Comparison of health outcomes for male seniors in the Veterans Health Administration and Medicare Advantage plans.

The Veterans Health Administration (VHA) is one of the largest integrated health care systems in the United States and provides health care to an aging veteran population (Ohldin et al. 2002). In 1995, VHA launched a major health care transformation by adopting managed care principles (Flynn, McGlynn, and Young 1997). It included the use of information technology, measurement and reporting of performance, and integration of services and realigned payment policies (Kizer, Demakis, and Feussner 2000). By 2000, the VHA performance as measured by processes of care was better than that in the Medicare fee-for-service (FFS) program and in commercial managed care plans (Jha et al. 2003; Asch et al. 2004;). However, whether this improvement has extended beyond processes of care and into patient outcomes has not yet been fully examined. The few studies that have compared patient outcomes in the VHA with other health care systems used data collected in the early stages of the VHA transformation. The evidence on health outcomes for the VHA is mixed. For example, using data from 1993 to 1996, Rosenthal, Kaboli, and Barnett (2003) found that the VHA had higher mortality rates after coronary artery bypass grafting when compared with private sector hospitals serving the same health care market. Landrum et al. (2004) found that elderly male veterans hospitalized for acute myocardial infarction in a VHA facility between October 1, 1996, and September 30, 1999, had higher mortality when compared with FFS Medicare patients. Studies that used data collected in the late 1990s found differences in risk-adjusted mortality that favored the VHA when compared with Medicare programs and private sector hospitals (Petersen et al. 2000; Selim et al. 2006; Vaughan-Sarrazin, Wakefield, and Rosenthal 2007;). These contrasting findings leave unresolved questions regarding how outcomes in the VHA compare to that in other systems. The answer is likely to depend on which systems of care are studied, whether one compares overall outcomes for patients or outcomes regarding particular health conditions, as well as the specific metrics that are used. In a prior study that used data collected between 1998 and 2000, we compared the VHA and the Medicare Advantage (MA) plans (Selim et al. 2007). This comparison was relevant because MA is a Medicare program that provides comprehensive health services to 4.6 million patients (12 percent of the Medicare population) through contracted private managed care organizations (MCOs) throughout the United States (Centers for Medicare and Medicare Services, HHS 2005). The MCOs are heterogeneous and we refer to them collectively as MA. We found that the adjusted probabilities of being alive with the same or better physical health at 2-years follow-up were comparable between the VHA and the MA (63.6 and 64.4 percent, respectively). The adjusted probability of being alive with the same or better mental health at 2-years follow-up in the VHA was significantly higher than in the MA; however, the magnitude of the difference was small (71.8 versus 70.1 percent, respectively). This cross-system comparison study was made at an early stage of the VHA transformation and was based on a limited number of patients. Given the continuing improvements in the VHA in the management of patients with chronic conditions (Asch et al. 2004; Kerr et al. 2004;), it is possible that the results would be different with the use of contemporary health outcome databases (Higashi et al. 2005). A study with a larger number of patients might also reveal differences in outcomes for certain vulnerable subpopulations that may be more susceptible to variations in quality of care, such as older patients, patients with multiple medical problems, or racial/ethnic minorities. In the present study, we sought to verify and extend the cross-system comparisons between the VHA and MA using more contemporary health outcome data and a larger number of patients. We gave special consideration to particular subpopulations that may be at the highest risk of poor health outcomes and in which the VHA has placed a special emphasis on improving care (Asch et al. 2006).