External Determinants of Non-Elderly Veterans' Demand of VA Health Care

美国医疗保健系统（包括联邦和州医疗保险）的快速变化环境 改革，增加自付费用，增加覆盖范围限制，可能会影响退伍军人使用VA 保健在2010财年，780万登记的退伍军人中约有30%接受了外部护理， 或者说，不寻求关怀。虽然人们对医疗保险的双重覆盖范围给予了关注，但对 非老年退伍军人（年龄< 65岁）中的非VA医疗保健使用，占所有 一般不被医保覆盖的参保者。仔细研究关键的外部因素对于更好地 了解VA医疗保健需求的区域差异以及主要持续和 公共和私营医疗保健部门的预期举措，如2010年的患者保护和 平价医疗法案（ACA）。特别重要的是低收入退伍军人，他们占VA的60%。 医疗保健注册，以及其医疗保健使用可能对自付费用增加最敏感， 其他保险的可用性、经济因素和供应商的可用性。我们建议的研究将解决这一问题 通过开发一个国家模型来估计非老年人VA需求的敏感性， 退伍军人的一系列外部因素，包括公共援助的无保险（医疗补助），自付 非VA护理成本，经济环境（失业）和非VA提供者可用性。 对于登记参加VA医疗保健的退伍军人，VA需求将通过总价值（$）和 VA医疗保健服务使用。数据将从VA管理数据库中获取，涵盖住院患者 护理、门诊和处方药（2008-2014财年）。对于有医疗补助和/或医疗保险的退伍军人 覆盖率，我们将使用非VA护理的数据来检查对VA的依赖（即，在VA中获得的总护理份额）。 关于外部决定因素计量的数据，分为四个不同的领域-公共政策、非脆弱性和适应性 患者成本、经济环境和当地非VA提供者的可用性将从一系列 患者和地区级二级数据源。我们将量化扩展模型的改进， 预测VAMC和VISN的资源使用。我们将测试三个地区需求的系统性差异， VA使用可能对外部因素特别敏感的高优先级亚群-农村居民， 少数种族/族裔和妇女-住院和门诊服务组合不同的临床队列： 糖尿病、充血性心力衰竭（CHF）、严重精神疾病和癌症。在准实验环境中 的马萨诸塞州卫生改革，我们将评估其对VA的需求和依赖的影响。作为次要目标， 我们将在2014财年评估ACA保险扩展对VA注册和利用的早期影响。 我们的主要目的是（1）发展一个基本模型的VA卫生保健需求和依赖调整为病人 案例组合，（2）扩展基础模型，包括外部决定因素的措施，（3）应用扩展的 模型，以检查农村居民，种族/少数民族，妇女， 评估马萨诸塞州卫生改革对退伍军人需求的影响， 靠山 拟议的研究回应了退伍军人事务部的战略倡议，即“预测和积极准备的需要， 退伍军人通过开发工具、分析方法、数据源和预测流程等 建模、预测、商业智能和数据挖掘。“我们与联合国人权事务高级专员办事处合作， ADUSH for Policy and Planning and Office of Productivity，Efficiency and Staffing（OPES），以告知当前 用于预算编制、资源规划和制定协议的业务模式 医生和人员配备的生产率标准（即，面板尺寸）。

The rapidly changing environment of the U.S. health care system, including federal and state health insurance reforms, rising out-of-pocket costs, and increased coverage limitations, is likely to impact Veterans' use of VA health care. In FY2010, approximately 30 percent of the 7.8 million enrolled Veterans, received care outside the VA or sought no care. While attention has been paid to dual coverage from Medicare, little is known about non-VA health care use among the non-elderly Veterans (age < 65 years), who comprise 55 percent of all enrollees generally uncovered by Medicare. A careful examination of key external factors is critical to better understand regional variations in VA health care demand and the potential impact from major ongoing and anticipated initiatives in the public and private health care sectors, such as the 2010 Patient Protection and Affordable Care Act (ACA). Of particular importance are low-income Veterans who comprise 60 percent of VA health care enrollment, and whose health care use may be most sensitive to out of pocket cost increases, availability of other insurance, economic factors and provider availability. Our proposed study will address this knowledge gap by developing a national model to estimate the sensitivity of VA demand for non-elderly Veterans to a range of external factors, including public assistance for uninsured (Medicaid), out-of-pocket costs for non-VA care, economic environment (unemployment) and non-VA provider availability. For Veterans enrolled for VA health care, VA demand will be measured by the total value ($) and volume of services of VA health care use. Data will be obtained from VA administrative databases covering inpatient care, outpatient visits and prescription drugs (FY 2008-2014). For Veterans with Medicaid and/or Medicare coverage, we will use data on non-VA care to examine reliance on VA (i.e., share of total care obtained in VA). Data on measures of external determinants, categorized into four distinct domains -- public policy, non-VA patient costs, economic environment, and local non-VA provider availability will be obtained from a range of patient- and area-level secondary data sources. We will quantify the improvement of the expanded model in projecting resource use by VAMC and VISN. We will test for systematic differences in demand across three high priority subpopulations whose VA use might be especially sensitive to external factors - rural residents, racial/ethnic minorities and women - and clinical cohorts with differing mix of inpatient and outpatient services: diabetes, congestive heart failure (CHF), serious mental illness and cancer. In the quasi-experimental setting of Massachusetts health reform, we will evaluate its impact on VA demand and reliance. As a secondary aim, we will evaluate the early impact of ACA insurance expansion on VA enrollment and utilization in FY2014. Our main aims are to (1) develop a base model of VA health care demand and reliance adjusted for patient case-mix, (2) extend the base model to include measures of external determinants, (3) apply the extended model to examine differential VA demand and reliance among rural residents, racial/ethnic minorities, women, and low income Veterans, and (4) evaluate the impact of Massachusetts health reform on VA demand and reliance. The proposed study responds to VA's strategic initiative to "anticipate and proactively prepare for the needs of Veterans" by the "development of tools, analytical methods, data sources, and processes, such as predictive modeling, forecasting, business intelligence and data mining." We have partnered with the Office of the ADUSH for Policy and Planning and Office of Productivity, Efficiency and Staffing (OPES) to inform current operations models used for budget formulation, resource planning and the development of protocols for productivity standards for physicians and staffing (i.e., panel size).