The Patient Protection and Affordable Care 

Act and the Health Care and Education 

Reconciliation Act (collectively referred to as 

the Affordable Care Act (ACA)) represents 

comprehensive reform of the health care 

delivery system and is intended to expand 

access to coverage, control health care costs, 

and improve the health care delivery system. 

When fully implemented, ACA will provide 

some Veterans with new options for health 

care, such as purchasing private health 

insurance through the soon to be established 

health insurance marketplaces or from 

Medicaid if the Veteran resides in a state that 

expands Medicaid eligibility. 

Dual Eligible Veterans 

Dual eligible Veterans are those Veterans 

who are enrolled in VA health care as well as 

another health care program (i.e. Medicare, 

Medicaid, TRICARE, etc). Of the 6.5 million 

Veterans who received health care coverage 

under VA, Medicare, or Medicaid in fiscal year 

2006 (which is the most recent data VA had), 

approximately one-third used more than one 

system of care. Veterans with dual and/or 

triple eligibility experience fragmented care, 

which diminishes continuity and coordination 

of care, resulting in more emergency 

department use, hospitalizations, diagnostic 

interventions, and adverse events.1

ACA will not change Veterans’ current 

eligibility for VA health care, covered benefits, 

or co-payments for services. However, 

ACA is expected to have an impact on 

the coordination of care for dual eligible 

Veterans. As such, VA must understand its 

dual eligible Veterans in light of the changing 

health care environment. The ACA contains 

several provisions intended to improve care 

for dual eligible beneficiaries through better 

coordination of care, improved quality 

measures, and increased access to home and 

community-based long-term care services.2, 3

Initial Analyses and Findings

To better understand dual and triple eligibles 

among enrolled Veterans and to identify 

potential policy and program interventions 

for these Veterans, the VHA Office of Policy 

and Planning conducted several analyses. 

Medicare and Medicaid claims data from fiscal 

year 2006 was merged with VA utilization 

data to identify dual/triple system users. 

Based on their health care utilization in FY 

2006, Veterans were classified into seven 

distinct user groups in order to compare 

the demographic characteristics, geographic 

distribution, and the morbidity/mortality of 

Veterans in these different user groups with 

a particular focus on those in the following 

dual/triple user groups: (1) VHA and 

Medicare; (2) VHA and Medicaid; and (3) 

VHA, Medicare, and Medicaid.

Demographic characteristics. Medicaid use was 

associated with being female and being of 

a younger age, on average, when compared 

to Medicare or VHA use. One-fifth of 

Medicaid only users were female compared 

to one-tenth of VA only users and onetwentieth of Medicare only users. Medicare 

users were older on average than individuals 

FORUM

Translating research into quality health care for Veterans

Commentary

The Impact of the Affordable Care Act on 

VA’s Dual Eligible Population

Patricia Vandenberg, M.H.A., Gita Uppal, M.P.H., FACHE, Amyre Barker, M.P.H., 

and Duane Flemming, P.M.P., VHA Office of the Assistant Deputy Under Secretary 

for Health for Policy and Planning, VA Central Office

 May 2013

Contents

What We Need to Know about 3 

Dual Use 

Quality Consequences of 4 

Medicare-VA Dual Use 

Health Information Exchange 5 

in the VA 

Dual Use in Colon Cancer 6

Outpatient Care Seeking by 7 

Medicare-Eligible Veterans 

2013 Under Secretary’s Award 8

for Outstanding Achievement 

A publication of the VA Office of Research & 

Development, Health Services Research & Development 

Service, Center for Information Dissemination 

and Education Resources, in conjunction with 

AcademyHealth. For past issues of FORUM, please visit 

www.hsrd.research.va.gov/publications/forum.
who used VHA and/or Medicaid. The

average age for Medicare only users was

75.1 years compared to 56.2 years for

VHA only and 49.8 years for Medicaid

only. Medicare-Medicaid-VA triple users

and Medicare-Medicaid dual users had the

highest mortality rates (47.9 percent and

57.7 percent, respectively) of all the cohorts

studied. VHA only users had the lowest

reported mortality rate (10.7 percent).

Geographic distribution. In 2006, Medicare-VA

users were concentrated in California,

Texas, Pennsylvania, New York, Illinois,

Ohio, North Carolina, Michigan, Missouri,

Indiana, Georgia, and Tennessee.

Medicaid-VA users were concentrated

in New York, Pennsylvania, Tennessee,

Florida, and Ohio.

Diagnostic picture. Overall, diabetes mellitus

was the most common diagnosis among

Veterans with a prevalence of 24.2 percent.

Heart disease was the second most common

diagnostic category (22.3 percent), followed by

lung disease (16.6 percent), neoplasms (14.0

percent), and vascular disorders (11.6 percent).

Although prevalence rates varied among

types of users (for example, the combined

prevalence for Medicaid only users was 17.4

percent compared to 83.4 percent among users

of all three systems), diabetes and heart disease

were each among the five most prevalent 

diagnoses for all seven cohorts. The prevalence

of psychiatric and substance use disorders

is higher among Veterans who use Medicaid

and/or Medicare in addition to VHA services

than those Veterans who used only VHA

services.

Our findings indicate that Veterans who 

received care exclusively from VA had better

health profiles than their dual or triple eligible 

users. Since VA serves a large number of

dual and triple eligibles, this represents an

opportunity for VA to enhance service delivery

and improve care coordination for these

socially and clinically complex patients.

There remain a number of unknowns

regarding exactly how ACA will be

implemented in terms of the health

insurance marketplaces and Medicaid

expansion. States are still deciding whether

they will expand Medicaid eligibility but

a number of states are indeed opting to

expand and receive the additional federal

funds for these newly eligible beneficiaries. 

Except for those individuals who, if

otherwise eligible, seek the premium tax

credit to defray the cost of insurance

premiums, VA will continue to have a

population of dual eligibles even after ACA

is implemented in 2014. The VHA Office of 

Policy and Planning will continue its efforts

to analyze the impact of ACA on VA’s dual

and triple eligible population in order to

improve the quality and continuity of care

for our Veterans.

References

1. Kizer, K.W. “Veterans and the Affordable Care

Act,” Journal of the American Medical Association 2012;

307(8):789-90.

2. Kaiser Family Foundation. Affordable Care

Act Provisions Relating to the Care of Dually

Eligible Medicare and Medicaid Beneficiaries. May 

2011. Available at www.kff.org/healthreform/

upload/8192.pdf.

3. Mechanic, D. “Seizing Opportunities under the

Affordable Care Act for Transforming the Mental

and Behavioral Health System,” Health Affairs 2012;

31(2):376-82.

FORUM — Translating research into quality health care for Veterans 2

Director’s Letter

Change is good, but too much change can be disorienting and

demoralizing. After almost two years of important, and I think

necessary, changes in HSR&D—the initiation of CREATEs and the

transition of our Centers to COINS—I am thrilled to have been

appointed as the new Director of HSR&D to continue some of

the initiatives begun under Seth Eisen. I hope over the next year,

while continuing to consolidate the changes we have made, also

to restore some of the stability that is necessary for an organization to function effectively and move ahead. I have described the changes we undertook in HSR&D as

a “course correction” as opposed to an about-face, and the sailing analogies from

my childhood with my grandfather on Buzzards Bay still seem apt. After changing

course (“coming about”) in a sailboat, there is always that period where one waits

for the sails to refill and for the boat to begin to move again. If I lost patience too

soon, and started pulling the tiller one way or the other trying to find a slightly better

breeze, I often found the boat dead in the water with the sail flapping in the wind.

I am confident we are headed on a course that has aligned our research with the

needs of the VA and Veterans and that will result in greater impact of our research.

From five years in HSR&D I know I can trust the soundness of our research centers

and all of our field investigators—our “boat” and “crew.” They will do the equivalent

of trimming the sails and handling the occasional squall (IT anyone?). But I can

already feel our “boat” beginning to pull through the water and pick up speed. Just

keep an eye out for pirates.

David Atkins, M.D., M.P.H., Director, HSR&D

VA Office of Research & Development, Health Services Research & Development Service May 2013
VA Office of Research & Development, Health Services Research & Development Service May 2013

As noted in the article by Pat Vandenberg 

et al., about a third of Veterans cared for 

by the VA also gets care outside of the VA, 

usually from private Medicare providers. 

Receiving care from two separate systems is 

not ideal in today’s health care environment 

(for reasons described in other papers in this 

issue) but it represents the willing choice of 

those Veterans and is thus not likely to go 

away. We need to understand this population and the care they seek for a number of 

reasons: first, to ensure that their current and 

future needs are met; and, second, to predict 

future demands on VHA resources. 

Patterns of Dual Use Care 

The research we need to guide practice and 

policy falls into at least three general areas. 

The first area is to understand at a macro 

level the patterns of dual use so that we 

can better forecast the future needs of the 

population for which we care. As the analysis from the Office of Policy and Planning 

indicates, broad patterns of dual use are 

influenced by the age and gender mix of the 

Veteran population, their geographic distribution (rural vs. urban), their health care 

needs, and external factors such as the state 

of the economy and availability of insurance. All of these factors are changing, some 

dramatically. The demobilization of large 

numbers of active-duty military and impending reductions to the defense budget will 

create a large new cohort of Veterans, many 

of them living in rural areas. The implementation of the Affordable Care Act and Medicaid expansion may provide alternatives to 

VA care for many poorer Veterans. 

Some forces will increase the number of 

eligible Veterans who seek care outside the 

VA (especially those that increase health care 

coverage options for Veterans) and some will 

decrease it (a slow economy with a population 

of Veterans whose needs are not well met in the 

private sector). We need to be able to forecast 

these trends more reliably or we will risk either 

building capacity we don’t need or being unable 

to meet the demand that develops. 

“We need to understand this 

population and the care they seek for 

a number of reasons: first, to ensure 

that their current and future needs are 

met; and, second, to predict future 

demands on VHA resources.” 

Influences on Dual Users

The second area of research is understanding at 

a micro-level the factors that influence a duallyeligible Veteran to seek care in the VA but to 

turn outside of the VA for certain aspects of 

that care. There will always be Veterans who 

seek acute care at private hospitals because they 

live too far from the nearest VAMC. But other 

instances of dual use reflect preferences that are 

amenable to change, i.e. a decision that the private provider offers better access, convenience, 

experience of care, or technical quality. The 

substantial investment the VA is making to promote access in rural areas, expand telehealth, and 

improve specialty access may reduce the number 

of Veterans who seek out local specialists. At the 

same time, by better understanding the choices 

our Veterans are making and why, we will improve our decision making as to investments 

that would increase the proportion of times the 

patient chooses VA for their care. 

Effects of Dual Use on Quality 

A third critical area, which has been the emphasis of much of the limited research on dual use 

to date, is to examine the effects of dual use on 

quality. If Veterans receiving dual care had identical health outcomes to those getting all their care 

in the VA, the issue would be one simply of cost 

and convenience. Unfortunately, studies such as 

those by Pizer, et al. suggest dual use is associated with worse outcomes. While we can guess at 

reasons this might be so, we actually don’t know 

the exact mechanisms by which dual use produces worse outcomes and, more importantly, 

how to mitigate them. Is it, as is often assumed, a 

result of poor communication and missed handoffs as patients traverse two independent health 

systems? Or is it related to more complex factors 

of patient activation and engagement, which 

may be diminished by fragmented care? The answers matter because the solutions are different. 

To the extent that poor outcomes are a result of 

miscommunication between clinicians or with 

patients, interventions such as regional information exchanges, medication reconciliation, and 

the Blue Button feature of MyHealtheVet may 

gradually improve things. But if the underlying 

problem is that a Veteran feels less connected 

to care, and thus less involved in effective selfmanagement, because his or her clinicians are 

not all on one team, the solutions are much more 

challenging. A principal notion behind the VA 

investment in Patient Aligned Care Teams was 

to have a “medical home” that would coordinate 

comprehensive care. How does one recreate the 

benefits of “home” for a patient commuting between two residences? 

One challenge for initiatives targeting these Veterans is that dual use can make the VA “business 

case” more complicated. If VA develops a successful program that improves coordination and 

reduces hospitalization in dual users, the savings 

may accrue to Medicare rather than to VA. There 

is no shortage of interesting questions for researchers to tackle and HSR&D is committed to 

building the knowledge needed to improve the 

care for this important and growing population. 

Moreover, the lessons we learn are likely to help 

us improve communication, coordination, and 

engagement for all of our patients. 

Response to Commentary

What We Need to Know about Dual Use

David Atkins, M.D., M.P.H., Director, HSR&D, Washington, D.C.

FORUM — Translating research into quality health care for Veterans 3
Over half of VA enrollees are dually enrolled in 

Medicare.1 Veterans who are dual Medicare enrollees include about 40 percent of Veterans in 

the highest priority groups—those with serviceconnected disabilities—and higher percentages in lower priority groups. Dually-enrolled 

Veterans frequently obtain health services from 

VA and Medicare in the same year, typically 

relying on VA for less than 40 percent of their 

outpatient care. When they need inpatient care, 

these Veterans are more than four times as likely 

to rely on Medicare as they are to rely on VA.2

These basic facts imply that VA costs are much 

lower than they would be if dual enrollees relied exclusively on VA for care. They also imply 

that the quality of VA care might be suffering 

because VA clinicians may have difficulty coordinating care and exchanging information with 

non-VA providers across the boundary between 

VA and non-VA networks.

To investigate the impact of dual use on quality of care, we combined VA utilization records 

with Medicare claims data and studied the relationship between fragmentation of care across 

the two systems and the likelihood of experiencing a hospitalization for an ambulatory care sensitive condition (ACSC).3

 These hospitalizations 

have been widely used to assess the quality of 

outpatient care in geographic regions. Because 

inpatient admissions are costly, they are also an 

important measure of inefficient resource use. 

Fragmentation Study 

Our research database contained 288,000 

observations on dually-enrolled Veterans with 

Medicare and/or VA outpatient use in 1999 

and 2000. We counted outpatient visits in 

each system by six-month periods and then 

characterized the degree of fragmentation of 

care for each patient in each period as one 

minus the percentage of the patient’s outpatient care provided by the VA or the percentage provided by Medicare, whichever was 

larger. This formula implies that a Veteran 

relying exclusively on either VA or Medicare 

would have a fragmentation measure equal to 

zero (1-1=0). The maximum degree of fragmentation possible is 0.5, arising if the Veteran evenly divided his or her outpatient visits 

between the two systems (1-0.5=0.5). 

We related this measure of fragmentation to 

the probability of experiencing a hospitalization for an ACSC, as defined by the Agency 

for Healthcare Research and Quality. ACSC 

hospitalizations consist of 13 types of adult 

admissions thought to be potentially preventable through high quality outpatient care. 

The most common ACSC admissions in the 

VA population are those for congestive heart 

failure (CHF), chronic obstructive pulmonary 

disease (COPD), dehydration, urinary tract 

infection (UTI), long-term complications of 

diabetes, and pneumonia. We risk adjusted 

this relationship by controlling for the age 

and priority status of each Veteran as well 

as 30 co-morbidities defined by ICD-9-CM 

codes recorded in the period before measuring for fragmentation and outcomes.

This analysis was complicated by the fact that 

patient health or behavior that is unobservable 

to the researcher may affect fragmentation and 

ACSC hospitalization. For example, a patient 

with poor self-care skills might need frequent 

outpatient visits in both systems to address 

minor problems; this patient might also experience ACSC hospitalizations when more serious 

problems develop. In this example, fragmentation of care does not necessarily cause hospitalizations, instead, poor self-care causes both 

fragmentation and hospitalizations. 

To address this methodological challenge, 

we used an instrumental variables statistical 

model constructed in two stages. The first 

stage predicted the degree of fragmentation 

of care for each Veteran as a function of the 

distance between that Veteran’s residence and 

the nearest VA Medical Center. The second 

stage estimated the relationship between the 

predictable component of fragmentation and 

the probability of ACSC hospitalization. 

Results and Implications

Our estimates indicated that the degree of 

fragmentation of outpatient care between 

VA and Medicare had a strong and statistically significant effect on the probability of 

hospitalization for an ACSC. A one-standard 

deviation change in fragmentation was associated with a 20 percent change in hospitalization rates. The instrumental variables 

statistical technique allows us to infer a causal 

relationship more confidently than we could 

from a simpler observational design, but the 

inference is not as strong as it would be with 

a randomized experiment. 

These results imply that VA and Medicare are 

spending substantial resources on inpatient 

care for Veterans who could be managed 

more efficiently and more effectively if their 

care were better coordinated. Several initiatives are currently being implemented by VA 

management to facilitate sharing of electronic 

medical records between VA and non-VA 

health plans and facilities. These efforts have 

the potential to reduce the harm from fragmentation. In addition, the reorganization of 

VA primary care to emphasize continuity and 

comprehensiveness of care from a patientcentered team has the potential to reduce 

fragmentation itself. With initiatives like 

these, VA managers have a rare opportunity 

to save money while simultaneously improving the quality of care for a particularly vulnerable population of Veterans.

References 

1. 2010 Survey of Veteran Enrollees’ Health and Reliance 

Upon VA. Assistant Deputy Under Secretary for Health 

for Policy and Planning. Washington, DC: U.S. Department of Veterans Affairs, July 2011.

2. Quality Initiative Undertaken by the Veterans Health 

Administration. Washington, DC: Congressional Budget 

Office, August 2009.

3. Pizer, S.D. and Gardner J.A. “Is Fragmented Financing 

Bad for Your Health?” Inquiry 2011; 48:109-122.

FORUM — Translating research into quality health care for Veterans 4

VA Office of Research & Development, Health Services Research & Development Service May 2013

Research Highlight

What are the Quality Consequences of 

Medicare-VA Dual Use? 

Steven D. Pizer, Ph.D., Health Care Financing and Economics, VA Boston 

Healthcare System, Boston, Massachusetts
VA Office of Research & Development, Health Services Research & Development Service May 2013

FORUM — Translating research into quality health care for Veterans 5

Although the VHA is a large integrated 

health care delivery system, no system of 

health care is closed. Many patients receive 

care or undergo procedures not only in the 

VA but in other medical institutions, such as 

academic medical centers, community-based 

hospital systems, free-standing clinics, laboratories, and pharmacies. In 2009, 50 percent of Veterans with Medicare Advantage 

received both VA and Medicare Advantage 

services. What happens when providers 

need information about care received by 

their patients in other institutions?

Health information exchange (HIE) enables 

information about patients to flow among 

a network of institutions with trust agreements and standards about how to share 

data. Under the Centers for Medicare & 

Medicaid Services (CMS) Stage 2 meaningful use requirements, eligible providers and 

hospitals must electronically transmit care 

summaries for at least 10 percent of their 

patient transfers or referrals. Providers may 

use standardized document formats, such as 

a Continuity of Care Document, to summarize a patient’s status. Allergies, medications, 

plans of care, procedures, immunizations, 

notes, discharge summaries, and advance 

directives can all be exchanged using the 

eHealth Exchange, which is a set of national 

standards, services, and policies that enable 

secure HIE via the Internet. Health information organizations, which operate mostly 

at regional levels, oversee HIE, facilitate 

systems’ interoperability and security, and 

ensure authorized purpose of use among 

those who access information. In 2009, 

the United States had about 88 operational 

health information organizations.

In 2009, President Obama announced the Virtual Lifetime Electronic Record (VLER) project, to aid the transition of patients and their 

administrative and medical records, starting 

with military service. VLER Health works with 

community partners in pursuing the interoperability of health information systems, including 

VA and DoD systems. More than a dozen VA 

medical centers have participated in a VLER 

HIE pilot that allows bi-directional exchange of 

health information about Veterans between the 

VA and its community partners in those cases 

when a patient is receiving care from both. Initial program sites include San Diego, Hampton, 

Puget Sound, Spokane, Altoona, Asheville, Buffalo, Charleston, Grand Junction, Indianapolis, 

Minneapolis, Richmond, and Salt Lake City; 

several of these pilot sites encompass both 

VA and DoD facilities. Through its graphical 

user interface, VistA Web makes information 

from the local VAMC, remote VA facilities, and 

partnering community-based facilities available 

to VA clinicians, for those Veterans who have 

consented to participate in this program. More 

than 68,000 Veterans have already authorized 

the VA to share their health information among 

VA and non-VA facilities. In some cases, the 

HIE partner requires its own additional consent 

from patients.

Evidence and Impact of HIE

What do we know about the impact of HIE on 

care? A study of 32,468 emergency encounters 

in Indiana showed that charges decreased by up 

to $26 per encounter.1 Another study of 25,952 

patients in Tennessee showed that a city-based 

HIE could save more than $1 million in a year, 

primarily due to a reduction in hospital admissions.2

 Many patients are supportive of HIE: 

a 2012 New York survey showed that twothirds are comfortable with automatic central data storage, and more than 90 percent 

indicated that a primary care doctor should 

have emergency access to records without 

permission.3 We also know that the usability of computer systems that display and 

manipulate HIE data for clinicians is likely 

linked with adoption and satisfaction with 

these systems.

Through an HSR&D IIR grant, investigators 

at the Richard L. Roudebush VA Medical 

Center are working with its facility’s administration and the region’s health information 

organization, the Indiana Health Information 

Exchange, to study outcomes of the VLER 

Health Initiative pilot in Indianapolis. This 

study aims to assess the proportion and predictors of health care received by Veterans 

outside the VA, to assess the impact of HIE 

upon quality of care received by Veterans, 

and to explore whether HIE is reducing 

health care costs for Veterans. Potential 

outcomes of HIE include improvements in 

the quality of ambulatory care, reductions in 

admission rates for ambulatory care-sensitive 

conditions, and reductions in other types of 

avoidable services. 

HIE is technically achievable, and incremental 

implementation is recommended. HIE has 

shown early promise in improving important 

measures of health care, and the VA’s program is now being studied. Care delivered 

across institutions is the reality in our mobile 

society. As the scope of HIE’s activity grows 

nationwide, health services researchers should 

consider how to expand the evidence base to 

understand more fully how HIE can increase 

the value of health care delivered to Veterans.

References

1. Overhage, J.M. et al. “A Randomized, Controlled 

Trial of Clinical Information Shared from Another 

Institution,”Annals of Emergency Medicine 2002; 

39(1):14-23.

2. Frisse, M.E. et al. “The Financial Impact of Health Information Exchange on Emergency Department Care,” 

Journal of the American Medical Informatics Association 2012; 

19(3):328-33.

3. Dhopeshwarkar, R.V. et al. “Health Care Consumers’ 

Preferences Around Health Information Exchange,” The 

Annals of Family Medicine 2012; 10(5):428-34.

Research Highlight

Health Information Exchange in the VA

Michael Weiner, M.D., M.P.H. and David A. Haggstrom, M.D., M.A.S., both with 

HSR&D’s Center of Excellence on Implementing Evidence-Based Practice, Richard L. 

Roudebush VA Medical Center, Indianapolis, Indiana

 
FORUM — Translating research into quality health care for Veterans 6

VA Office of Research & Development, Health Services Research & Development Service May 2013

Approximately 175,000 patients receive cancer 

care each year from the VA health care system. 

Among some Veterans, including those who live 

in urban areas with many health care options 

or who have a high comorbidity burden, dual 

use of VA and Medicare services is substantial. 

Several recent studies suggest that patients might 

receive different and possibly duplicative cancerrelated services in the two settings.1

At the Center for Management of Complex 

Chronic Care based at the Hines VA Hospital, 

we have undertaken research on dual use of 

VA and Medicare in cancer. One study in particular focused on quality of care, survival, and 

costs in colon cancer (HSR&D IIR 03-196). 

The VA Information Resource Center (SDR02-237) provided support for this study. We 

conducted a retrospective cohort study linking 

data from eight National Cancer Institute Surveillance, Epidemiology, End Result (SEER) 

programs and the VA Central Cancer Registry 

(VACCR) with VA and Medicare claims data 

on Veterans aged 66 or older with colon cancer. Forty eight percent of the cohort received 

their cancer care predominantly from the VA, 

36 percent predominantly from Medicare, and 

13 percent used both systems for substantial 

portions of their cancer care. Overall, we 

tracked care for 3,949 Veterans diagnosed with 

colon cancer through 2004 and examined surgery and chemotherapy use, survival, and costs. 

Older Patients Receive Less 

Chemotherapy in Both Settings

In early work focused on colon cancer patients in California, we found similarities 

across those initially treated in VA settings 

compared to those initially treated in nonVA settings. However, we discovered that 

older patients were not receiving adjuvant 

chemotherapy at the recommended rate. 

The 601 Veterans with stage I to III colon 

cancer treated at VA and non-VA facilities 

experienced similar colectomy rates and stage 

III patients had similar odds of receiving adjuvant chemotherapy. In both settings, older 

patients had lower odds of receiving chemotherapy than their younger counterparts, even 

when race and comorbidity were considered.2

Differences in Survival in Dual 

Use versus Predominantly Single 

System Setting

We found differences in survival between predominantly dual users and predominantly single system users. When we compared 3-year 

overall and cancer event-free survival (OS, 

EFS) among patients with non-metastatic 

colon cancer who were dual users with those 

who were predominantly single system (VA or 

Medicare fee-for-service (FFS)) users, VA and 

non-VA users (all stages) had reduced hazard 

of dying compared to dual users. For EFS, we 

found similar stage I outcomes, whereas stage 

II and III VA users, but not non-VA users, 

had improved EFS. Improved survival among 

VA and non-VA users compared to dual users 

raises questions about coordination of care 

and unmet needs.3

Higher Colon Cancer Costs among 

Dual Users

We found significantly higher mean colon 

cancer-related costs over the first year after 

diagnosis among those who were dual users 

compared to those who used predominantly 

VA services or Medicare services. The cost 

of care for dual users of colon cancer treatment in our study was 14 percent greater 

than the cost for predominantly VA users, 

and 18 percent greater than that of predominantly Medicare users. The higher costs for 

dual users than for single-system users could 

reflect higher rates of fragmented and duplicative care among dual users. Furthermore, 

our research indicated higher costs among 

patients who were African American, had 

more comorbidities, were older, or had more 

advanced-stage disease. 

Although VA patients can be reassured that 

care is consistent with recommended guidelines, our findings signal potential concerns 

among patients with colon cancer who are 

dual users. In particular, efforts should be 

focused on exploring the apparent underuse 

of adjuvant chemotherapy among older Veterans with colon cancer. Greater understanding about the mechanisms of dual use is also 

important to determine causal and temporal 

relationships with subsequent health care 

use. Further research is recommended to 

understand the contribution of the possible 

causes of treatment variation: differences in 

unmeasured health status, patient preferences, 

physician communication or bias, and variations in provider or system quality. Research 

that seeks to explore and examine alternative 

care coordination options for cancer patients 

and that includes evaluation of VA and nonVA providers and consideration of mechanisms to facilitate improved care coordination 

across systems may offer potential avenues to 

achieve improved outcomes and costs. 

References

1. Keating, N.L. et al. “Quality of Care for Older Patients 

with Cancer in the Veterans Health Administration versus 

the Private Sector: a Cohort Study,” Annals of Internal 

Medicine 2011; 154(11):727-36.

2. Hynes, D.M. et al. “Surgery and Adjuvant Chemotherapy 

Use Among Veterans with Colon Cancer: Insights Using 

California SEER, Medicare and VA-linked Data,” Journal 

of Clinical Oncology 2010; 28:1-9.

3. Tarlov, E. et al. “Reduced Overall and Event-Free Survival Among Colon Cancer Patients Using Dual System 

Care,” Cancer Epidemiology Biomarkers & Prevention 2012; 

published online October 11, 2012. 

Research Highlight

Dual Use in Colon Cancer: What Have 

We Learned about Quality and Costs 

of Care? 

Denise M. Hynes, M.P.H., Ph.D., R.N., VA Information Resource Center (VIReC) 

and Center for Management of Complex Chronic Care (CMC3), located at the 

Edward Hines, Jr. VA Hospital, Hines, Illinois 
VA Office of Research & Development, Health Services Research & Development Service May 2013

FORUM — Translating research into quality health care for Veterans 7

Medicare-eligible Veterans are unique in being 

able to obtain care from two public health 

insurance programs (VA and Medicare) depending on convenience, relative prices, health 

care needs, availability of services and other 

factors. A significant proportion of Medicareeligible Veterans obtain outpatient or inpatient 

care in both systems, which can complicate 

continuity of care, care coordination, and 

medication management. Care that is fragmented due to dual use of VA and Medicare 

may result in under-use or over-use in services, which could adversely impact health 

outcomes of Veterans. Furthermore, VA performance metrics may be affected by missing 

non-VA services. 

Numerous studies have examined age-eligible 

Veterans’ use of inpatient services, but fewer 

studies have examined Veterans’ use of outpatient care or how utilization patterns change 

over time. This article summarizes findings 

from an examination of changes in VA and 

Medicare outpatient utilization in fiscal years 

(FY) 2001 through 2004 from a nationally 

representative sample of Medicare-eligible 

Veterans who used the Veterans Administration’s primary care services in FY2000.

VA Reliance by Type of Outpatient 

Care and Over Time

Medicare-eligible Veterans obtained more 

primary care from VA than from Medicare in 

2001 through 2004, but they obtained more 

specialty care from Medicare than from VA.1

These Veterans used much more specialty care 

than primary care, and their reliance on VA 

services declined consistently for both types of 

care. The number of VA primary care visits per 

person decreased from 2.4 in FY2001 to 1.9 in 

FY2004, whereas Medicare visits per person 

increased over time from 1.3 in FY2001 to 1.6 

in FY2004. The number of Medicare specialty 

care visits per person increased from 6.7 in 

FY2001 to 8.8 in FY2004, more than offsetting a modest decline in VA specialty care visits 

from 4.1 per person in FY2001 to 3.7 per person in FY2004. Medicare-eligible Veterans obtained most of their outpatient mental health 

services in VA in all years. 

For these patients, VA primary care providers 

are essentially co-managing dual users of VA 

and Medicare services with non-VA primary 

care providers. However, VA and non-VA 

providers currently lack clinical information 

that is integrated across health systems in 

order to co-manage effectively. The complexity of care coordination among VA and 

non-VA providers could present additional 

challenges as VA’s systemwide implementation of Patient Aligned Care Teams (PACT), a 

patient-centered medical home model, evolves 

to address the needs of these patients. Dual 

use also creates opportunities to develop and 

test care coordination initiatives within PACT. 

VA Reliance Differs by Type of 

Veteran

There are important variations in VA reliance by Medicare eligibility (age or disability) and usual source of primary care in VA 

(community-based outpatient clinic (CBOC) 

or VA medical center (VAMC)). Age-eligible 

and disability-eligible Veterans sought primary 

care and mental health care most commonly in 

VA, but these Veterans most often sought specialty care in both systems.2

 Disability-eligible 

Veterans were more reliant on VA for primary 

care, specialty care, and mental health care than 

age-eligible Veterans throughout FY2001-2004. 

Greater VA reliance for primary care and specialty care visits by disability-eligible Veterans is 

most likely related to their greater health needs. 

Veterans obtaining primary care at CBOCs 

used less VA primary care and specialty care 

over time than Veterans obtaining VAMCbased primary care, but used more primary 

care and specialty care covered by Medicare.3

By FY2004, many VAMC-based Veterans and 

most CBOC-based Veterans obtained at least 

some primary and specialty care outside the 

VA. Increasing access to VA primary care in 

community settings via CBOCs may unintentionally result in fragmented care arising from 

dual use of VA and Medicare services.

These analyses from 2001 through 2004 

showed that reliance on VA outpatient care 

decreased over time for Veterans of all types, 

particularly for primary care and specialty care. 

Unsurprisingly, Veterans obtaining mental 

health care relied on VA for such care. Research is needed to improve our understanding 

of whether reliance on VA has changed since 

the introduction of Medicare Part D in 2006. 

Most research to date on dual use of VA and 

non-VA services focuses on age-eligible Veterans in the Medicare fee-for-service program; 

additional subgroups of Medicare-eligible 

Veterans merit further examination, including 

Medicare Advantage enrollees, disability-eligible 

Veterans, and Veterans enrolled in Medicaid. 

Future research also needs to assess the impact 

of PACT on processes and outcomes of care 

for Medicare-eligible Veterans. 

The quality of research and subsequent 

policymaking related to dual users could be 

enhanced through a partnership between 

HSR&D and Operations; Operations is aware 

of the information gaps that need to be filled 

to improve decision-making, and HSR&D researchers have the measurement and methods 

expertise needed to fill these gaps.

References

1. Liu, C.F. et al. “Reliance on Veterans Affairs Outpatient 

Care by Medicare-eligible Veterans,” Medical Care 2011; 

49(10):911-17.

2. Liu, C.F. et al. “Use of Outpatient Care in VA and Medicare among Disability-eligible and Age-eligible Veteran 

Patients,” BMC Health Services Research 2012; 12(1):51.

3. Liu, C.F. 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 Services Research 2010; 45(5 Pt 

1):1268-86.

Research Highlight

Changes in Outpatient Care-Seeking by 

Medicare-Eligible Veterans 

Matthew L. Maciejewski, Ph.D., Center for Health Services Research in Primary Care, 

Durham VA Medical Center, Durham, North Carolina and Chuan-Fen Liu, Ph.D., 

M.P.H., Northwest Center for Outcomes Research in Older Adults, VA Puget Sound 

Health Care System, Seattle, Washington
Peter L. Almenoff, M.D., FCCP, 

Director of Operational 

Analytics and Reporting, Office 

of Informatics and Analytics, 

Washington, D.C.

David Atkins, M.D., M.P.H.,

Director, HSR&D

VA Central Office, 

Washington, D.C.

Cynthia Caroselli, Ph.D., R.N.,

Associate Director for Patient 

Services & Chief Nurse 

Executive, VA New York 

Harbor Health Care System, 

New York, NY

Martin P. Charns, D.B.A., 

Director, VA HSR&D Center 

of Excellence, Boston, MA

Seth A. Eisen, M.D., M.Sc., 

Past Director, HSR&D

VA Central Office,

Washington, D.C.

Joseph Francis, M.D., M.P.H., 

Director of Clinical Analytics 

and Reporting, Office of 

Informatics and Analytics, 

Washington, D.C.

Skye McDougall, Ph.D.,

Chief Medical Officer

VAMC Long Beach, 

Long Beach, CA 

Richard Owen, M.D., Director, 

VA HSR&D Center of 

Excellence, Little Rock, AR 

DeAnne M. Seekins, MBA, VA 

Medical Center Director, 

Durham, NC

Frances Weaver, Ph.D.,

Director, VA HSR&D Center of 

Excellence, Hines, IL

FORUM

Geraldine McGlynn, Editor-in-Chief

Margaret Trinity, Editor

Editorial Board

Hayden B. Bosworth, Ph.D., 

will receive this year’s Under 

Secretary’s Award for Outstanding Achievement in 

Health Services Research. 

The highest honor for a VA 

health services researcher, 

the award recognizes work 

that has met three key criteria: improved our 

understanding of factors that affect the health 

of Veterans and improved the quality of their 

care; contributed to the future of VA health services research by inspiring and training the next 

generation of investigators; and enhanced the 

visibility of VA research. 

Dr. Bosworth’s research focuses on three areas 

of significant importance to the care and health 

care of Veterans: 1) self-management in chronic 

care; 2) development of quality measurements to 

monitor and improve health care; and 3) translating research findings into clinical care practice. 

Over the past 15 years, his work has explored innovative approaches to improving outcomes for 

patients with chronic diseases, including hyperlipidemia, diabetes, osteoarthritis, and depression 

—all conditions that are prevalent among Veterans. His work has also helped to reduce health 

care disparities, particularly among individuals 

with low literacy, and under-represented groups 

such as African American and Women Veterans. 

Dr. Bosworth serves as Associate Director of 

HSR&D’s Center for Health Services Research 

in Primary Care in Durham, North Carolina, 

where he has also directed the local VA Office 

of Academic Affairs Ph.D. Post-Doctoral Fellowship program for the past 13 years. He is a 

developmental health psychologist and tenured 

Research Professor at the Duke University 

Medical Center, and is both a highly sought after 

mentor and prolific author.

Bosworth Receives 2013 Under Secretary’s Award for Outstanding 

Achievement in Health Services Research 

FORUM

Translating research into quality health care for Veterans

Center for Information Dissemination and Education Resources 

VA Boston Healthcare System (152C) 

150 South Huntington Avenue, Boston, MA 02130-4893

Organization

U.S. Postage

PAID

Permit No. 3999

Washington, DC AcademyHealth

1150 17th Street, NW Suite 600

Washington, DC 20036
Peter L. Almenoff, M.D., FCCP, 

Director of Operational 

Analytics and Reporting, Office 

of Informatics and Analytics, 

Washington, D.C.

David Atkins, M.D., M.P.H.,

Director, HSR&D

VA Central Office, 

Washington, D.C.

Cynthia Caroselli, Ph.D., R.N.,

Associate Director for Patient 

Services & Chief Nurse 

Executive, VA New York 

Harbor Health Care System, 

New York, NY

Martin P. Charns, D.B.A., 

Director, VA HSR&D Center 

of Excellence, Boston, MA

Seth A. Eisen, M.D., M.Sc., 

Past Director, HSR&D

VA Central Office,

Washington, D.C.

Joseph Francis, M.D., M.P.H., 

Director of Clinical Analytics 

and Reporting, Office of 

Informatics and Analytics, 

Washington, D.C.

Skye McDougall, Ph.D.,

Chief Medical Officer

VAMC Long Beach, 

Long Beach, CA 

Richard Owen, M.D., Director, 

VA HSR&D Center of 

Excellence, Little Rock, AR 

DeAnne M. Seekins, MBA, VA 

Medical Center Director, 

Durham, NC

Frances Weaver, Ph.D.,

Director, VA HSR&D Center of 

Excellence, Hines, IL

FORUM

Geraldine McGlynn, Editor-in-Chief

Margaret Trinity, Editor

Editorial Board

FORUM

Translating research into quality health care for Veterans

Center for Information Dissemination and Education Resources 

VA Boston Healthcare System (152C) 

150 South Huntington Avenue, Boston, MA 02130-4893

Organization

U.S. Postage

PAID

Permit No. 3999

Washington, DC

Hayden B. Bosworth, Ph.D., 

will receive this year’s Under 

Secretary’s Award for Outstanding Achievement in 

Health Services Research. 

The highest honor for a VA 

health services researcher, 

the award recognizes work 

that has met three key criteria: improved our 

understanding of factors that affect the health 

of Veterans and improved the quality of their 

care; contributed to the future of VA health services research by inspiring and training the next 

generation of investigators; and enhanced the 

visibility of VA research. 

Dr. Bosworth’s research focuses on three areas 

of significant importance to the care and health 

care of Veterans: 1) self-management in chronic 

care; 2) development of quality measurements to 

monitor and improve health care; and 3) translating research findings into clinical care practice. 

Over the past 15 years, his work has explored innovative approaches to improving outcomes for 

patients with chronic diseases, including hyperlipidemia, diabetes, osteoarthritis, and depression 

—all conditions that are prevalent among Veterans. His work has also helped to reduce health 

care disparities, particularly among individuals 

with low literacy, and under-represented groups 

such as African American and Women Veterans. 

Dr. Bosworth serves as Associate Director of 

HSR&D’s Center for Health Services Research 

in Primary Care in Durham, North Carolina, 

where he has also directed the local VA Office 

of Academic Affairs Ph.D. Post-Doctoral Fellowship program for the past 13 years. He is a 

developmental health psychologist and tenured 

Research Professor at the Duke University 

Medical Center, and is both a highly sought after 

mentor and prolific author.

Bosworth Receives 2013 Under Secretary’s Award for Outstanding 

Achievement in Health Services Research