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BACKGROUND: Unlike fee-for-service Medicare, the Veterans Health Administration (VHA) allows for the provision of concurrent care, incorporating cancer treatment while in hospice. METHODS: We compared trends of aggressive care at end of life between Medicare and VHA decedents with advanced nonsmall cell lung cancer from 2006 to 2012, and the relation between regional level end-of-life care between Medicare and VHA beneficiaries. RESULTS: Among 18,371 Veterans and 25,283 Medicare beneficiaries, aggressive care at end of life decreased 15% in VHA and 4% in SEER (Surveillance, Epidemiology, and End Results)-Medicare (p

BACKGROUND AND OBJECTIVES: Because of the limited capacity of its own dialysis facilities, the Department of Veterans Affairs (VA) Veterans Health Administration routinely outsources dialysis care to community providers. Prior to 2011—when the VA implemented a process of standardizing payments and establishing national contracts for community-based dialysis care—payments to community providers were largely unregulated. This study examined the association of changes in the Department of Veterans Affairs payment policy for community dialysis with temporal trends in VA spending and veterans’ access to dialysis care and mortality. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: An interrupted time series design and VA, Medicare, and US Renal Data System data were used to identify veterans who received VA–financed dialysis in community-based dialysis facilities before (2006–2008), during (2009–2010), and after the enactment of VA policies to standardize dialysis payments (2011–2016). We used multivariable, differential trend/intercept shift regression models to examine trends in average reimbursement for community-based dialysis, access to quality care (veterans’ distance to community dialysis, number of community dialysis providers, and dialysis facility quality indicators), and 1-year mortality over this time period. RESULTS: Before payment reform, the unadjusted average per-treatment reimbursement for non–VA dialysis care varied widely ($47–$1575). After payment reform, there was a 44% reduction ($44–$250) in the adjusted price per dialysis session (P

Objectives To assess whether prevailing antipsychotic use rates in community nursing homes (CNH) influence new initiation of antipsychotics and diagnosis with antipsychotic indications among Veterans. Methods We used linked 2013-2016 Veterans Administration (VA) data, Medicare claims, Nursing Home Compare, and Minimum Data Set (MDS) assessments. The exposure was the proportion (in quintiles) of all CNH residents prescribed antipsychotics in the quarter preceding a Veteran's admission date. Using adjusted logistic regression, we analyzed two outcomes measured using MDS: antipsychotic initiation, and new diagnosis of an antipsychotic quality-measure exclusionary condition (i.e., schizophrenia, Tourette's syndrome, or Huntington's disease). Results Among 8201 Veterans without an indication for antipsychotics at baseline, 21.1% initiated antipsychotics and 3.5% were newly diagnosed with any exclusionary diagnosis after CNH admission. Schizophrenia accounted for almost all (96.8%) the new diagnoses. Antipsychotic initiation increased with higher CNH antipsychotic use rates: OR = 2.55, 95% CI: 2.08--3.12, quintile 5 versus 1. CNHs with the highest prevalent use of antipsychotics were associated with increased odds of Veterans acquiring an exclusionary diagnosis (OR = 2.09, 95% CI: 1.32-3.32, quintile 5 vs. 1). Conclusions Incident antipsychotic use is common among Veterans admitted to CNHs. CNH antipsychotic prescribing practices are associated with Veterans being newly diagnosed with antipsychotic prescription indications, primarily schizophrenia.

OBJECTIVES: The Veterans Health Administration (VHA) purchases community nursing home care; however, the administrative burden may lead nursing homes to avoid contracting with the VHA. This study aimed to describe how the VHA’s purchasing policies impede or facilitate contracting with nursing homes. DESIGN: Semistructured interviews of key stakeholders in the VHA’s community nursing home contracting process. SETTING AND PARTICIPANTS: We interviewed 15 VHA and 21 nursing home staff at 6 VHA medical centers and 17 nursing homes. VHA medical centers were selected from sites with the greatest magnitude of difference in quality rankings between VHA contracted and noncontracted nursing homes in the same market area. METHODS: Qualitative content analysis of interviews. RESULTS: Five themes emerged: (1) VHA purchases nursing home care to fill gaps in geographic, specialty, and quality care needs; (2) business opportunities and the mission to care for Veterans motivate nursing homes to work with the VHA; (3) the VHA’s reputation for unreliable or insufficient payment and inability of nursing homes to comply with federal wage standards serve as barriers to establishing contracts; (4) complexity of establishing a contract, ambiguity about new policies, and inadequate VHA staffing for the nursing home inspection team hinder the VHA’s ability to establish contracts with nursing homes; and (5) nursing homes that have established corporate processes, nursing home administrators with prior experience working with the VHA, and relationships between VHA and nursing home staff serve as facilitators to establishing new nursing home contracts. CONCLUSIONS AND IMPLICATIONS: Nursing homes will work with the VHA, but the process of executing VHA contracts is burdensome. Streamlining and standardizing the purchasing processes and ensuring timely payment may expand the number of nursing homes willing to contract with the VHA, thereby increasing choices for Veterans and becoming a model for other long-term care networks.

OBJECTIVE: To examine characteristics that are associated with receipt of Aid and Attendance (A&A), an enhanced pension benefit for Veterans who qualify on the basis of needing daily assistance, among Veterans who receive pensions. DATA SOURCES: Secondary data analysis of 2016‐2017 national VA administrative data linked with Medicare claims. STUDY DESIGN: Observational study examining sociodemographic, medical, and healthcare utilization characteristics associated with receipt of A&A among Veterans receiving pension. PRINCIPAL FINDINGS: In 2017, 9.7% of Veterans with pension newly received the A&A benefit. The probability of receiving A&A among black and Hispanic pensioners was 4.6 percentage points lower than for white pensioners (95%CI = −0.051, −0.042). Married Veterans receiving pension had a 4.4‐percentage point higher probability of receiving A&A (95%CI = 0.039, 0.048). Most indicators of need for assistance (eg, home health utilization, dementia, stroke) were associated with significantly higher probabilities of receiving A&A, with notable exceptions: pensioners with a diagnosis of Post‐Traumatic Stress Disorder (marginal effect = −0.029 95%CI = −0.037, −0.021) or enrolled in Medicaid (marginal effect = −0.053, 95%CI = −0.057, −0.050) had lower probabilities of receiving A&A. Unadjusted and adjusted rates of receiving A&A among Veterans receiving pension varied by VA medical center. CONCLUSIONS: This study identified potential inequities in receipt of the A&A enhanced pension among a sample of Veterans receiving pension. Increased Veteran outreach, provider education, and VA office coordination can potentially reduce inequities in access to this benefit.

End‐stage kidney disease (ESKD) is common among Veterans. VA’s limited capacity to deliver dialysis treatment means that VA relies heavily on community providers, making chronic dialysis the single largest VA expenditure for outpatient community care. In the past, VA paid for non‐VA dialysis on a local, ad hoc basis, with some payments greatly exceeding Medicare’s reimbursement rates. In 2009‐2011, the VA began implementing payment policies to standardize the process of pricing non‐VA dialysis care, beginning with the use of the Medicare fee schedule and national dialysis contracts with non‐VA dialysis facilities. This study examined the effect of VA’s standardized pricing policies on VA costs, access to non‐VA dialysis care, and patient outcomes. We used an interrupted time series design and 2006‐2016 data from VA, Medicare, and the US Renal Data System to identify Veterans receiving VA‐financed dialysis in the community from non‐VA providers. Changes over time in prices for non‐VA dialysis treatments and associated ancillary services were ascertained from >7 million VA‐paid community dialysis claims. We performed multivariable regression analyses using differential trend/intercept shift models to examine the effects of VA national contract pricing on (a) VA treatment prices for non‐VA dialysis, (b) access to non‐VA dialysis care defined as the number of non‐VA dialysis providers, and non‐VA dialysis providers’ publicly reported quality hospitalization and mortality rates, patient distance to non‐VA dialysis care, and (c) Veterans’ one‐year mortality, controlling for patient and facility fixed effects. National cohort of 24,130 VA‐enrolled Veterans who received ≥1 community‐based chronic dialysis treatment financed by VA in 2006‐2016. Before implementation of national contracts, treatment prices for non‐VA dialysis care varied widely across VA facilities from as little as $61 to as much as $1,575 per treatment. After implementation of national contracts, there was significantly reduced variation in the cost of treatment across individuals ($73.40 to $663.37) and the average price per dialysis session dropped by 40% (P

Background: Aggressive care at the end of life (EOL) is a persistent issue for patients with stage IV nonsmall cell lung cancer (NSCLC). We evaluated the use of concurrent care (CC) with hospice care and cancer-directed treatment simultaneously within the Veteran's Health Administration (VHA) and aggressive care at the EOL. Objective: To determine whether VHA facility-level CC is associated with changes in aggressive care at the EOL. Design/Setting: Veterans with stage IV NSCLC who died between 2006 and 2012 and received lung cancer care within the VHA. Measurements: The primary outcome was aggressive care at EOL (i.e., hospital admissions, chemotherapy, and intensive care unit) within the last month of life. To compare aggressive care across VHA facilities, we used a random intercept multilevel logistic regression model to examine the association between facility-level CC within each study year (

Background and Objectives U.S. Department of Veterans Affairs Medical Centers (VAMCs) contract with nursing homes (NHs) in their community to serve Veterans. This study compares the characteristics and performance of Veterans Affairs (VA)-paid and non-VA-paid NHs both nationally and within local VAMC markets. Research Design and Methods VA-paid NHs were identified, characterized, and linked to VAMC markets using data drawn from VA administrative files. NHs in the United States in December 2015 were eligible for the analysis, including. 1,307 VA-paid NHs and 14,253 non-VA-paid NHs with NH Compare measures in 128 VAMC markets with any VA-paid NHs. Measurements were derived from the Centers for Medicare and Medicaid Services (CMS) five-star rating system, NH Compare. Results VA-paid NHs had more beds, residents per day, and were more likely to be for-profit relative to non-VA-paid NHs. Nationally, the average CMS NH Compare star rating was slightly lower among VA-paid NHs than non-VA-paid NHs (3.05 vs. 3.21, p = .04). This difference was seen in all 3 domains: inspection (3.11 vs. 3.23, p < .001), quality (2.68 vs. 2.83, p < .001), and total nurse staffing (3.36 vs. 3.42, p < .10). There was wide variability across VAMC markets in the ratio of average star rating of VA-paid and non-VA-paid NHs (mean ratio = 0.93, interquartile range = 0.78–1.08). Discussion and Implications With increased community NH use expected following the implementation of the MISSION Act, comparison of the quality of purchased services to other available services becomes critical for ensuring quality, including for NH care. Methods presented in this article can be used to examine the quality of purchased care following the MISSION Act implementation. In particular, dashboards such as that for VA-paid NHs that compare to similar non-VA-paid NHs can provide useful information to quality improvement efforts.

Importance Medicare hospice beneficiaries discontinue disease-modifying treatments because the hospice benefit limits access. While veterans have concurrent access to hospice care and Veterans Affairs (VA) Medical Center (VAMC)-provided treatments, the association of this with changes in treatment and costs of veterans’ end-of-life care is unknown. Objective To determine whether increasing availability of hospice care, without restrictions on disease-modifying treatments, is associated with reduced aggressive treatments and medical care costs at the end of life. Design, Setting, and Participants A modified difference-in-differences study design, using facility fixed effects, compared patient outcomes during years with relatively high vs lower hospice use. This study evaluated 13 085 veterans newly diagnosed with stage IV non–small cell lung cancer (NSCLC) from 113 VAMCs with a minimum of 5 veterans diagnosed with stage IV NSCLC per year, between 2006 and 2012. Data analyses were conducted between January 2017 and July 2018. Exposures Using VA inpatient, outpatient, pharmacy claims, and similar Medicare data, we created VAMC-level annual aggregates of all patients who died of cancer for hospice use, cancer treatment, and/or concurrent receipt of both in the last month of life, dividing all VAMC years into quintiles of exposure to hospice availability. Main Outcomes and Measures Receipt of aggressive treatments (2 or more hospital admissions within 30 days, tube feeding, mechanical ventilation, intensive care unit [ICU] admission) and total costs in the first 6 months after diagnosis. Results Of the 13 085 veterans included in the study, 12 858 (98%) were men; 10 531 (81%) were white, and 5949 (46%) were older than 65 years. Veterans with NSCLC treated in a VAMC in the top hospice quintile (79% hospice users), relative to the bottom quintile (55% hospice users), were more than twice as likely to have concurrent cancer treatment after initiating hospice care (adjusted odds ratio [AOR], 2.28; 95% CI, 1.67-3.31). Nonetheless, for veterans with NSCLC seen in VAMCs in the top hospice quintile, the AOR of receiving aggressive treatment in the 6 months after diagnosis was 0.66 (95% CI, 0.53-0.81), and the AOR of ICU use was 0.78 (95% CI, 0.62-0.99) relative to patients seen in VAMCs in the bottom hospice quintile. The 6-month costs were lower by an estimated $266 (95% CI, −$358 to −$164) per day for the high-quintile group vs the low-quintile group. There was no survival difference. Conclusions and Relevance Increasing the availability of hospice care without restricting treatment access for veterans with advanced lung cancer was associated with less aggressive medical treatment and significantly lower costs while still providing cancer treatment.

12025 Background: The Veteran’s Health Administration (VHA) allows simultaneous receipt of cancer treatment and hospice care, termed concurrent care, while fee-for-service Medicare does not. Although many physicians who care for patients in the VHA also care for private sector patients, it is unclear whether there is a “spillover” relation between end of life (EOL) care in the VHA and Medicare systems at the regional level. We examined temporal trends, as well as regional-level associations between Medicare and VHA EOL practice for patients with advanced lung cancer. Methods: We conducted a retrospective study on VHA and SEER-Medicare (SM) decedents from 2006-2012 with stage IV non-small cell lung cancer (NSCLC) who received any lung cancer care. Aggressive care (AC) at EOL was defined as any of the following within 30 days of death– intensive care unit (ICU) admission, no-hospice care, cardiopulmonary resuscitation(CPR), mechanical ventilation (MV), > 1 inpatient admission and receipt of chemotherapy. Descriptive statistics were used to compare outcomes. We also analyzed the association between Medicare hospital referral region (HRR) hospice admissions, Medicare HRR EOL spending, and VHA AC use adjusted for patient’s characteristics using a random intercept mixed effect logistic regression model after matching VHA facilities with Medicare facilities in a particular HRR. Results: AC use significantly decreased during the study period, from 46% to 31% among 18,371 Veterans and from 42% to 38% among 25,283 in the SM cohort, (t-test P < .05). Hospice use significantly increased within both cohorts (p < .001). The receipt of chemotherapy at EOL was similar for both cohorts throughout the study period. Veterans who received care in regions with higher hospice admissions among Medicare beneficiaries were significantly less likely to receive AC at EOL (adjusted Odds Ratio (aOR): 0.13 95%CI: 0.08-0.23, P < .001) than veterans in regions with lower Medicare hospice use. Medicare HRR spending at the EOL was not associated with receipt of AC among Medicare beneficiaries (aOR): 1.004 95%CI: 1.00-1.009, P = 0.07). Conclusions: Perhaps due to availability of concurrent care, VHA patients received less aggressive care at EOL as compared to SM patients. At the regional level, greater hospice use among Medicare beneficiaries was significantly associated with reduced AC within the VHA.

The Veterans Benefit Administration’s (VBA) Aid and Attendance enhanced pension benefit (A&A) is available to older, low-income Veterans who require assistance meeting their daily needs. However, reports indicate that A&A is underutilized with only 1/3 of eligible Veterans receiving this benefit. The objective of this mixed methods study is to characterize the variability in A&A enrollment across VA Medical Centers (VAMCs) and determine factors attributable to the variation. Using VA administrative data, we calculated the rate of enrollment in A&A among Veterans receiving pension. We then purposefully sampled 16 Chiefs of Social Work at VAMCs with the highest (n=7) and lowest (n=9) rates of enrollment. Interviews were transcribed, coded, and analyzed using conventional qualitative research methods. The rate of enrollment in A&A varies from

139 Background: The VA advocates for both palliative care and concurrent care (hospice care and cancer-directed treatment). Studies indicate that these policies have increased hospice use and have improved family-reported outcomes and other quality metrics. However, little is known about how palliative care, hospice care and concurrent care may interact to obtain these outcomes. Methods: This was a retrospective cohort study of veterans dying with stage IV non-small cell lung cancer in 2012. VA and Medicare administrative data were used to identify the cohort, chemotherapy and radiation use, hospitalizations, hospice use and length of stay (LOS). Palliative care use was determined by VA data only. Analyses included descriptive statistics, chi-square and analysis of variance. Results: Of the 1763 veterans, 850 (48.2%) received both palliative care and hospice, 392 (22.2%) received hospice only, 241 (13.7%) received palliative care only and 280 (15.9%) received neither. Receipt of cancer-directed treatment or hospitalization in the last 30 days of life was significantly different across these groups (p < 0.0001) and was highest at 65% (182/280) in the neither palliative care or hospice group. In the remaining groups, rates of cancer-directed treatment or hospitalization in the last 30 days were: 39.4% (95/241) in palliative care only, 29.3% (115/392) in hospice only and 23% (198/850) with both palliative care and hospice. Concurrent care was received by 314 veterans (17.8%), 275 also receiving palliative care. Among veterans receiving palliative care and Medicare hospice, concurrent care did not alter hospice utilization rates or LOS: 36.4% (100/275), LOS mean 22.3, median 16.5, range 1-97 and 37.2% (214/575), LOS mean 20.1, median 13, range 1-94, for concurrent care and non-concurrent care respectively. Conclusions: The rates of cancer-directed treatment or hospitalization in the last 30 days of life appeared to be reduced in a continuum from receipt of neither hospice nor palliative care, to receipt of palliative care or hospice alone, followed by receipt of both together. Concurrent care use was facilitated by palliative care without impacting Medicare hospice use or LOS in palliative care recipients.