Fractured financing among veterans

One thing we do “well” in America is establish conditions that promote lack of coordination among health care providers and health systems. This is a problem extensively studied in the VA (Veterans Health Administration).

On that point, the following is an exceedingly well-referenced excerpt from a recent article in Health Services Research: Use of Outpatient Care in Veterans Health Administration and Medicare among Veterans Receiving Primary Care in Community-Based and Hospital Outpatient Clinics, by Chuan-Fen Liu, Michael Chapko, Chris L. Bryson, James F. Burgess Jr., John C. Fortney, Mark Perkins, Nancy D. Sharp, and Matthew L. Maciejewski.

In VA, a significant proportion of veterans also have coverage through private insurance, Medicaid, Medicare, TRICARE through military services, or Indian Health Services (Wright et al. 1997; Borowsky and Cowper 1999; Wright et al. 1999; Shen et al. 2003; Hynes et al. 2007; Ross et al. 2008; Kramer, Vivrette, and Satter 2009; Liu et al. 2009). Eligibility for non-VA health care provides veterans with increased choice, access, and flexibility in their health care (Petersen and Wright 1999; Weeks et al. 2005a; Weeks, Mahar, and Wright 2005b) and may provide access to services unavailable in their local VA system (Hoff and Rosenheck 1998; Petersen and Wright 1999; Bean-Mayberry et al. 2004; Weeks et al. 2005a). However, the continuity and coordination of care may suffer, especially for individuals with chronic conditions requiring ongoing and effective management. Historically, some government dual utilization (e.g., Medicare/Medicaid dual use) has had some degree of coordination (Holahan, Miller, and Rousseau 2009a, b); however, there is little or no formal coordination between VA and Medicare services. Use of non-VA health care may lead to duplication of care, resulting in an inefficient allocation of financial resources and underestimation of health care costs (Boyd et al. 2005; Hester, Cook, and Robbins 2005; Rosen et al. 2005). Finally, provider- or system-level performance measures may be affected if non-VA services are not included.


Bean-Mayberry, B., C. C. Chang, M. McNeil, P. Hayes, and S. H. Scholle. 2004. “Comprehensive Care for Women Veterans: Indicators of Dual Use of VA and Non-VA Providers. Journal of the American Medical Women’s Association 59 (3): 192–7.

Borowsky, S. J., and D. C. Cowper. 1999. “Dual Use of VA and Non-VA Primary Care. Journal of General Internal Medicine 14 (5): 274–80.

Boyd, C. M., J. Darer, C. Boult, L. P. Fried, L. Boult, and A. W. Wu. 2005. “Clinical Practice Guidelines and Quality of Care for Older Patients with Multiple Comorbid Diseases: Implications for Pay for Performance. Journal of the American Medical Association 294: 716–24.

Hester, E. J., D. J. Cook, and L. J. Robbins. 2005. “The VA and Medicare HMOs—Complementary or Redundant? New England Journal of Medicine 353 (12): 1302–3.

Hoff, R. A., and R. A. Rosenheck. 1998. “The Use of VA and Non-VA Mental Health Services by Female Veterans. Medical Care 36 (11): 1524–33.

Holahan, J., D. M. Miller, and D. Rousseau. 2009a. “Dual Eligibles: Medicaid Enrollment and Spending for Medicare Beneficiaries in 2005.” The Henry J. Kaiser Family Foundation: The Kaiser Commission on Medicaid and the Uninsured.

Holahan, J., D. M. Miller, and D. Rousseau. 2009b. “Rethinking Medicaid’s Financing Role for Medicare Enrollees.” The Henry J. Kaiser Family Foundation: The Kaiser Commission on Medicaid and the Uninsured.

Hynes DM, Koelling K, Stroupe K, et al. Veterans’ access to and use of Medicare and Veterans Affairs health care. Med Care. 2007;45(3):214-23.

Kramer, B. J., R. L. Vivrette, and D. E. Satter. 2009. “Dual Use of Veterans Health Administration and Indian Health Service: Healthcare Provider and Patient Perspectives. Journal of General Internal Medicine 24 (6): 758–64.

Liu, C. F., C. Bolkan, D. Chan, E. M. Yano, L. V. Rubenstein, and E. F. Chaney. 2009. “Dual Use of VA and Non-VA Services among Primary Care Patients with Depression. Journal of General Internal Medicine 24 (3): 305–11.

Petersen, L. A., and S. Wright. 1999. “Does the VA Provide “Primary” Primary Care? Journal of General Internal Medicine 14 (5): 318–9.

Rosen, A. K., J. Gardner, M. Montez, S. Loveland, and A. Hendricks. 2005. “Dual-System Use: Are There Implications for Risk Adjustment and Quality Assessment? American Journal of Medical Quality 20 (4): 182–94.

Ross, J. S., S. Keyhani, P. S. Keenan, S. M. Bernheim, J. D. Penrod, K. S. Boockvar, H. M. Krumholz, and A. L. Siu. 2008. “Dual Use of Veterans Affairs Services and Use of Recommended Ambulatory Care. Medical Care 46 (3): 309–16.

Shen Y, Hendricks A, Zhang S, Kazis LE. VHA enrollees’ health care coverage and use of care. Med Care Res Rev. 2003;60(2):253-67.

Weeks WB, Bott DM, Lamkin RP, Wright SM. Veterans Health Administration and Medicare outpatient health care utilization by older rural and urban New England veterans. J Rural Health. 2005;21(2):167-71

Weeks, W. B., P. J. Mahar, and S. M. Wright. 2005b. “Utilization of VA and Medicare Services by Medicare-Eligible Veterans: The Impact of Additional Access Points in a Rural Setting. Journal of Healthcare Management 50 (2): 95–106, discussion 06–7.

Weeks WB, Lee RE, Wallace AE, West AN, Bagian JP. Do older rural and urban veterans experience different rates of unplanned readmission to VA and non-VA hospitals? J Rural Health. 2009;25(1):62-9.

Wright SM, Daley J, Fisher ES, Thibault GE. Where do elderly veterans obtain care for acute myocardial infarction: Department of Veterans Affairs or Medicare? Health Serv Res. 1997;31(6):739-54.

Wright SM, Petersen LA, Lamkin RP, Daley J. Increasing use of Medicare services by veterans with acute myocardial infarction. Med Care. 1999;37(6):527-528.

Hidden information below


Email Address*