facility unknown 250

Working cohort 14,753

Age eligible 12,295

Disabled 2,458


Matching VA and Medicare Outpatient Services

Central challenge of identifying primary care in VA and Medicare Data generating process

Clinical data vs. billing records Financial incentives Medicare doesn’t have stop codes

Goal: Classify VA and Medicare encounters as primary care or “other” in consistent way


Context of Reconciling Patient Data in Two Systems

VA providers Closed system Employed by VA Focus on treatment ICD-9 coding higher priority

than CPT coding Providers code CPTs Clinic stops used to define

outpatient care types

Medicare providers Fee-for-service Individual practices Focus on billing payors CPT coding is priority Coders are instrumental UB-92 bill used to organize

care Primary care not explicit

Incentives & organizational structures differ in two Incentives & organizational structures differ in two systemssystems


Philosophies of Matching

Try to make VA look like Medicare Use CPTs and match as though VA data are

billing data (severely undercounts VA work) Try to make Medicare look like VA

Classify Medicare claims into “Clinic Stops” Create a hybrid and transform both

Pick and choose from data advantages and disadvantages in each sector

Classification of VA and Medicare Outpatient Databy Care Type


General Approach Classify VA and Medicare outpatient encounters into

“Care Type” using variables common to both systems Primary Care Specialty Mental Health Diagnostic

Combination of provider specialty and procedure

(CPT-4) codes Goal: Identify primary care with face validity and

consistency


Provider Specialty Types

Primary care: Physicians: family practice; internal medicine Nurse practitioners: family practice; primary care;

women’s health Specialty care Mental health Diagnostic care


Classification of CPT Codes

General Category CPT code range

Anesthesia00001 to 09999

99100 to 99150 *

Evaluation / Management (E&M) 99201 to 99499

Medicine 90281 to 99602 *

Pathology/Laboratory 80000 to 89999

Psychiatry 90800 to 90900 *

Radiology 70000 to 79999

Surgery 10000 to 69999

* Some codes classified into other categories


E&M Codes

Specialty care E&M codes Performed by specialists Performed in acute care and hospital settings

Primary Care E&M codes


Data Management Outpatient encounter definition

Same patient, same date and same provider specialty Omitted records for selected provider specialties

Podiatrists, dentists, etc. Medicare claims

Need to convert Medicare claims into encounters VA records: face-to-face encounters

Exclude phone stops or stops without provider contacts Provider specialty

Medicare – one per record VA – up to 3 per record

Use the first physician or nurse practitioner specialty code Eliminate nurse, PA, intern, resident, nutritionist, or pharmacist as a

provider


General Principles

If specialty provider, encounter cannot be primary care

If specialty E/M procedure or “Medicine procedure” encounter cannot be primary care


Hierarchical Algorithmyes

no

yes

no

yes

no

yes

no

yes

no

Primary care provider + primary care E&M code

Specialty Care

Primary Care

Psychiatric CPT codes, or

Mental health provider + primary care E&M code

Specialty CareSpecialty care provider, or

Surgical or anesthesiologic CPT code

Mental Health Care

Specialty care E&M codes or medicine CPT

Diagnostic Care• Diagnostic care provider, or

• Diagnostic CPT codes

Undetermined care type


Primary Care Type Classification between Medicare and VA

Classification Algorithm Medicare(N = 739 K)

VA(N = 724 K)

Number of encounters

% Number of encounters

%

VA-specific stop code N/A N/A 199,438 27.5

Primary care E/M codes 249,280 33.7 338,947 46.8

Primary care provider type

197,274 20.8 326,324 45.1

Primary care type (E/M and provider type)

103,032 13.9 123,504 17.1


Comparisons of Primary Care Use among VAMC and CBOC Patients


Variable Definitions

VAMC/CBOC primary care user defined based on the majority of primary care visits in each year

Primary care user status in each year: Dual users: at least one primary care visit in VA and one in

Medicare VA-only Medicare only Non-user

Number of VA, Medicare and total primary care visits in 2001 – 2004


Data Analysis

Generalized estimating equation (GEE) model with negative binomial distribution and log link with exchangeble correlation

Adjusted for sampling weights from the original CBOC study

Preliminary Results


Patient CharacteristicsBaseline Characteristic (2000) CBOC (n=8301) VAMC (n=6452)

Age (mean/SD)*** 69.9 (9.1) 68.9 (9.9)

Age < 45 (%) 2.4 2.2

Age 45-54 (%)*** 6.7 10.5

Age 55-64 (%) 8.8 9.4

Age 65+ (%)*** 82.2 77.9

Female (%) 2.7 2.8

Race - White (%)*** 90.6 86.5

Married (%)* 67.8 64.7

Percent Service Connected Disability (mean/SD)*** 17.2 (27.1) 20.3 (30.5)

Medicaid Enrollee (%) 5.2 5.8

Free care - disability (%) 38.3 40.5

- low income (%) 42.7 44.3

Distance to the closest VA (mi) (mean/SD)* 16.9 (18.2) 18.1 (17.2)

DCG FY00 (including VA and Medicare Diagnoses) (mean/SD) 0.96 (0.67) 0.99 (0.67)

Per Capita Income in Zip Code (mean/SD) 19570 (6117) 19463 (8877)

% High School Graduates in Zip Code 79.6 (10.1) 79.5 (11.3)

Population per SQ. Mile in County (mean/SD) 861 (3320) 1018 (5517)

*p<0.05; ***p<0.001


VA and Medicare Primary Care Use

2001 2002 2003 2004

CBOC % % % %

Primary care in VA only 47.7 41.9 37.2 36.5

Primary care in Medicare only 10.9 14.5 18.6 18.2

Dual use 29.1 28.9 27.2 28.7

No primary care use 12.3 14.3 17.0 16.6

VAMC

Primary care in VA only 59.3 56.2 51.9 52.9

Primary care in Medicare only 5.8 7.9 10.3 9.5

Dual use 25.4 24.0 24.3 24.2

No primary care use 9.6 12.0 13.6 13.4


Unadjusted Primary Care Visits

***p<0.001

YEARVA Medicare Total

CBOC VAMC CBOC VAMC CBOC VAMC

20012.38

(2.36)***3.21

(3.59)1.47

(2.76)***1.08

(2.60)3.84

(3.44)***4.29

(4.25)

20022.06

(2.21)***3.05

(3.04)1.62

(2.85)***1.20

(2.58)3.68

(3.41)***4.26

(3.74)

20031.80

(2.10)***2.96

(2.87)1.84

(3.12)***1.45

(2.79)3.63

(3.58)***4.41

(3.80)

20041.91

(2.28)***3.11

(3.00)1.98

(3.32)***1.30

(2.87)3.89

(3.80)***3.42

(3.93)


Multivariate Results of Primary Care Use

Adjusted for patient characteristics***p<0.001

Coefficient

VA Medicare Total

CBOC (reference group = VAMC)

-0.24*** 0.13*** -0.09***


Summary CBOC patients were more likely than VAMC

patients to use primary care services in Medicare Similar time trends between CBOC and VAMC

patients The proportion of VA only primary care users decreased Dual use stayed stable Medicare only increased over time

Compared to VAMC patients, CBOC patients had Fewer VA primary care visits More Medicare primary care visits Fewer total primary care visits, including both VA and

Medicare


Limitations

Not a random sample of VA primary care users: original sample is primary care users in large CBOCs & VAMCs in 2000

Imperfect classification of primary care visits across VA and Medicare systems with hybrid algorithm

No Medicaid data on non-elderly Medicare-eligible vets


Conclusions

Among Medicare eligible veterans: CBOC patients use less VA primary care than VAMC

patients CBOC patients use more Medicare primary care Difference between CBOC and VAMC patients in total

primary care use decreases when Medicare use is included Continuity of care, chronic disease management

and performance assessment may be impacted by dual use of VA and Medicare primary care services, particularly for CBOC users.


Highlights of the Project

Determinants of primary care reliance in VA Comparisons of continuity of primary care

among VA-only primary care users, Medicare only primary care users and dual users

Duplication of services among dual users

use of primary care in va and medicare among vamc and cboc patients chuan-fen liu, mph phd herc...

Documents

use of primary care

cost of va care slide

primary care visits

continuity of care

medical care

vamcs primary care use

different primary care

contract va