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Objective To estimate the effect of Medicare use on the receipt of outpatient services from 2001 through 2015 for a cohort of Veterans Administration (VA) users who became age-eligible for Medicare in 1998-2000. Data sources/study setting VA administrative data linked with Medicare claims for veterans who participated in the 1999 Large Health Survey of Enrolled Veterans. Study design We coded each veteran as VA-reliant or Medicare-reliant based on the number of visits in each system and compared the health and social risk factors between VA-reliant and Medicare-reliant veterans. We used bivariate probit and instrumental variables models to estimate the association between a veteran's reliance on Medicare and the receipt of outpatient procedures in Medicare and the VA. Principal findings Veterans who chose to rely on the VA (n = 4,317) had substantially worse social and health risk factors than Medicare-reliant veterans (n = 2,567). Medicare reliance was associated with greater use of outpatient services for 24 of the 28 types of services considered. Instrumental variable estimates found significant effects of Medicare reliance on receipt of advanced imaging and cardiovascular testing. Conclusions Expanded access to fee-for-service care in the community may be expensive, while the VA will likely continue to care for the most vulnerable veterans.

Objective To examine whether nurse practitioner (NP)-assigned patients exhibited differences in utilization, costs, and clinical outcomes compared to medical doctor (MD)-assigned patients. Data sources Veterans Affairs (VA) administrative data capturing characteristics, outcomes, and provider assignments of 806 434 VA patients assigned to an MD primary care provider (PCP) who left VA practice between 2010 and 2012. Study design We applied a difference-in-difference approach comparing outcomes between patients reassigned to MD and NP PCPs, respectively. We examined measures of outpatient (primary care, specialty care, and mental health) and inpatient (total and ambulatory care sensitive hospitalizations) utilization, costs (outpatient, inpatient and total), and clinical outcomes (control of hemoglobin A1c, LDL, and blood pressure) in the year following reassignment. Principal findings Compared to MD-assigned patients, NP-assigned patients were less likely to use primary care and specialty care services and incurred fewer total and ambulatory care sensitive hospitalizations. Differences in costs, clinical outcomes, and receipt of diagnostic tests between groups were not statistically significant. Conclusions Patients reassigned to NPs experienced similar outcomes and incurred less utilization at comparable cost relative to MD patients. NPs may offer a cost-effective approach to addressing anticipated shortages of primary care physicians.

Objective To compare two approaches to measuring racial/ethnic disparities in the use of high-quality hospitals. Data Sources Simulated data. Study Design Through simulations, we compared the “minority-serving” approach of assessing differences in risk-adjusted outcomes at minority-serving and non-minority-serving hospitals with a “fixed-effect” approach that estimated the reduction in adverse outcomes if the distribution of minority and white patients across hospitals was the same. We evaluated each method's ability to detect and measure a disparity in outcomes caused by minority patients receiving care at poor-quality hospitals, which we label a “between-hospital” disparity, and to reject it when the disparity in outcomes was caused by factors other than hospital quality. Principal Findings The minority-serving and fixed-effect approaches correctly identified between-hospital disparities in quality when they existed and rejected them when racial differences in outcomes were caused by other disparities; however, the fixed-effect approach has many advantages. It does not require an ad hoc definition of a minority-serving hospital, and it estimated the magnitude of the disparity accurately, while the minority-serving approach underestimated the disparity by 35–46 percent. Conclusions Researchers should consider using the fixed-effect approach for measuring disparities in use of high-quality hospital care by vulnerable populations.

Influenza outbreaks occur nearly every year and cause significant excess medical costs (McBean, Babish, and Warren 1993), as well as an average of 36,000 excess deaths, mostly among the elderly (Bridges et al. 2003). Influenza vaccination has been shown to significantly reduce influenza-related morbidity and mortality (Bridges et al. 2003), and the Advisory Committee on Immunization Practices recommends that nearly all persons over the age of 50 receive annual vaccination (Bridges et al. 2003). Since 1993, Medicare has covered the full cost of influenza vaccination. While the Healthy People 2000 goal of 60 percent influenza vaccination among the elderly has been met at the national level, significant racial disparities persist (CDC 2003a, b). Behavioral Risk Factor Surveillance System (BRFSS) data for 2000 and 2001 combined indicate rates of 66.0 percent among elderly non-Hispanic whites, 48.3% among non-Hispanic blacks, and 53.7 percent among Hispanics (CDC 2003a). National Health Interview Survey data indicate similar rates in 2002 of 69.6, 48.5, and 50.7 percent, respectively (CDC 2003b). Elimination of these disparities is a goal of Healthy People 2010 (HHS 1999) and the Racial and Ethnic Adult Disparities in Immunization Initiative (READII) at the Department of Health and Human Services (HHS 2002). This work is made more difficult because the causes of the disparity are poorly understood and the effectiveness of strategies to increase immunizations has not been established in minority populations. Meta-analyses (Szilagyi et al. 2000; Stone et al. 2002) have documented the effectiveness of both patient-focused strategies, such as mailed reminders and patient education, and clinic-based strategies, such as providing physician reminders and incentives, allocating space and personnel at clinics for the purpose of providing vaccinations, and empowering nurses to provide influenza vaccinations. However, many of these studies were conducted in areas with low minority populations, or used administrative databases that do not identify the race of the beneficiary. How well these strategies will work in minority populations, which may have different barriers to overcome, is not clear. For example, organizational changes at a clinic will have little effect on populations that access clinical care infrequently, and postcard reminders may have little effect on populations with resistant attitudes or beliefs regarding vaccination. The purpose of this study was to identify the causes of racial and ethnic disparities in influenza vaccination in the elderly in order to better inform efforts to eliminate the disparity. We explored three possible causes of the disparity: (1) differences in resistant attitudes and beliefs regarding influenza vaccination, (2) differences in access to care during weeks when influenza vaccinations were given, and (3) discriminatory treatment of African-American and Hispanic patients by their providers.

To explore three potential causes of racial/ethnic differences in influenza vaccination rates in the elderly: (1) resistant attitudes and beliefs regarding vaccination by African-American and Hispanic Medicare beneficiaries, (2) poor access to care during influenza vaccination weeks, and (3) discriminatory behavior by providers.Medicare beneficiaries who responded to both the 1995 and 1996 Medicare Current Beneficiary Survey (MCBS) (n=6,746).We combined survey information from the MCBS with Medicare claims. We measured resistance to vaccination by self-reported reasons for not receiving vaccination, access to care by claims submitted during vaccination weeks, and discrimination by racial differences in vaccinations among beneficiaries who visited the same providers during vaccination weeks.White beneficiaries (66.6 percent) were more likely to self-report having received vaccination than were African Americans (43.3 percent) or Hispanics (52.5 percent). Resistance to vaccination plays a role in low vaccination rates of African-American (-11.8 percentage points), but not Hispanic beneficiaries. Unequal access accounts for2 percent of the disparity. Minority beneficiaries remained unvaccinated despite having medical encounters with their usual providers on days when those same providers were administering vaccinations to white beneficiaries. This disparity is attributable not to provider discrimination but to a 1.6-5 x higher likelihood of white beneficiaries initiating encounters for the purpose of receiving vaccination.Disparities in access to care and provider discrimination play little role in explaining racial/ethnic disparities in influenza vaccination. Eliminating missed opportunities for vaccination in 1995 would have raised vaccination rates in three racial/ethnic groups to the Healthy People 2000 goal of 60 percent vaccination.