Original Research

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

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

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.

Discussion

In order to better understand comanagement of dual-use patients, this study focused on the experiences and perceptions of staff at VHA primary care clinics in the upper Midwest. The data indicated that:

VHA clinical staff perceive the primary reason patients choose to seek non-VHA care is because of access, convenience, and
distance
In order for comanagement to occur, communication and information exchange—currently facilitated largely by patients—needs to improve
Education of patients and their non-VHA providers is recommended, to increase understanding of rules and regulations tied to exchange of patient information across health care systems
Education may facilitate communication, develop relationships, and overcome barriers to information exchange

Distance to health care and perceived convenience were clearly seen by clinic staff as the driving factors behind their patients’ dual use. In the authors’ prior work, interviews with veterans and their VA providers supported this assertion as well; however, it was also found that distance must not be understood in isolation of other contingencies, such as urgency of need.⁴

Clinic staff identified institutional and individual barriers that lead to miscommunication and confusion on the part of patients and reported misunderstandings with non-VHA providers, including 3 potential barriers to comanagement. These included (1) inconsistent communication and flow of information between VHA and non-VHA providers; (2) uncertainty about who will (and should) be responsible for information flow between providers; and (3) VHA and federal regulations over patient privacy. Throughout the interviews, access to less expensive prescription medications in VHA was considered an additional driver of dual use. According to clinic staff interviewed, education of patients and non-VHA providers could facilitate efficient and safe comanagement for dual-use patients.⁷

This study suggests both advantages and disadvantages for patients choosing to use multiple health care systems from the perspective of the clinic staff. The primary advantage is better overall health care access, especially for rural patients and those with longer travel times to VHA facilities. The primary disadvantage of dual use is discontinuity of care between multiple care sites. Specifically, this study identified concerns regarding poor communication between providers and transfer of patient medical records. An underlying theme was a concern for quality of care and patient safety, which are recognized by others in the literature as potential consequences of inadequate comanagement.^8-12

If there is one aspect of co-management for dual-use patients to target, this study’s findings point to developing strategies to improve communication between providers caring for dual-use patients and, more specifically, cultivating relationships that are currently underdeveloped. This will necessitate a clearer articulation of what constitutes a relationship between comanaging providers and is a direction for further research that would have applicability beyond VHA to any comanagement of patients using multiple health care systems.

There are 3 simultaneous, yet unrelated, factors that may contribute to increasing dual use. First is the rise in VHA eligible veterans from Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn.^13,14 All returning veterans who meet minimal requirements are eligible for 5 years of VHA health care. A large proportion of these individuals are in the Reserve and National Guard, most of whom have nonmilitary jobs that may provide employer-based health insurance. Thus, these veterans have a greater opportunity for dual use. Second, with the aging cohort of Vietnam-era veterans, a greater proportion is becoming Medicare eligible. Third, with the recent passing of the ACA, more patients, including veterans, may choose to purchase insurance through ACA health exchanges. Taken individually or collectively, these factors will likely have effects reaching beyond VHA, especially when veterans receiving care in non-VHA health care systems engage in dual use.^3,13,15,16

Limitations

This study has a number of limitations. First, it was limited to VHA facilities located in the upper Midwest, which may limit generalizability to other parts of the country. The convenience sample of clinic staff at VHA clinics may not represent the full range of perspectives among HCPs generally. This study did not interview clinic staff in non-VHA clinics, although this has been the focus of other studies.^17,18 Although dual use also applies to specialty care and related access issues in rural areas, this was not a focus of this study. Last, the data were collected in 2009, prior to the implementation of the patient-aligned care team (PACT) model and prior to the recently revealed issues regarding patient wait times for VHA care. Thus, perceptions may have changed, and additional study is needed.

Conclusions

The results of this study support prior assumptions of barriers to care, but also introduce previously unreported challenges. Dual use is perceived to have both positive and negative impacts, but for the positives to outweigh the negatives, thoughtful comanagement is critical. This may be particularly so in rural areas where dual use is encouraged as a way to overcome distance and increase convenience in accessing care.