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Open Access Publications from the University of California

Scholarly Works (27 results)

  • Article
  • Peer Reviewed
UC San Francisco Previously Published Works (2017)

Background

Management of patients with chronic conditions relies on accurate measurement. It is unknown how transition to the ICD-10 coding system affected reporting of chronic condition rates over time. We measured chronic condition rates 2 years before and 1 year after the transition to ICD-10 to examine changes in prevalence rates and potential measurement issues in the Veterans Affairs (VA) health care system.

Methods

We developed definitions for 34 chronic conditions using ICD-9 and ICD-10 codes and compared the prevalence rates of these conditions from FY2014 to 2016 in a 20% random sample (1.0 million) of all VA patients. In each year we estimated the total number of patients diagnosed with the conditions. We regressed each condition on an indicator of ICD-10 (versus ICD-9) measurement to obtain the odds ratio associated with ICD-10.

Results

Condition prevalence estimates were similar for most conditions before and after ICD-10 transition. We found significant changes in a few exceptions. Alzheimer's disease and spinal cord injury had more than twice the odds of being measured with ICD-10 compared to ICD-9. HIV/AIDS had one-third the odds, and arthritis had half the odds of being measured with ICD-10. Alcohol dependence and tobacco/nicotine dependence had half the odds of being measured in ICD-10.

Conclusion

Many chronic condition rates were consistent from FY14-16, and there did not appear to be widespread undercoding of conditions after ICD-10 transition. It is unknown whether increased sensitivity or undercoding led to decreases in mental health conditions.
    Cover page: Comparing chronic condition rates using ICD-9 and ICD-10 in VA patients FY2014–2016Creative Commons 'BY' version 4.0 license
    • Article
    • Peer Reviewed
    UC San Francisco Previously Published Works (2022)

    Introduction

    The abrupt change in care delivery caused by the coronavirus disease 2019 pandemic may have left some patients, particularly those with chronic conditions, unable to receive timely and appropriate routine care. Understanding the effect of the pandemic and the switch to virtual care for patients with chronic conditions requires in-depth qualitative feedback from providers who care for these patients.

    Materials and methods

    We interviewed 13 primary care providers and clinical pharmacists from the Veterans Health Administration. Interviews elicited experiences managing patients with chronic conditions, specifically diabetes and hypertension, during the coronavirus disease 2019 pandemic. We employed a rapid analytic approach for data analysis.

    Results

    In general, interview participants maintained that most patients' chronic conditions could be managed remotely without significant disruption. However, patients who lack familiarity with technology and/or reliable broadband access, patients not compliant with recommended self-assessments, and older patients with hearing loss or cognitive disorders may be more difficult to manage virtually. Although providers reported minimal disruptions to care because of the pandemic, they did note that the closure of labs and experiences of social isolation may have negatively impacted patients. Providers suggested optimizing virtual management through more robust patient instruction on virtual care technology, increased use of Veterans Affairs home health services, and removing institutional barriers that may de-incentivize virtual care modalities.

    Conclusions

    For many patients with chronic conditions, virtual care is a promising approach to provide ongoing management in primary care. However, more tailored strategies may be needed to care for sicker, more vulnerable patients.
      Cover page: Virtual Management of Chronic Conditions During the COVID-19 Pandemic: Insights From Primary Care Providers and Clinical Pharmacists.
      • Article
      Recent Work (2006)

      Despite marginal improvements in job-based health insurance for adults and public program enrollment for children, one in five (6.5 million) Californians remain uninsured. Using data from the 2005 California Health Interview Survey (CHIS) -- as well as data from CHIS 2003 and CHIS 2001 -- researchers were able to identify how changes in employment-based coverage and public programs effected un-insurance rates for California's adult and child populations. The study shows that the percentage of adults who received health insurance through their employers increased to 56.2 percent in 2005, up from 55.1 percent in 2003. The authors credit the state's current tight labor market for this increase, but note that this figure is still behind the 2001 level of 57 percent. Moreover, they note that this improvement is unlikely to continue given the instability of employment-based insurance in the face of dramatically rising costs. The percentage of children without insurance for all or part of the year was statistically unchanged from 11.3 percent in 2003 to 10.7 percent in 2005, although the percentage was significantly lower than the rate in 2001 (14.8 percent). Researchers attribute this decline in the uninsured rate to recent expansions of children's enrollment and retention in public insurance programs, which is more than compensating for a decline since 2001 in the percentage of children being insured through their parents' employer.

        Cover page: One in Five Californians Were Uninsured in 2005 Despite Modest Gains in Coverage
        • Article
        • Peer Reviewed
        UC San Francisco Previously Published Works (2019)

        Background

        Not much is known about nonelderly veterans and their reliance on care from the Veterans Affairs (VA) health care system when they have access to non-VA care.

        Objectives

        To estimate VA reliance for nonelderly veterans enrolled in VA and Medicaid.

        Research design

        Retrospective, longitudinal analysis of Medicaid claims data and VA administrative data to compare patients' utilization of VA and Medicaid services 12 months before and for up to 12 months after Medicaid enrollment began.

        Subjects

        Nonelderly veterans (below 65 y) receiving VA care and newly enrolled in Medicaid, calendar years 2006-2010 (N=19,890).

        Measures

        VA reliance (proportion of care received in VA) for major categories of outpatient and inpatient care.

        Results

        Patients used VA outpatient care at similar levels after enrolling in Medicaid with the exceptions of emergency department (ED) and obstetrics/gynecology care, which decreased. VA inpatient utilization was similar after Medicaid enrollment for most types of care. VA-adjusted outpatient reliance was highest for mental health care (0.99) and lowest for ED care (0.02). VA-adjusted inpatient reliance was highest for respiratory (0.80) and cancer stays (0.80) and lowest for musculoskeletal stays (0.20). Associations between VA reliance and distance to VA providers varied by type of care.

        Conclusions

        Veterans dually enrolled in Medicaid received most of their outpatient care from the VA except ED, obstetrics/gynecology, and dental care. Patients received most of their inpatient care from Medicaid except mental health, respiratory, and cancer care. Sensitivity to travel distance to VA providers explained some of these differences.
          Cover page: Veterans’ Reliance on VA Care by Type of Service and Distance to VA for Nonelderly VA-Medicaid Dual Enrollees
          • Article
          Recent Work (2007)

          This report from the UCLA Center for Health Policy Research shows that job-based health insurance coverage -- the backbone of the state's system of health insurance – continues to decline. More than 6.5 million Californians under age 65 (more than one in five nonelderly residents) went without insurance for at least part of 2005. Even with the strong economic recovery, employment-based coverage of the nonelderly population as a whole fell from 56.4% in 2001 to 54.3% in 2005. Expanding enrollment of children in Medi-Cal and Healthy Families more than offset children’s loss of employment-based insurance between 2001 and 2005. Nearly one in three California children is now covered by Medi-Cal or Healthy Families (30.9%). Other findings from the report include: The erosion of job-based insurance is most severe for low- and moderate-income adults, but they lack the safety net that helps many children. The uninsured have more health problems than the insured, but get less health care, including preventive screenings and treatment for chronic conditions. Three-fourths of uninsured employees worked for a firm that does not offer coverage at all or were not eligible for their employer’s health plan. Lack of access to affordable health insurance is the main obstacle to coverage for working families and individuals.

            Cover page: The State of Health Insurance in California: Findings from the 2005 California Health Interview Study
            • Article
            • Peer Reviewed
            UC San Francisco Previously Published Works (2018)

            Objective

            To examine Veterans Health Administration (VA) enrollees' use of VA services for treatment of behavioral health conditions (BHCs) after gaining Medicaid, and if VA reliance varies by complexity of BHCs.

            Data sources/study setting

            VA and Medicaid Analytic eXtract utilization data from 31 states, 2006-2010.

            Study design

            A retrospective, longitudinal study of Veterans enrolled in VA care in the year before and year after enrollment in Medicaid among 7,249 nonelderly Veterans with serious mental illness (SMI), substance use disorder (SUD), posttraumatic stress disorder (PTSD), depression, or other BHCs.

            Data collection/extraction methods

            Utilization and VA reliance (proportion of care received at VA) for BH outpatient and inpatient services in unadjusted and adjusted analyses.

            Principal findings

            In adjusted analyses, we found that overall Veterans did not significantly change their use of VA outpatient BH services after Medicaid enrollment. In beta-binomial models predicting VA BH outpatient reliance, veterans with SMI (IRR = 1.38, p < .05), PTSD (IRR = 1.62, p < .01), and depression (IRR = 1.36, p < .05) had higher reliance than veterans with other BHCs after Medicaid enrollment.

            Conclusions

            While veterans did not change the amount of VA outpatient BH services they used after enrolling in Medicaid, the proportion of care they received through VA or Medicaid varied by BHC.
              Cover page: The Impact of Medicaid Enrollment on&nbsp;Veterans Health Administration Enrollees' Behavioral Health Services Use.
              • Article
              • Peer Reviewed
              UC San Francisco Previously Published Works (2018)

              Objectives

              To examine how dual coverage for nonelderly, low-income veterans by Veterans Affairs (VA) and Medicaid affects their demand for care.

              Data sources

              Veterans Affairs utilization data and Medicaid Analytic Extract Files.

              Study design

              A retrospective, longitudinal study of VA users prior to and following enrollment in Medicaid 2006-2010.

              Data collection/extraction methods

              Veterans Affairs reliance, or proportion of care provided by VA, was estimated with beta-binomial models, adjusting for patient and state Medicaid program factors.

              Principal findings

              In a cohort of 19,890 nonelderly veterans, VA utilization levels were similar before and after enrolling in Medicaid. VA outpatient reliance was 0.65, and VA inpatient reliance was 0.53 after Medicaid enrollment. Factors significantly associated with greater VA reliance included sociodemographic factors, having a service-connected disability, comorbidity, and higher state Medicaid reimbursement. Factors significantly associated with less VA reliance included months enrolled in Medicaid, managed care enrollment, Medicaid eligibility type, longer drive time to VA care, greater Medicaid eligibility generosity, and better Medicaid quality.

              Conclusion

              Veterans Affairs utilization following new Medicaid enrollment remained relatively unchanged, and the VA continued to provide the large majority of care for dually enrolled veterans. There was variation among patients as Medicaid eligibility and other program factors influenced their use of Medicaid services.
                Cover page: Use of Veterans Affairs and Medicaid Services for Dually Enrolled Veterans
                • Article
                • Peer Reviewed
                UC San Francisco Previously Published Works (2018)

                Objectives

                To examine high-cost patients in VA and factors associated with persistence in high costs over time.

                Data sources

                Secondary data for FY2008-2012.

                Data extraction

                We obtained VA and Medicare utilization and cost records for VA enrollees and drew a 20 percent random sample (N = 1,028,568).

                Study design

                We identified high-cost patients, defined as those in the top 10 percent of combined VA and Medicare costs, and determined the number of years they remained high cost over 4 years. We compared sociodemographics, clinical characteristics, and baseline utilization by number of high-cost years and conducted a discrete time survival analysis to predict high-cost persistence.

                Principal findings

                Among 105,703 patients with the highest 10 percent of costs at baseline, 68 percent did not remain high cost in subsequent years, 32 percent had high costs after 1 year, and 7 percent had high costs in all four follow-up years. Mortality, which was 47 percent by end of follow-up, largely explained low persistence. The largest percentage of patients who persisted as high cost until end of follow-up was for spinal cord injury (16 percent).

                Conclusion

                Most high-cost patients did not remain high cost in subsequent years, which poses challenges to providers and payers to manage utilization of these patients.
                  Cover page: Persistence of High Health Care Costs among VA Patients
                  • Article
                  • Peer Reviewed
                  UCLA Previously Published Works (2024)
                  Veterans enrolled in the Veterans Affairs (VA) health care system gained greater access to non-VA care beginning in 2014. We examined hospital and Veteran characteristics associated with hospital choice. We conducted a longitudinal study of elective hospitalizations 2011 to 2017 in 11 states and modeled patients choice of VA hospital, large non-VA hospital, or small non-VA hospital in conditional logit models. Patients had higher odds of choosing a hospital with an academic affiliation, better patient experience rating, location closer to them, and a more common hospital type. Patients who were male, racial/ethnic minorities, had higher VA enrollment priority, and had a mental health comorbidity were more likely than other patients to choose a VA hospital than a non-VA hospital. Our findings suggest that patients respond to certain hospital attributes. VA hospitals may need to maintain or achieve high levels of quality and patient experience to attract or retain patients in the future.
                    Cover page: Hospital and Patient Factors Affecting Veterans Hospital Choice.
                    • Article
                    • Peer Reviewed
                    UC San Francisco Previously Published Works (2018)

                    Objective

                    It remains unknown whether high-functioning teams can compensate for poor continuity of care to support important patient outcomes.

                    Data source

                    Linked VA administrative and Medicare claims data to measure the relationship of team-based care and continuity of care with high-cost utilization.

                    Study design

                    Retrospective cohort study of 1.2 million VA-Medicare dual eligible Veterans assigned to a VA primary care provider (PCP) in 2012. Continuity was the proportion of primary care visits to the assigned VA provider of care. Clinics were categorized as low, average, or high-team functioning based on survey data. Our primary outcomes were the number of all-cause hospitalizations, ambulatory care sensitive (ACSC) hospitalizations, and emergency department (ED) visits in 2013.

                    Principal findings

                    A 10-percentage point increase in continuity with a VA PCP was associated with 4.5 fewer hospitalizations (p < .001), 3.2 fewer ACSC hospitalizations (p < .001), and 2.6 more ED visits (p = .07) per 1,000 patients. Team-based care was not significantly associated with any high-cost utilization category. Associations were heterogeneous across VA-reliant and nonreliant Veterans. Finally, the interaction results demonstrated that the quality of team-based care functioning could not compensate for poor continuity on hospitalizations, ACSC hospitalizations, or ED visits.

                    Conclusions

                    In Veterans who were reliant on the VA for services, increasing continuity with a VA PCP and high-functioning team-based care clinics was associated with fewer ED visits and hospitalizations. Furthermore, leveraging combined data from VA and Medicare allowed to better measure continuity and assess high-cost utilization among Veterans who are and are not reliant on the VA for services.
                      Cover page: Association between Continuity and Team‐Based Care and Health Care Utilization: An Observational Study of Medicare‐Eligible Veterans in VA Patient Aligned Care Team
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