标题：Use of Preventive Care by Elderly Male Veterans Receiving Care Through the Veterans Health Administration, Medicare Fee-for-Service, and Medicare HMO Plans
摘要：Objectives. We compared use of preventive care among veterans receiving care through the Veterans Health Administration (VHA), Medicare fee-for-service (FFS) plans, and Medicare health maintenance organizations (HMOs). Methods. Using both the Costs and Use, and Access to Care files of the Medicare Current Beneficiary Survey (2000–2003), we performed a cross-sectional analysis examining self-reported use of influenza vaccination, pneumococcal vaccination, serum cholesterol screening, and serum prostate-specific antigen measurement among male veterans 65 years or older. Veterans’ care was categorized as received through VHA, Medicare FFS, Medicare HMOs, VHA and Medicare FFS, or VHA and Medicare HMOs. Results. Veterans receiving care through VHA reported 10% greater use of influenza vaccination ( P <.05), 14% greater use of pneumococcal vaccination ( P <.01), a nonsignificant 6% greater use of serum cholesterol screening ( P =.1), and 15% greater use of prostate cancer screening ( P <.01) than did veterans receiving care through Medicare HMOs. Veterans receiving care through Medicare FFS reported less use of all 4 preventive measures ( P <.01) than did veterans receiving care through Medicare HMOs. Conclusions. Receiving care through VHA was associated with greater use of preventive care. The Veterans Health Administration (VHA) is the largest integrated public-sector health care system in the United States. 1 Under a set of reforms in 1995 that emphasized increased use of information technology, performance measurement, and service integration, VHA has become a leader in delivering high-quality care to veterans. 2 – 6 One comprehensive cross-sectional study of 596 VHA patients and 992 community patients (older than 35 years) between 1997 and 2000 found that veterans treated at VHA scored significantly higher for overall quality of care, chronic disease care, and preventive care. 7 Previous research has also demonstrated that Medicare health maintenance organizations (HMOs) are superior to Medicare fee-for-service (FFS) plans in delivering preventive care to patients. 8 Medicare HMOs can use health care management techniques such as performance measurement, data analysis, and care coordination to improve the efficiency and quality of care delivered to patients. 9 , 10 There are few studies, however, that have compared Medicare HMOs and VHA. 11 , 12 Only 1 study to date has compared the quality of care delivered by VHA to the care delivered by high-performing commercial managed-care programs. 11 That study, which focused on diabetes, found that diabetes-related processes of care (e.g., eye examination and hemoglobin A1C measurement) and 2 intermediate outcomes (targets for hemoglobin A1C and low-density lipoprotein cholesterol) were more likely to be achieved for patients cared for in the VHA system than for patients cared for in commercial managed-care plans. In contrast to VHA, in which the strides in quality improvement have been relatively uniform across the 21 different Veterans Integrated Service Networks, there is large variation in the quality of care delivered by Medicare HMOs plans. 13 This variation may be because of different organizational characteristics among plans. A plan can be structured as a staff-model organization, in which the plan owns the hospital and physicians are salaried, or as a loose financial arrangement between multiple providers in unrelated practice settings. 10 , 13 Previous research has identified 4 factors in high-performing managed-care programs that lead to the delivery of high-quality care: (1) a strong working relationship with the plan’s physicians; (2) quality-focused leadership, culture, and values; (3) a high-quality physician practice base in the delivery system; and (4) an emphasis on the use of data and analysis in clinical improvement. 10 , 14 VHA has all 4 of these characteristics. It has strong local practice leadership, with emphasis on performance measurement and quality improvement; strong relationships with academic medical centers, which creates a high-quality physician practice base; and an electronic health record that facilitates use of data for clinical improvement. VHA is in effect a large managed-care organization caring for over 5 million veterans across the country. 1 , 15 Our primary objective was to use pooled data on veterans from the Medicare Current Beneficiary Survey (MCBS) to compare the preventive care delivered to veterans in VHA with care delivered to veterans by Medicare HMO and FFS plans. Many elderly veterans, however, are eligible to receive care from both Medicare and VHA and can also use both programs simultaneously (dual users). Therefore, we also compared the preventive care received by veterans through dual use of these sources with care received through Medicare HMO plans. We focused on measures of preventive care because these measures have an important role in reducing morbidity and mortality in the elderly. 16 – 19
