Racial and Ethnic Differences in Satisfaction with Care Coordination Among VA and non-VA Medicare Beneficiaries.

Purpose: Patients who have multiple sources of care are at risk for fragmented and uncoordinated care, which can lead to poorer outcomes. Veteran Medicare beneficiaries who use the Veterans Health Administration (VHA) system (VA users), particularly racial/ethnic minorities, often have complex medical conditions that may require care from multiple sources, leaving them especially vulnerable to the effects of fragmented care. We examined racial/ethnic differences in the level of satisfaction with care coordination among Medicare beneficiaries, comparing those who do and do not use the VHA healthcare system. Methods: We conducted a retrospective, pooled, cross-sectional study of Medicare beneficiaries using the 2009-2011 Medicare Current Beneficiary Survey. The outcomes are self-reported satisfaction with care items related to three dimensions of care coordination: (1) integrated care, (2) care continuity, and (3) follow-up care. We present descriptive statistics and use generalized linear models to examine racial/ethnic differences across VA and non-VA users, after accounting for other demographic characteristics, health status, functional limitations, insurance coverage, and geographic variation. Results: VA users are more likely to be very satisfied with receiving both integrated and follow-up care compared with non-VA users. Despite the existence of significant racial/ethnic disparities in the likelihood of being very satisfied with receiving well-coordinated care in the larger Medicare population, racial/ethnic minority VA users are just as likely as White non-Hispanics to be very satisfied with receiving well-coordinated care. Conclusions: Future research should continue to study care coordination among VA users and reasons for preferring the VA over other healthcare systems, especially among racial/ethnic minority groups.

The association of Medicare drug coverage with use of evidence-based medications in the Veterans Health Administration.

BACKGROUND: Veterans with Medicare managed-care plans have access to pharmacy benefits outside the Veterans Health Administration (VA), but how this coverage affects use of medications for specific disease conditions within the VA is unclear. OBJECTIVE: To examine patterns of pharmacotherapy among patients with diabetes mellitus, ischemic heart disease, and chronic heart failure enrolled in fee-for-service (FFS) or managed-care (HMO) plans and to test whether pharmacy benefit coverage within Medicare is associated with the receipt of evidence-based medications in the VA. METHODS: A retrospective analysis of veterans dually enrolled in the VA and Medicare healthcare systems was conducted. We used VA and Medicare administrative data from 2002 in multivariable logistic regression analysis to determine the unique association of enrollment in Medicare FFS or managedcare plans on the use of medications, after adjusting for sociodemographic, geographic, and patient clinical factors. RESULTS: A total of 369,697 enrollees met inclusion criteria for diabetes, ischemic heart disease, or chronic heart failure. Among patients with diabetes, adjusted odds ratios (ORs) of receiving angiotensin-converting enzyme (ACE) inhibitors and oral hypoglycemics in the FFS group were, respectively, 0.86 and 0.80 (p < 0.001). Among patients with ischemic heart disease, FFS patients were generally less likely to receive beta-blockers, antianginals, and statins. Among patients with chronic heart failure, adjusted ORs of receiving ACE inhibitors, angiotensin-receptor blockers, and statins in the FFS group were, respectively, 0.90, 0.78, and 0.79 (all p < 0.05). There were few systematic differences within HMO coverage levels. CONCLUSIONS: FFS-enrolled veterans were generally less likely to be receiving condition-related medications from the VA, compared with HMO-enrolled veterans with lower levels of prescription drug coverage. Pharmacy prescription coverage within Medicare affects the use of evidence-based medications for specific disease conditions in the VA.

VHA pharmacy use in veterans with Medicare drug coverage.

OBJECTIVE: To determine how Medicare benefits affect veterans' use of Veterans Health Administration (VHA) pharmacy services. STUDY DESIGN: Retrospective analysis of veterans dually enrolled in the Veterans Health Administration and Medicare healthcare systems. METHODS: We used VHA and Medicare administrative data for calendar year 2002 to examine the effect of Medicare HMO pharmacy benefit levels on VHA pharmacy use. RESULTS: In 2002, 64% of the VHA and Medicare dually enrolled veterans in our study sample received medications from the VHA. Use of VHA pharmacy services varied monotonically by the level of pharmacy benefits among Medicare HMO enrollees, with veterans enrolled in plans with both low and high pharmacy benefit levels significantly less likely to use VHA pharmacy services than veterans in plans with no pharmacy benefits (odds ratios = .83 and .53, respectively, versus plans with no benefits). Among VHA pharmacy users, enrollment in plans with high levels of benefits was associated with significantly lower annual pharmacy costs than enrollment in plans with no benefits or enrollment in traditional Medicare. CONCLUSIONS: Our findings indicate that non-VHA pharmacy benefits affect both the likelihood and magnitude of VHA pharmacy use. This suggests that Medicare pharmacy coverage (Part D) may significantly reduce the demand for VHA pharmacy services, particularly in geographic regions previously underserved by Medicare managed care plans.

Utilization and determinants of adjuvant therapy among older patients who receive curative surgery for pancreatic cancer.

OBJECTIVE: We conducted a population-based study to describe the utilization, determinants, and survival effects of adjuvant therapies after surgery among older patients with pancreatic cancer. METHODS: Using Surveillance, Epidemiology, and End Results-Medicare data, we identified patients older than 65 years who received surgical resection for pancreatic cancer during 1992-2002. We constructed multiple logistic regression models to examine patient, clinical, and hospital factors associated with receiving adjuvant therapy. Cox proportional hazards models were used to examine the effect of therapy on survival. RESULTS: Approximately 49% of patients received adjuvant therapy after surgery. Patient factors associated with increased receipt of adjuvant therapy included more recent diagnosis, younger age, stage II disease, higher income, and geographic location. Hospital factors associated with increased receipt of adjuvant therapy included cooperative group membership and larger size. Adjuvant treatments associated with a significant reduction in 2-year mortality (relative to surgery alone) were chemoradiation or radiation alone but not chemotherapy alone. CONCLUSIONS: Our findings suggest that adjuvant chemoradiation and, to a lesser degree, radiation only are associated with a reduction in the risk of mortality among older patients who undergo surgery for pancreatic cancer. However, receipt of adjuvant therapy varied by period and geography as well as by certain patient and hospital factors.

Does poorer familiarity with Medicare translate into worse access to health care?

OBJECTIVES: To examine the relationship between a global measure of Medicare program familiarity and a broad set of measures of actual and perceived healthcare access. DESIGN: Mailed survey in fall of 2004 (2,997 completed surveys; 53% response rate). SETTING: Metropolitan and nonmetropolitan areas across the United States. PARTICIPANTS: White, black, and Hispanic Medicare beneficiaries. MEASUREMENTS: Familiarity with Medicare and self-reported measures of health status, healthcare use, and perceived access to care. RESULTS: Reported poorer familiarity with Medicare is associated with a greater likelihood of delayed care due to cost, multiple emergency department visits, lack of prescription medication use, poorer perceived access to care, poorer overall health, and a greater reported decline in health from the prior year. Black and Hispanic respondents were more likely to be unfamiliar than whites, although the relationship between familiarity and healthcare access persisted after adjusting for race or ethnicity, Medicare health plan enrollment status, supplemental insurance status, age, sex, income level, education, geographic area, and general healthcare use. CONCLUSION: Poorer familiarity with Medicare may affect beneficiaries' ability to access needed care effectively, may lead them to delay or avoid seeking care, and ultimately may have negatively affect the quality of the health care that they receive and their outcomes.

Do secondary conditions explain the relationship between depression and health care cost in women with physical disabilities?

OBJECTIVE: To examine the influence of depression on health care utilization and costs among women with disabilities and to determine whether the severity of other secondary health conditions affects this association. DESIGN: A time series of 7 interviews over a 1-year period. SETTING: Large, southern metropolitan area. PARTICIPANTS: Community-dwelling women (N=349) with a self-identified diagnosis of a physical disability. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Primary disability, secondary health conditions (Health Conditions Checklist), depressive symptoms (Beck Depression Inventory-Second Edition), and health care utilization (based on the Health and Social Service Utilization Questionnaire and the Stanford Health Assessment Questionnaire). We estimated health care costs using standardized criteria and published average costs. RESULTS: Outpatient and emergency department health care utilization and overall costs were higher in women with depressive symptoms and increased with the frequency and severity of the symptoms. Depressive symptoms were highly correlated with the severity of secondary health conditions. Adjusting for demographics and primary disability, both the presence and severity of depressive symptoms were associated with significantly higher health care costs. However, secondary health condition severity explained the association between depressive symptoms and cost; it also substantially increased the variance in cost that was explained by the multivariate models. CONCLUSIONS: Secondary health conditions are significantly associated with depressive symptoms and higher health care costs, with secondary health conditions accounting for the association between depressive symptoms and costs. This association suggests that effective management of secondary health conditions may help reduce both depressive symptomatology and health care costs.