Payer shifting after expansions in access to private care among veterans

Abstract

Objective: To investigate whether expanded access to Veterans Affairs (VA)-purchased care increased overall utilization or induced a shift from other payers to VA for emergency care among VA enrollees.

Data sources and study setting: This study included all emergency department (ED) encounters in 2019 from hospitals in the state of New York.

Study design: We conducted a difference-in-differences analysis comparing VA enrollees to the general population before and after the implementation of the Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act in June 2019.

Data collection/extraction methods: We included all ED visits with individuals aged 30 or older at the time of the encounter. Individuals were considered eligible for the policy change if they were enrolled with VA at the beginning of 2019.

Principal findings: Of the 5,577,199 ED visits in the sample, 4.9% (n = 253,799) were made by VA enrollees. Of these, 44.9% of visits were paid by Medicare, 32.8% occurred in VA facilities, and 7% were paid by private health insurance. There was a 6.4% (2.91 percentage points; std. error = 0.18; p < 0.01) decrease in the proportion of ED visits paid by Medicare among VA enrollees relative to the general population after the implementation of the MISSION Act in June 2019. This decrease was larger for ED visits with a subsequent inpatient admission (-8.4%; 4.87 percentage points; std. error = 0.33; p < 0.01). There was no statistically significant change in the total volume of ED visits (0.06%; std. error = 0.08; p = 0.45).

Conclusions: Leveraging a novel dataset, we demonstrate that MISSION Act implementation coincided with a shift in the financing of non-VA ED visits from Medicare to VA without any increase in overall ED utilization. These findings have important implications for VA health care financing and delivery.

Keywords: emergency care; insurance; medicare; veterans health; veterans health services.

FIGURE 1

Proportion of emergency department (ED) visits by insurance type and age group for Veterans Affairs (VA) enrollees. Payer mix for all ED visits for VA enrollees in New York in 2019 (a) and split out by individuals aged 30–64 and 65+ at the time of visit (b). Payer categories are mutually exclusive, with proportions shown within each age group. Medicare includes both fee‐for‐service Medicare and Medicare Advantage. [Color figure can be viewed at wileyonlinelibrary.com]

FIGURE 2

Difference in probability of having Medicare as the payer of an emergency department (ED) visit for Veterans Affairs (VA) enrollees compared to all other individuals by month, all ED visits, and visits with and without a subsequent admission. Event study figure showing the difference in probability that Medicare pays for an ED visit between VA enrollees and all others by month. The dashed line represents the implementation of the MISSION Act in June 2019. Estimates are relative to May 2019, just before the law was implemented. All ED visits are shown in green, visits with a subsequent admission in pink, and visits without a subsequent admission in blue. [Color figure can be viewed at wileyonlinelibrary.com]

FIGURE 3

Change in the count of emergency department visits for Veterans Affairs (VA) enrollees relative to May 2019. Event study figure showing the difference in the count of all emergency department (ED) encounters for VA enrollees at all providers by month. The dashed line represents the implementation of the Maintaining Internal Systems and Strengthening Integrated Outside Networks Act in June 2019. Estimates are relative to May 2019, just before the law was implemented. All emergency department visits are shown in green, visits with a subsequent admission in pink, and visits without a subsequent admission in blue. [Color figure can be viewed at wileyonlinelibrary.com]