Original Research

A Qualitative Study of Treating Dual-Use Patients Across Health Care Systems

Improved communication and increased education may enhance the experience and outcomes for veterans using multiple health care systems, according to this qualitative assessment of health care provider views.

Fed Pract. 2015 August;32(8):32-37

Author(s):

Sarah S. Ono, PhD

Kathleen M. Dziak, MHA, MBA

Stacy M. Wittrock, MA

Colin D. Buzza, MD, MSc

Kenda R. Stewart, PhD

Mary E. Charlton, PhD

Peter J. Kaboli, MS

Heather Schacht Reisinger, PhD

PDF Download

References

1. Department of Veterans Affairs Office of Rural Health, VHA. Veterans Rural Health: Perspectives and Opportunities. Rockville, MD: Booz Allen Hamilton; 2008. http://www.ruralhealth.va.gov/docs/PAO-final-report-0208.pdf. Accessed July 6, 2015.

2. Petersen LA, Byrne MM, Daw CN, Hasche J, Reis B, Pietz K. Relationship between clinical conditions and use of Veterans Affairs health care among Medicare‐enrolled veterans. Health Serv Res. 2010;45(3):762-791.

3. Liu CF, Chapko M, Bryson CL, et al. Use of outpatient care in Veterans Health Administration and Medicare among veterans receiving primary care in community-based and hospital outpatient clinics. Health Serv Res. 2010;45(5 pt 1):1268-1286.

4. Buzza C, Ono SS, Turvey C, et al. Distance is relative: unpacking a principal barrier in rural healthcare. J Gen Intern Med. 2011;26(suppl 2):648-654.

5. Bernard HR, Ryan GW. Analyzing Qualitative Data: Systematic Approaches. Los Angeles, CA: SAGE; 2010.

6. Guest G, Bunce A, Johnson L. How many interviews are enough? An experiment with data saturation and variability. Field Methods. 2006;18(1):59-82.

7. Kramer BJ, Vivrette RL, Satter DE, Jouldjian S, McDonald LR. Dual use of Veterans Health Administration and Indian Health Service: healthcare provider and patient perspectives. J Gen Intern Med. 2009;24(6):758-764.

8. Ajmera M, Wilkins TL, Sambamoorthi U. Dual Medicare and Veteran Health Administration use and ambulatory care sensitive hospitalizations. J Gen Intern Med. 2011;26(suppl 2):669-675.

9. Jia H, Zheng Y, Reker DM, et al. Multiple system utilization and mortality for veterans with stroke. Stroke. 2007;38(2):355-360.

10. Trivedi AN, Grebla RC, Jiang L, Yoon J, Mor V, Kizer KW. Duplicate federal payments for dual enrollees in Medicare Advantage plans and the Veterans Affairs health care system. JAMA. 2012;308(1):67-72.

11. Kaboli PJ, Shivapour DM, Henderson MS, Ishani A, Charlton ME. The impact of primary care dual-management on quality of care. J Prim Care Community Health. 2012;3(1):11-16.

12. Wolinsky FD, Miller TR, An H, Brezinski PR, Vaughn TE, Rosenthal GE. Dual use of Medicare and the Veterans Health Administration: are there adverse health outcomes? BMC Health Serv Res. 2006;6:131.

13. Liu CF, Bryson CL, Burgess JF Jr, Sharp N, Perkins M, Maciejewski ML. Use of outpatient care in VA and Medicare among disability-eligible and age-eligible veteran patients. BMC Health Serv Res. 2012;12:51.

14. Miller EA, Intrator O. Veterans use of non-VHA services: implications for policy and planning. Soc Work Public Health. 2012;27(4):379-391.

15. Bachman SS, Gonyea JG. Improving health care delivery to aging adults with disabilities: social work with dual eligibles in a climate of health care reform. J Gerontol Soc Work. 2012;55(2):191-207.

16. Kizer KW. Veterans and the Affordable Care Act. JAMA. 2012;307(8):789-790.

17. Lampman MA, Mueller KJ. Experiences of rural non-VA providers in treating dual care veterans and the development of electronic health information exchange networks between the two systems. J Rural Soc Sci. 2011;26(3):201-219.

18. Gaglioti A, Cozad A, Wittrock S, et al. Non-VA primary care providers’ perspectives on comanagement for rural veterans. Mil Med. 2014;179(11):1236-1243.

19. U.S. Department of Veterans Affairs. Acting Secretary Gibson outlines problems, actions taken, and budget resources needed to ensure access to care. U.S. Department of Veterans Affairs Website. http://www.va.gov/opa/pressrel/pressrelease.cfm?id=2586. Published July 16, 2014. Accessed July 6, 2015.

20. Office of Rural Health Central Region. Co-managed care toolkit. U.S. Department of Veterans Affairs Website. http://www.ruralhealth.va.gov/resource-centers/central/comanagement-toolkit.asp. Updated June 3, 2015. Accessed July 6, 2015.

The VHA assigns all enrolled veterans to a primary care provider (PCP). However, almost 80% of veterans enrolled in VHA have another form of health care coverage, including Medicare, Medicaid, private insurance, and TRICARE for Life program.¹ Consequently, veterans may choose to use more than 1 health care system to manage their health care needs.

Studies based on merged VHA and Medicare claims data have demonstrated substantial dual use by VHA enrollees with Medicare. Petersen and colleagues reported that about 80% of VHA enrollees with Medicare chose to use services in both systems and that greater distance to VHA facilities and lower priority level for VHA care predicted lower VHA reliance.² Among those aged < 65 years who had Medicare due to disability, 58% weredual users. These dual users relied more on private sector care for many health conditions, with the notable exception of substance abuse and mental health disorders, for which reliance on VHA care was greater.² Another study found that over half of VHA enrollees assigned to a PCP at a community-based outpatient clinic (CBOC) received some or all of their care outside VHA and that reliance on VHA outpatient care declined over the 4-year study period.³

This use of multiple health care providers (HCPs), facilities, and modalities is often described as dual use or comanagement. Dual use in the case of veterans refers to use of both VHA and non-VHA health care, whereas comanagement implies an expectation of shared decision making and open communication between VHA and non-VHA providers. In addition to VHA PCPs, rural veterans frequently receive care from local, non-VHA HCPs in the community where they live. As health care in the U.S. evolves and patients have increasing choices through the Affordable Care Act (ACA), the challenge of comanagement for patients receiving care in multiple systems is likely to increase both within and outside VHA.

This study was part of a qualitative rural health needs assessment designed to ascertain the issues facing rural veterans and their providers in the upper Midwest.⁴ The objective was to examine VHA primary care clinic staff perspectives on dual users, perceived barriers that inhibit comanagement, and factors that contribute to the need for dual use in rural areas.

Methods

A qualitative study design with in-person interviews was used to elicit the perspective of VHA clinic staff on the current and ideal states of comanagement. Clinics were selected using a stratified purposeful sample of 15 urban and rural primary care clinics at VHA CBOCs and VAMCs in 8 Midwestern states (Illinois, Iowa, Minnesota, Nebraska, North Dakota, South Dakota, Wisconsin, and Wyoming). The stratification criteria included (1) urban and rural; (2) geographic coverage of VISN 23; and (3) VHA-managed and contract clinics, resulting in a purposeful sample of 2 urban VAMC clinics, 3 urban CBOCs, 7 rural VHA-managed CBOCs, and 3 rural contract CBOCs. The distance from the CBOC to the closest VAMC ranged from 32 to 242 miles.

Interview guides were developed and tested by the research team for comprehension, length, and timing prior to data collection and iteratively revised as analysis evolved and new topics emerged. Clinic staff were asked about their perceptions of rural veteran use of VHA care; barriers and facilitators to accessing care; and their personal experience working within VHA. Several questions focused on dual use and why rural veterans use multiple health care systems, their perspectives of dual use, their expectations of patients’ role(s) in health care coordination, and the perceived barriers that inhibit comanagement. Interviewers used comanagement and dual use interchangeably to discuss patients with multiple care providers, allowing interviewees to use their preferred terminology; assigned meanings were probed for clarification but not corrected by interviewers.

Between June and October 2009, teams of 2 to 3 researchers visited 15 clinics for 1 to 2 business days each. Researchers conducted interviews with a convenience sample of clinical staff. Consent forms and an explanation of the study were distributed, and those electing to participate voluntarily came to a designated room to complete an interview. All interviews were audio recorded for accuracy.

Interview recordings were transcribed verbatim and reviewed for accuracy. Prior to coding, transcripts were imported into a qualitative data management software program. A codebook, including a priori research hypotheses and de novo themes, was developed based on a systematic review of a randomly selected subset of interview transcripts.⁵ Four coders were responsible for coding all transcripts and validating coding through tests of agreement at predetermined intervals.