摘要：Objectives . During the mid-1990s, the Veterans Health Administration (VHA) reorganized and placed greater emphasis on high-quality primary care. To determine whether the reorganization was associated with changes in patterns of out-patient VHA use, we sought to evaluate changes in characteristics of veterans who use VHA outpatient services between 1992 and 2000. Methods . We merged 2 waves of the National Survey of Veterans to determine changes in patterns of outpatient care use. We evaluated the extent to which veterans who received outpatient care received that care from the VHA. Results . The odds ratio for VHA-only outpatient care relative to non-VHA–only care in 2000 relative to 1992 was 1.75 (95% confidence interval [CI]=1.51, 2.04), and the odds ratio for dual relative to non-VHA-only care was 1.22 (95% CI=1.08, 1.37). Veterans who were older, had low incomes, and had no additional health insurance coverage were most likely to increase their use of VHA outpatient care. Conclusions . Our results suggest that the VHA is increasingly serving veterans who have trouble accessing the private health care system. In the mid-1990s, the administrative structure and clinical priorities of the Veterans Health Administration (VHA) were reorganized to ensure predictable and consistent provision of cost-effective, high-quality care. Key elements of the reorganization included a universal primary care system for all veterans, eligibility reform, and a performance management program that assessed, among other areas, delivery of preventive care. 1 Evaluations of the VHA system since this reorganization indicate marked increases in provision of outpatient preventive and disease-specific care, as well as disease-specific decreases in urgent care visits, VHA bed days, and mortality. 2 , 3 In addition, the care provided by the VHA appears to be at least comparable to, if not better than, care provided outside of the VHA 2 , 4 However, these evaluations have focused solely on veterans accessing VHA care. During this same period, shifts in the health care landscape also were occurring outside the VHA. The number of Americans lacking health insurance coverage rose, and employers and insurance companies shifted more of the costs of providing care to individual consumers. 5 , 6 In addition, costs of medical care, drug costs in particular, continued to rise faster than costs in other sectors of the economy. 7 , 8 While all health care consumers were affected, specific groups were potentially more vulnerable to these changes, including those without medical insurance, low-income populations, the elderly, and those with heavy disease burdens. 9 One option available to veterans that is not available to other populations who have difficulty accessing or paying for care is the VHA. Part of the VHA mandate is to care for veterans who would have difficulty obtaining care from other health service providers. 10 One way the VHA accomplishes this mandate is by providing inexpensive or free care (including prescription medications) to veterans who have difficulty affording such services elsewhere. Given the changes in the VHA and the broad trends in US health care markets, little is known about shifts in how veterans access the VHA system. In this study, we examined how the characteristics of veterans who use outpatient VHA services have changed since 1992. We hypothesized that, given both the reorganization of the VHA and the changing health care environment outside the VHA, veterans who might have difficulty obtaining needed care elsewhere used VHA services more frequently. Our specific aims were to (1) describe trends in both VHA and non-VHA out-patient health care use among veterans from 1992 to 2000, (2) identify characteristics associated with veterans’ use of VHA versus non-VHA outpatient health care services, and (3) measure changes in these characteristics between 1992 and 2000.
